RA Test 2.1

There are three major acute complications of diabetes-related to short-term imbalances in blood glucose, which include the following, except: 1. HHNS 2. DKA 3. Hypoglycemia 4. Neuropathy

Neuropathy Rationale: Neuropathy is a long-term (chronic) complication of diabetes.

A nurse manager is creating an educational session for pediatric staff nurses about general injury prevention information. Which of the following interventions are correct to include in the session? Select all that apply. 1. Tolerate a toddler's habit of staying in the bathroom alone to provide privacy. 2. Confirm that crib sides are up every time the baby is in the crib. 3. To add for comfort, surround the infant with large and soft pillows in the crib. 4. Let an infant play with toys that are large, soft and without small parts. 5. Pin an infant's pacifier on the clothing with an attached stretchable ribbon. 6. It is fine to leave an infant alone on a changing table as long as it is under 5 minutes.

"Confirm that crib sides are up every time the baby is in the crib", "Let an infant play with toys that are large, soft and without small parts." Rationale: To promote safety and avoid injury, toddlers should be not be left alone near water sources such as tubs, pools, and bathrooms because of the risk of drowning. Infants should also never be left alone on a changing table because the infant might be able to roll over and fall. Therefore, when in a crib always ensure that crib sides are up. Large, soft pillows surrounding the infant in the crib places the infant at risk for suffocation. Toys that are large, soft and without small parts are encouraged because detachable small parts from toys increase the risk of choking.

A 34-year old primigravida client is being assessed by a nurse at an outpatient clinic. She has been a marathon runner for several years and the client tells of her concern that she is no longer able to run in marathons. She is also uneasy about the developing brown discoloration on her face and her increasing size. Which statements by the nurse are considered therapeutic when conversing with this client? Select all that apply. 1. "A price had to be paid for a baby and one of these is the permanent changes that you just verbalized." 2. "I can see you're saddened at not being able to run marathons as you are used to." 3. "Do not worry too much. After you deliver the baby, you'll be back to your pre-pregnant body in no time." 4. "Just wait and see. You will be back to marathon running after deliver before you know it." 5. "Tell me more about your feelings about the body changes that you're seeing." 6. "You will have to ask your doctor about your insistence on marathon running."

"I can see you're saddened at not being able to run marathons as you are used to." "Tell me more about your feelings about the body changes that you're seeing." Rationale: Therapeutic communication techniques include focusing on the client's feelings and concerns and acknowledging them by the varying techniques. When the nurse said: "I can see you're saddened at not being able to run marathons as you are used to," the nurse is using a technique called clarifying. While saying "tell me more about your feelings about the body changes you're noticing," is a technique called encouraging discussion of feelings. Telling a client "not to worry", discussion avoidance and placing the client's feelings on hold are non-therapeutic communication techniques.

The nurse is performing health teaching to the family members of a patient with Tuberculosis. Which indicates an understanding of the instructions? Select all that apply. 1. "I need to throw all my clothing when I got home." 2. "I need to cover my mouth and nose when coughing and sneezing." 3. "I need to isolate myself from my family." 4. "I need to use paper tissues to cough in and throw them properly." 5. "I need to use regular plate and utensils during lunchbreak."

"I need to cover my mouth and nose when coughing and sneezing.", "I need to use paper tissues to cough in and throw them properly.", "I need to use regular plate and utensils during lunchbreak. "Rationale: The patient diagnosed with Tuberculosis must carefully dispose paper tissues after use to prevent the spread of infection.

Upon reviewing with a client, the nurse determines that the client understands accurately how to perform a breast self-examination (BSE) when she states which of the following? Select all that apply. 1. "I should stand before a mirror and inspect each breast for anything unusual." 2. "Monthly BSE is required." 3. "If I detect lumps in my armpit area, I shouldn't be worried." 4. "It is encouraged that I palpate my breasts with soapy water while I am taking a shower." 5. "BSE should be done on the first day of my period." 6. "Some discharge may be noted when I squeeze my nipples."

"I should stand before a mirror and inspect each breast for anything unusual." "Monthly BSE is required." "It is encouraged that I palpate my breasts with soapy water while I am taking a shower." Rationale: Breast self-examination (BSE) is done once a month to have familiarity with the usual feel and appearance of the breasts. It should be done when the breasts are least likely to be tender and swollen, which is 2 or 3 days after menstruation ends. The client correctly stands before a mirror and inspects each breast for anything unusual and palpates each breast, including the axillary area. The client may perform this part of the examination in the shower using soap allowing the finger to glide easily over the breasts' skin. Any lumps and nipple discharges are abnormal and the client is taught to report these findings immediately.

A client newly diagnosed with breast cancer is scheduled for lymph node biopsy and asks the nurse why it is necessary when a diagnosis of cancer has already been made. The nurse's response is based on which of the following? 1. A lymph node biopsy is necessary to determine what type of cancer cells are present. 2. A lymph node biopsy is performed on all females with cancer. 3. A lymph node biopsy is performed to determine if cancer has metastasized. 4. A lymph node biopsy is performed to determine what type of chemotherapy is indicated.

A lymph node biopsy is performed to determine if cancer has metastasized. Rationale: A lymph node biopsy is performed to assess any metastasis from the primary site of cancer, and a common mestastatic site for breast cancer is regional lymph nodes.

A client presents on admission with pressure ulcers extending into the subcutaneous tissues. The nurse documents this ulcer at what stage? Provide a numerical answer. 1. 2 2. 3 3. 4 4. 1

2. 3 Rationale: Stage 3 ulcers result in full thickness skin loss with extensive damage to the subcutaneous tissues.

Based on BLS recommendations, which compression-ventilation ratio should a nurse use for 1-rescuer CPR? 1. 5 compressions to 1 ventilation 2. 5 compressions to 2 ventilations 3. 15 compressions to 2 ventilations 4. 30 compressions to 2 ventilations

30 compressions to 2 ventilations Rationale: According to the American Heart Association's BLS Guidelines (2010), the ratio of 30 compressions to 2 ventilation is recommended for both 1- and 2-rescuer adult CPR.

Using the Rule of Nines, the nurse determines the percentage of the body burned on a client with both legs burned to be? 1. 1% 2. 9% 3. 18% 4. 36%

36% Rationale: Using the Rule of Nines, each leg is 18%. Both legs would be 36%.

A client with thrombocytopenia presents to the primary care center. During the assessment, the nurse notices petechiae. Does the nurse interpret that which laboratory result best supports the presence of a disorder of hemostasis? 1. Decreased erythrocyte count 2. A platelet count below 150,000/uL 3. An elevated lymphocyte count 4. A hemoglobin value to 14 or more

A platelet count below 150,000/uL Rationale: Clients with thrombocytopenia have decreasedplatelet counts below 150,000/uL.

A new nurse in the unit is admitting a severely leukopenic client who is receiving radiation therapy. The preceptor determines that the new nurse understands precautionary measures necessary for this client when he or she admits the client to which of the following rooms? 1. A semi-private room with a client who has pneumonia. 2. A private room with contact isolation. 3. A private room with protective isolation. 4. A private room with no isolation precautions.

A private room with protective isolation. Rationale: Because of the immunosuppression, the client is at severe risk of infection. Precautionary measures such as a private room and protective isolation must be instituted to protect the client from sources of infection.

A client is prescribed with desmopressin (DDAVP) nasal spray. The nurse should teach the client that the therapeutic effects of this medication are obtained when the client no longer has? 1. Nasal congestion 2. Headache 3. Pharyngitis 4. Polydipsia

Polydipsia Rationale: The therapeutic effects of desmopressin (DDAVP) nasal spray are relief of polydipsia and control of polyuria and nocturia in clients with diabetes insipidus.

A nurse in the intensive care unit is taking care of a patient with an endotracheal (ET) tube in place and monitors for the behavioral indicators of pain. Which of the following manifestations are markers that the client is in pain? Select all that apply. 1. Abdominal guarding 2. Restlessness 3. Immobilization 4. Muscle tension 5. Increased hand and finger movements 6. Increased attention span

Abdominal guarding Restlessness, Immobilization, Muscle tension, Increased hand and finger movements

When assessing a 4-month-old infant, which of the following would the nurse expect to find? 1. Ability to sit up with support 2. Fine motor finger-to-thumb grasp 3. Ability to say mama or dada 4. Ability to reach for a toy

Ability to sit up with support Rationale: Even if the specific month that an infant can sit with support is at 6months, among the choices, this is the most nearest/possible answer to the question given.

The nurse volunteers to help with a health fair in her community. She was asked to participate in a booth that will offer information about osteoporosis. The nurse should identify the following as risk factors for osteoporosis, except (Select all that apply) 1. African American 2. Male gender 3. Cigarette smoking 4. Alcohol abuse 5. Early menopause 6. Increasing age

African American Male gender Rationale: Risk factors for osteoporosis include: White or Asian race, female gender, cigarette smoking, alcohol abuse, early menopause, and increasing age.

Dr. Roberts has ordered a CT scan of the patient's chest with IV contrast. The patient has been assessed for a history of which data that warrants the nurse to notify the doctor? 1. Increased blood pressure 2. Allergy to shrimp 3. Urinary Tract Infection 4. Penicillin allergy

Allergy to shrimp Rationale: A client with an allergy to iodine or shellfish may have an adverse reaction to the contrast medium. CT scan with IV contrast does not contraindicate a patient with hypertension. A UTI is not a contraindication for a CT scan with IV contrast. An allergy to penicillin is not a contraindication for a CT scan with IV contrast.

A client has undergone a renal arteriogram. Which of the following is an inappropriate nursing intervention following the procedure? 1. Ambulating the client 2. Monitoring for presence of pulses distal to insertion site 3. Monitoring for signs and symptoms of infection 4. Maintaining bed rest for 8 hours

Ambulating the client Rationale: Following renal arteriogram, the client should be maintained on bed rest for 8 hours to prevent bleeding and hematoma formation at catheter insertion site.

Following BLS guidelines in providing rescue breaths, what action can a nurse make to assist another rescuer to help reduce the chances of gastric inflation? 1. Provide pressure on the gastric area 2. Apply circoid pressure 3. Encourage the other rescuer to breathe faster 4. Assist in opening the airway

Apply circoid pressure Rationale: Cricoid pressure, or Sellick technique, is the application of pressure to the unresponsive victim's cricoid cartilage. Cricoid pressure is effective for preventing gastric inflation during positive pressure ventilation of unresponsive client.

The nurse is performing perineal heat lamp exposure. Which of the following is inappropriate nursing action when performing this procedure? 1. Keep the lamp at least 18 inches away from the perineum 2. Apply prescribed topical medication into the perineal area before the procedure 3. Provide privacy by proper draping 4. Perform perineal flushing before the procedure

Apply prescribed topical medication into the perineal area before the procedure Rationale: Prescribed topical medication must be applied after the procedure.

The skin in the diaper area of a 4-month-old infant is excoriated and red. The nurse should instruct the mother to do the following, except: 1. Apply talcum powder with diaper changes 2. Change the diaper more often 3. Maintain proper hydration 4. Wash and dry the area gently

Apply talcum powder with diaper changes Rationale: Talc is contraindicated in children because of the risks of inhaling the fine powder.

Kussmaul's respiration in a client with diabetes mellitus : 1. Are among the major assessment findings associated with diabetes. 2. Are an attempt by the body to correct an acid-base imbalance. 3. Indicate hypoglycemia. 4. Indicate cerebral anoxia.

Are an attempt by the body to correct an acid-base imbalance Rationale: The respiratory system is the first compensatory system activated in response to a decreasing blood pH. Carbon dioxide is "blown off" in an attempt to rid the body of excess acid.

The nurse is caring for a client with atypical depression who is taking phenelzine (Nardil). Which of the following would the nurse include in the teaching about foods to avoid while on this medication? 1. Bologna 2. Fried chicken 3. Fresh Fish 4. Hamburger

Bologna "PANAMAMA" Rationale: Phenelzine (Nardil) is a monoamine oxidase inhibitor (MAOI). MAOIs block the enzyme monoamine oxidase, which is involved in the decomposition and inactivation of norepinephrine, serotonin, dopamine, and tyramine (a precursor to the previously stated neurotransmitters). Foods high in tyramine - those that are fermented, pickled, aged, or smoked - must be avoided because, when they are ingested in combination with MAOIs, a hypertensive crisis will occur.

The nurse is teaching a client who is undergoing disulfiram (Antabuse) therapy. Using alcohol when taking this medication can result in all of the following, except: 1. Bradypnea 2. Flushing 3. Vomiting 4. Dizziness

Bradypnea Rationale: Flushing, vomiting, and dizziness are associated with incomplete breakdown of alcohol metabolites, brought about by disulfiram (Antabuse).

The nurse is assessing a premature newborn for respiratory distress syndrome. The following are the manifestations that may be observed, except: 1. Nasal flaring 2. Intercostal retractions 3. Bradypnea 4. Cyanosis

Bradypnea Rationale: Nasal flaring, intercostal retractions, cyanosis are some of the manifestations of respiratory distress syndrome. Tachypnea, not bradypnea, is seen in respiratory distress syndrome.

For which of the following patients is this position indicated for? 1. Gastroesophageal reflux disease 2. Hiatal hernia 3. Lung Cancer with SVC Syndrome 4. Bronchitis with fluids in anterior lower lobes

Bronchitis with fluids in anterior lower lobes Rationale: Avoid trendelenburg in GERD and hiatal hernia as this can worsen the acid backflow and reflux. For SVC Syndrome, it may cause further congestion to the site. Patients having Bronchitis with fluids in anterior lower lobes maybe positioned in trendelenburg for mobilization of secretions.

The community nurse finds a person who is unresponsive. She opens the airway and finds out that the victim is not breathing. The nurse provided 2 rescue breaths and checks for signs of circulation. Where should the nurse feel for the pulse of an unresponsive adult victim? 1. Femoral pulse 2. Radial pulse 3. Brachial pulse 4. Carotid pulse

Carotid pulse Rationale: To perform a pulse check in the adult, the healthcare provider typically attempts to palpate a carotid pulse.

The nurse is teaching a newly diagnosed diabetic client about complications of insulin therapy, such as hypoglycemia. The nurse should include all of the following as early clinical signs of hypoglycemia, except: 1. Confusion 2. Diaphoresis 3. Nervousness 4. Tachycardia

Confusion Rationale: Early clinical signs of hypoglycemia include adrenergic responses, e.g., diaphoresis, nervousness, tachycardia, palpitations, and cold clammy skin.

The nurse is caring for a client who is recovering from abdominal surgery. A nasogastric tube is inserted. The nurse understands that the primary reason that the tube is in place is to achieve which of the following functions in the gastrointestinal tract? 1. Gavage 2. Decompression 3. Lavage 4. Enteral Feeding

Decompression Rationale: After abdominal surgery, the reason for inserting a nasogastric tube is to decompress the gastrointestinal tract until peristaltic action returns.

A client enters the emergency department manifesting signs of a severe level of anxiety. Which of the following measures should the nurse implement? Select all that apply. 1. Immediately place the client in isolation 2. Decrease stimulation by environment 3. Stay with the client 4. Utilize dramatic nonverbal language to help calm the client 5. State clear and simple sentences 6. Place the client in a silent room

Decrease stimulation by environment , Stay with the client, State clear and simple sentences , Place the client in a silent room Rationale: A client on severe anxiety is unable to solve problems and may be unaware of events around his/her environment. The nurse taking care of this client is to remain with him/her, stay calm, minimize environmental stimuli and move the client to a quiet setting. Complex instructions are not helpful because the client with severe anxiety has difficulty concentrating and has impaired information processing. Therefore, clear, simple and repetitive statements spoken with a low-pitched voice would be more beneficial. Dramatic nonverbal language will only increase the client's anxiety. The nurse should assess the client's need for medication and isolation; however, these are considered to be last interventions and are done only after all other efforts are exhausted.

Physical assessments constitute an important part of the assessment phase of the nursing process. Which of the following techniques involves inspection? 1. Detecting a fruity breath odor 2. Taking an apical pulse 3. Taking the radial pulse 4. Striking the chest area to produce audible sound waves

Detecting a fruity breath odor Rationale: Inspection uses sight and smell to collect data, such as detecting a fruity odor.

Retinal detachment is associated with the following clinical manifestations, except: 1. Dull eye pain 2. Blurred vision 3. Spots floating before the eyes 4. Flashes of lights

Dull eye pain Rationale: Because the retina does not contain sense nerves that relay feelings of pain, the condition is painless.

In assessing a client with pulmonary embolism, the following signs and symptoms are expected? Select all that apply. 1. Dyspnea 2. Bradypnea 3. Hemoptysis 4. Cyanosis 5. Cough

Dyspnea, Hemoptysis, Cyanosis, Cough Rationale: Signs and symptoms of pulmonary embolism include difficulty of breathing, tachycardia, cyanosis, cough and hemoptysis.

A child has been diagnosed with a brain tumor, but surgery cannot be scheduled for several days. The mother asks what she can do to ease her child's headaches. Does the nurse suggest that the mother? 1. Help the child drink plenty of liquids 2. Discourage the child from having bowel movement 3. Encourage the child to sleep in a semi-Fowler's position 4. Encourage the child to blow the nose when headaches become severe

Encourage the child to sleep in a semi-Fowler's position Rationale: When the client is lying flat, the blood flow to the brain is greater, increasing the intracranial pressure. If the client sleeps in semi-Fowler's position, less pressure will develop, which in turn should ease headache.

The nurse is caring for a patient with stomatitis. Which of the following health teaching is inappropriate for this client? 1. Instruct the client to eat bland diet 2. Teach proper mouth care 3. Encourage the client to take hot drinks 4. Encourage the client to take cool drinks

Encourage the client to take hot drinks Rationale: In caring for the client with stomatitis, the nurse must provide and teach the proper technique for mouth care; as well as dietary instruction on a bland diet and cool drinks to decrease further irritation.

The nurse assigned in the emergency department is providing care for a 19-year-old victim of a sexual assault. When following legal and agency guidelines, which intervention is most important? 1. Preserve the client's privacy 2. Determine the perpetrator's identity 3. Identify the extent of injury 4. Ensure an unbroken chain of evidence

Ensure an unbroken chain of evidence Rationale: Establishing an unbroken chain of evidence is essential in order to ensure that the prosecution of the perpetrator can occur.

In teaching nursing students about the functions of the adrenal gland, the nurse should name the following as hormones secreted by the adrenal cortex, except: 1. Epinephrine 2. Cortisol 3. Aldosterone 4. Cortisone

Epinephrine Rationale: Epinephrine is secreted by the adrenal medulla

Which of the following antituberculosis drugs can cause damage to the optic nerve? 1. Ethambutol HCl 2. Streptomycin 3. Isoniazid 4. Rifampicin

Ethambutol HCl Rationale: A common side effect of ethambutol HCl is optic neuritis.

A nurse taking care of an adolescent who recently sustained an ankle fracture is teaching him how to walk with crutches using the three-point gait. Arranged the options in the appropriate order of instruction. · Explain the procedure to the client. · Assess client for strength, mobility, range of motion, perceptual difficulties and balance. · Assist the client to a standing position with crutches. Support as needed. · Advance both crutches and the weaker leg forward together 4-6 inches. · Put weight on hand grip as the client moves the stronger leg forward. · Repeat the three-point gait.

Explain the procedure to the client. · Assess client for strength, mobility, range of motion, perceptual difficulties and balance. · Assist the client to a standing position with crutches. Support as needed. · Advance both crutches and the weaker leg forward together 4-6 inches. · Put weight on hand grip as the client moves the stronger leg forward. · Repeat the three-point gait.

While caring for a client undergoing blood transfusion, the nurse should be aware that transfusion reactions usually occur within the first 15 minutes of receiving blood, and maybe manifested by which of the following signs and symptoms? 1. Hypertension 2. Flank pain 3. Bradypnea 4. Hypothermia

Flank pain Rationale: Flank pain may indicate a hemolytic reaction to the blood transfusion. Also present are hemoglobinemia, hemoglobinuria, DIC, renal failure, and immune-mediated cardiovascular collapse. Also present are fever, chills, joint pain, and chest tightening.

The nurse is teaching family members about precautions to take in visiting a client who has neutropenia. Which of the following instructions would not be included by the nurse in the discussion? 1. People who have colds or infectious diseases should not visit. 2. Visitors must wash their hands before and after a visit. 3. Face mask should be worn by all those who come in contact with the client 4. Fresh flowers will help to provide a cheerful environment.

Fresh flowers will help to provide a cheerful environment. Rationale: A client with neutropenia has a compromised immune system and is predisposed to infections. Fresh fruits and flowers in the client's room are not allowed because they tend to harbor bacteria.

The following interventions would be appropriate for the nurse to include in a plan to prevent pressure ulcer, except: 1. Gentle massage of bony prominences every shift 2. Daily gentle cleansing of the skin 3. Avoiding harsh soaps and hot water 4. Changing the client's position every 2 hours

Gentle massage of bony prominences every shift Rationale: Massage of bony prominences is not done, because it can actually increase damage to the underlying tissues.

To decrease the hospitalized client's chance of developing an upper respiratory infection, he should be encouraged to do the following, except: 1. Breathe deeply 2. Get enough rest and stay in bed as much as possible 3. Turn from side to side frequently 4. Do coughing exercises

Get enough rest and stay in bed as much as possible Rationale: To decrease the hospitalized client's chance of developing an upper respiratory infection, he should be encouraged to ambulate, do deep breathing and coughing exercises, and turn from side to side frequently.

The nurse finds a client who is unresponsive. She sends a colleague to phone the emergency response number. The nurse performs a head tilt-chin lift and looks, listens, and feels for breathing. The client is not breathing. What should the nurse do next? 1. Give 2 rapid breaths 2. Give 1 slow breath 3. Give 1 rapid breath 4. Give 2 slow breaths

Give 2 slow breaths Rationale: To provide rescue breathing, BLS recommends delivery of 2 slow breaths (2 seconds each), allowing complete exhalation between breaths to diminish the likelihood of exceeding the esophageal opening pressure.

A 32-year-old woman becomes unresponsive at a restaurant. Her husband says that she suddenly stopped talking, clutched her throat with both hands, turned blue, and collapsed. The nurse's next action should be too? 1. Have someone phone 911 and get the AED 2. Check the pulse 3. Attempt the ventilation 4. Perform a finger sweep

Have someone phone 911 and get the AED Rationale: The first link in the chain of survival is to activate the EMS system, e.g., calling 911.

A 58-year-old client is diagnosed with Cushing's disease. The following test results would be consistent with this diagnosis, except: 1. Hypokalemia 2. Hyponatremia 3. Hypertension 4. Hyperglycemia

Hyponatremia Rationale: Clients with Cushing's disease have hypernatremia, not hyponatremia. Sodium retention is typically accompanied by potassium depletion. Hypertension, hypokalemia, edema, postprandial or persistent hyperglycemia are also associated with Cushing's disease.

The community nurse is teaching a group of mothers about the proper way of taking oral temperature. Which of the following interventions, if mentioned by one of the mothers, would indicate the need for further explanation? 1. "I will place the thermometer under the tongue" 2. "I will take oral temperature for 2 to 3 minutes" 3. "I will wash the thermometer from the bulb to the stem before use" 4. "I will take oral temperature using a thermometer with a pear-shaped bulb"

I will take oral temperature using a thermometer with a pear-shaped bulb Rationale: Thermometer with a pear-shaped bulb is usually used for rectal temperature taking.

The patient has been confirmed of pancreatitis, which will include which of the following laboratory results? 1. Increased BUN 2. Increased serum lipase 3. Increased AST 4. Increased LD

Increased serum lipase Rationale: The most reliable indicator of pancreatitis is elevation of serum lipase because this enzyme is produced solely by the pancreas. A client's BUN is typically elevated in relation to renal dysfunction; the AST, in relation to liver dysfunction; and LD, in relation to damaged cardiac muscle.

Hyperthyroidism is the second most prevalent endocrine disorder after diabetes mellitus. Which of the following is considered a common cause of hyperthyroidism? 1. Infection 2. Antithyroid medications 3. Iodine excess 4. Radioactive iodine therapy

Infection Rationale: Hyperthyroidism may appear after an emotional shock, stress, or an infection, but the exact significance of these relationships is not understood. Other common causes include thyroiditis, and excessive ingestion of thyroid hormone. Antithyroid medications, iodine excess, and radioactive iodine can cause hypothyroidism.

Which of the following actions require surgical asepsis? Select all that apply. 1. Inserting an intravenous (IV) line 2. Applying a Nitroglycerine transdermal patch 3. Cleaning and changing the dressing of a grade II bedsore 4. Suctioning a patient with a tracheostomy in place 5. Removing a dressing 6. Draining a colostomy bag

Inserting an intravenous (IV) line, Cleaning and changing the dressing of a grade II bedsore, Suctioning a patient with a tracheostomy in place Rationale: Surgical asepsis involves the use of sterile technique, which consists of those practices that eliminate all microorganisms and spores from an object or area. Invasive procedures such as inserting an IV line, suctioning a patient with tracheostomy in place require surgical asepsis. Cleaning and changing the dressing of bedsore will also require the nurse to utilize sterile technique to facilitate wound healing and prevent further infection. Applying a Nitroglycerine transdermal patch, removing a dressing and draining a colostomy bag can be done by a clean technique using clean gloves.

The nurse is caring for a client with a schizoid personality disorder. Which of the following behaviors is unexpected from a client with this disorder? 1. Detached and aloof 2. No interest in seeking the approval of others 3. Interested to join group activities 4. Introvert

Interested to join group activities Rationale: A client with schizoid personality disorder is typically detached, aloof, socially isolated, introvert, and no interest in seeking the approval of others.

The nurse is doing an assessment on a client exhibiting prominent neck veins, hypertension, and a bounding pulse. These clinical findings are indicative of fluid excess in which specific body compartment? 1. Intracellular compartment 2. Extracellular compartment 3. Intravascular compartment 4. Interstitial compartment

Intravascular compartment Rationale: The extracellular fluid compartment consists of two divisions, interstitial and intravascular. Prominent neck veins, hypertension, and bounding pulse are indicative of fluid excess in the intravascular (plasma) compartment.

When explaining the disorder to a client with tinea corporis, the nurse should include which of the following about this skin disorder? 1. It requires no treatment 2. It can be passed human to human 3. It should be exposed to sunlight 4. It is a malignant skin condition

It can be passed human to human Rationale: Fungal infections such as tinea corporis may be transmitted by direct contact with animals and other persons.

A new graduate nurse is being oriented by his charge nurse regarding telephone and verbal order guidelines. Which of the following are incorrect guidelines to include? Select all that apply. 1. The nurse should clarify the physician's orders by repeating the prescribed orders back. 2. Doubts and questions should be timely clarified with the physician. 3. It is never acceptable to receive verbal orders. All orders should be documented on the client's chart. 4. As long as the primary physician is the one giving the orders, it is unnecessary to document them. 5. It is never acceptable to use abbreviations. 6. If the nurse repeats back the order for verification, cosigning the order is unnecessary.

It is never acceptable to receive verbal orders. All orders should be documented on the client's chart, As long as the primary physician is the one giving the orders, it is unnecessary to document them, It is never acceptable to use abbreviations, If the nurse repeats back the order for verification, cosigning the order is unnecessary. Rationale: A telephone order is when a physician prescribes a treatment or procedure to a nurse over the phone, usually given during an emergency or in the evening. Telephone orders are legal as long as it is given only when absolutely necessary. A verbal order is acceptable during an emergency situation where it is imprudent to write the order before the nurse carries it out. Telephone and verbal order guidelines are the following:(1) Client's name, room number, and diagnosis are clearly stated.(2) Orders are repeated back to the physician. Questions are timely clarified.(3) When documenting, indicate VO (verbal order) or TO (telephone order) and include client's name, date, time, prescribed order, physician's and nurse's name.(4) As per hospital protocol (standard is 24 hours), ask the prescribing physician to cosign the order.

Osteoporosis is a disorder characterized by abnormal loss of bone density and deterioration of bone tissue resulting in increased fracture risk. Which of the following risk factors places the patients at great possibility for developing osteoporosis? Select all that apply. 1. Lack of calcium and vitamin D intake 2. Asian race 3. Dark-skinned, large boned woman 4. Physical active lifestyle 5. Early menopause 6. Family history of osteoprosis

Lack of calcium and vitamin D intake, Asian race, Early menopause, Family history of osteoprosis Rationale: Those at greatest risk for osteoporosis are the small-boned, fair-skinned, white and Asian women. Inadequate intake of calcium and vitamin D is a major risk factor because it results in an abnormal loss of bone density and determination of bone tissue. Other risk factors include early menopause, sedentary lifestyle and family history of osteoporosis. Bone resorption also increases when there is an increased intake of alcohol, corticosteroids, and anticonvulsants. Smoking and drinking alcohol also increases the risk of bone destruction.

The nurse identifies which of the following as signs of scoliosis? Select all that apply. 1. Lateral deviation and rotation of each vertebrae 2. Unequal rib heights 3. Chest asymmetry 4. Equal waist angles 5. Equal shoulder heights 6. Equal rib promininces

Lateral deviation and rotation of each vertebrae , Unequal rib heights, Chest asymmetry Rationale: Scoliosis is defined as the lateral curvature of the spine. Children ages 9 to 15 years old should be screened for scoliosis to ensure early detection and treatment. At greatest risk for developing scoliosis are girls 10 years old through adolescence. The proper way of checking for scoliosis is having the child wear only underpants so that the chest, back, and hips can be clearly seen. The child should stand with his or her weight equally on both feet. Legs should be straight and arms hanging loosely at the sides. The signs that are definitive for scoliosis include non-painful lateral curvature of the spins, a curve with one turn (C curve) or two compensating curves (S curve), lateral deviation and rotation of each vertebra, unequal shoulder heights, unequal waist angles, unequal rib prominences, chest asymmetry, and unequal rib heights.

When preparing to administer a tapwater enema, the nurse should place the client in which position? 1. Left Sims' 2. High Fowler's 3. Right Lateral 4. Prone

Left Sims' Rationale: When administering an enema, the nurse should position the client in a left Sims' position. This position facilitates the flow of fluid into the rectum and colon.

A male client was diagnosed with conductive hearing loss based on the Rinne test result. Does this mean he hears the vibrations from a tuning fork? 1. Longer by bone conduction than by air conduction 2. Longer by air conduction than by bone conduction 3. Poorly by both air and bone conduction 4. Equally well by air and bone conduction

Longer by bone conduction than by air conduction Rationale: In conductive hearing loss, the sound is heard for a longer time when conducted by bone than by air.

The nurse should instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? 1. Whole grains 2. Green leafy vegetables 3. Meats and dairy products 4. Orange juice

Meats and dairy products Rationale: Good sources of vitamin B12 include meats and dairy products. "M.A.D." Meat products Animal products Dairy products

The nurse provides information to a client about the early detection of testicular cancer. Which of the following information should be included in the teaching session? Select all that apply. 1. Testicular tumors are very painful 2. Lumps smaller than a pea felt when doing the Testicular self examination (TSE) are normal 3. TSEs are best performed before taking a shower 4. Men between 15 and 35 years are most commonly affected with testicular cancer 5. A feeling of heaviness in the scrotum is a sign of testicular tumor 6. TSEs should be performed monthly

Men between 15 and 35 years are most commonly affected with testicular cancer, A feeling of heaviness in the scrotum is a sign of testicular tumor, TSEs should be performed monthly Rationale: Testicular cancer is the most common and serious solid tumor cancer in men between the ages of 15 and 35 years. The client is taught to perform a monthly TSE and the best time to perform this is after bathing because the warm water causes the scrotum to relax and makes the testicles more accessible and therefore, easier to examine. Lumps regardless of size are immediately reported to the health care provider for further investigation.

The nurse would anticipate which of the following acid-base imbalances to develop in a client with nasogastric tube inserted? 1. Respiratory acidosis 2. Metabolic alkalosis 3. Respiratory alkalosis 4. Metabolic acidosis

Metabolic alkalosis Rationale: Nasogastric tube insertion may remove gastric acid from the gastrointestinal tract, thus creating a base bicarbonate excess and a state of metabolic alkalosis.

When caring for a postpartum client, the nurse should be aware that which of the following amounts of blood loss following birthmarks the criterion for describing postpartum hemorrhage? 1. More than 250 ml 2. More than 300 ml 3. More than 400 ml 4. More than 500 ml

More than 500 ml Rationale: Postpartum hemorrhage is defined as blood loss of more than 500 mL following birth.

The nurse is caring for a 60-year-old male client with pericarditis. His systolic blood pressure begins to fall and heart sounds cannot be heard. What should be the nurse's initial action? 1. Continue to monitor the client's vital signs 2. Document the findings 3. Notify the physician immediately 4. Assess the client's level of pain

Notify the physician immediately Rationale: One of the objectives of management for clients with pericarditis is being alert for cardiac tamponade, which is a life-threatening condition. The signs and symptoms of cardiac tamponade begin with falling arterial pressure. Usually, the systolic pressure falls while the diastolic pressure remains stable. Heart sounds may progress from being distant to being imperceptible. In such situations, the nurse notifies the physician immediately and prepares to assist with pericardiocentesis.

The client in the Obstetric Department with Raynaud's disease is complaining of an acute attack. The nurse should document which assessment data? 1. Muscle contraction 2. Facial weakness 3. Numbness of the fingers and blanching of fingertips 4. Sensitive to light

Numbness of the fingers and blanching of fingertips Rationale: The cause of Raynaud's disease is idiopathick; however, after exposure to cold or stress, the client typically experiences blanching of the skin at the fingertips and numbness and tingling of the fingers. amyotrophic lateral sclerosis (ALS) includes involuntary muscle contractions and twitching. Unilateral facial weakness and drooping mouth are signs of Bell's Palsy. Photophobia is not related to Raynaud's disease.

During community health teaching, the nurse should state which of the following conditions as the most significant risk factor for the development of type 2 diabetes mellitus? 1. Hypertension 2. Alcohol 3. High cholesterol diet 4. Obesity

Obesity Rationale: The most important factor predisposing to the development of type 2 DM is obesity. Insulin resistance increases with obesity.

The physician prescribes raloxifene hydrochloride (Evista) for a 65-year old postmenopausal woman. The nurse should instruct the client that this drug is useful in preventing which of the following? 1. Osteoporosis 2. Hot flashes 3. Hyperglycemia 4. Migraine / Headache

Osteoporosis Rationale: Raloxifene HCl (Evista), an estrogen receptor modulator, increases bone mineral density without stimulating the endometrium. The drug is useful in preventing osteoporosis in postmenopausal women.

The nurse is assessing a newborn baby. The following are common and normal newborn findings, except: 1. Acrocyanosis 2. Periorbital cyanosis during feeding 3. Milia 4. Mongolian spots

Periorbital cyanosis during feeding Rationale: Periorbital cyanosis is a symptom of possible cardiac problems.

Which of the following nutrients should be restricted for a child diagnosed with chronic renal failure? 1. Phosphorus 2. Vitamin C 3. Calcium 4. Magnesium

Phosphorus Rationale: With minimal or absent kidney function, the serum phosphate level rises; hence, the need to restrict phosphorus on the patient's diet.

An elderly client asks the nurse why she is having trouble sleeping. The nurse explains that she has a deficiency of melatonin caused by decreased function of the? 1. Hypothalamus 2. Pineal gland 3. Pituitary gland 4. Thyroid gland

Pineal gland Rationale: In the elderly, the pineal gland is calcified leading to less melatonin, hence, less sleep.

Glomerulonephritis is a nonbacterial inflammation of the glomeruli in both kidneys that involves an antigen-antibody reaction. Which of the following signs and symptoms is not associated with this disorder? 1. Fever 2. Chills 3. Elevated BUN 4. Polyuria

Polyuria Rationale: Glomerulonephritis involves scarring and loss of renal function. Oliguria, not polyuria, is associated with this disorder.

A 35-year-old primigravid client is having preeclampsia. What are the signs and symptoms that can be seen in this client? (Select all that apply) 1. Proteinuria 2. Hypertension 3. Facial or hand edema 4. Hyporeflexia 5. Weight gain of 5 pounds per week 6. Visual disturbances 7. Hyperreflexia

Proteinuria , Hypertension, Facial or hand edema, Weight gain of 5 pounds per week , Visual disturbances , Hyperreflexia Rationale: All of the selected responses are manifestations of pre-eclampsia.

Select all the characteristics that aptly describe case management. 1. Providing direct care is usually not done by the case manager. 2. Critical pathways and CareMaps are two types of case management. 3. In case management, the process of evaluation includes examining and monitoring the needs of the client. 4. A case manager gathers other staff members to collaborate with them and also supervises them on care delivery. 5. A case manager organizes a hospitalized client's acute care and follows up with the client upon discharge. 6. Cost management is no concern of the case manager.

Providing direct care is usually not done by the case manager, In case management, the process of evaluation includes examining and monitoring the needs of the client, A case manager gathers other staff members to collaborate with them and also supervises them on care delivery, A case manager organizes a hospitalized client's acute care and follows up with the client upon discharge. Rationale: Case management is an approach that coordinates services of health care to the client and their families while keeping in mind care quality and decreasing, if appropriate and possible, costs. Direct care is not usually provided by case managers; rather, they coordinate with their staff members and supervise the care they deliver. In addition, they organize the care their patients acutely need and furnish their discharge plans. The evaluation process includes scrutinizing and monitoring the needs of the client. Critical pathways and CareMaps are multidisciplinary treatment plans that are designed to rapidly deliver interventions in the timeliest manner.

Which of the following types of insulin can be given intravenously? 1. Lente 2. NPH 3. Regular 4. Lispro

Regular Rationale: Regular insulin can be given intravenously. Lente, NPH, and Lispro insulin should be given subcutaneously.

A relative of a client diagnosed with depression asks the nurse about the cause of the client's disorder. In responding, the nurse should be aware that according to the biogenic amine theory, an individual with depression has a deficiency in which neurotransmitters? 1. Aldosterone and Cortisone 2. Acetylcholine and Epinephrine 3. Serotonin and Norepinephrine 4. Dopamine and GABA

Serotonin and Norepinephrine Rationale: The biogenic amine theory of depression describes deficiencies in the neurotransmitters serotonin and norepinephrine.

A woman is taking oral contraceptives. The following may be a common benign side effect that accompanies oral contraceptive use, except: 1. Mild headache 2. Breakthrough pain 3. Severe calf pain 4. Weight gain

Severe calf pain Rationale: Women who take oral contraceptives are at increased risk for thromboembolic conditions. Severe calf pain would need to be investigated as a potential sign of deep vein thrombosis.

While a nurse is performing range-of-motion (ROM) exercises on a client, the client suddenly exhibits spastic muscle contractions. Which of the following interventions should the nurse implement? Select all that apply. 1. Vigorously massage the affected muscle group 2. Notify physician immediately 3. Stop the range-of-motion exercises 4. Continue forcing the joint supporting the muscle 5. Apply continuous but gentle pressure on affected part until it relaxes 6. Instruct client to walk rapidly around the room

Stop the range-of-motion exercises, Apply continuous but gentle pressure on affected part until it relaxes Rationale: An unexpected outcome when performing range-of-motion exercises is the development of spastic muscle contractions. ROM exercises should put each joint on the most optimal range of motion without causing discomfort to the patient. When spastic muscle contractions occur, the nurse should stop the exercises and apply continuous but gentle pressure on the affected part of the muscle group until it relaxes. Once the contractions wean down, the exercises may be resumed but with a steadier and slower movement. Vigorous massage in the area may worsen the contractions. Notifying the physician is not an immediate need unless nursing interventions have proven to be ineffective in relieving the contractions. Asking the client to stand walk rapidly around the room is an inappropriate measure. Had the client been able to walk, ROM exercises are probably unnecessary.

A client with borderline personality disorder rushes into marriage following a breakup with her boyfriend. Her behavior reflects which defense mechanism? 1. Substitution 2. Depression 3. Denial 4. Undoing

Substitution Rationale: Substitution involves replacement of an unacceptable need, attitude, or emotion with one that is more acceptable.

The nurse is performing routine tracheostomy care. The following would be appropriate for the nurse to include in the performance of the procedure, except: 1. Securing the tracheostomy ties with a square knot 2. Suctioning the inner cannula after completion of the procedure 3. Performing tracheostomy care every 8 hours 4. Using precut tracheostomy dressings under the neck plate to protect the skin surrounding the stoma

Suctioning the inner cannula after completion of the procedure Rationale: The inner cannula should be suctioned before cleansing, not afterward.

The nurse is assessing the newborn for signs of increased intracranial pressure. The following may be observed, except: 1. High pitched shill cry 2. Flaccidity 3. Poor sucking 4. Sunken fontanels

Sunken fontanels Rationale: In the neonate, the fontanels will bulge and become firm in the presence of increased intracranial pressure. A sunken fontanel is related to possibility of fluid volume deficit or hypovolemia.

A nurse is caring for a client who is suffering from second- and third-degree burns over 50% of his body. The nurse should be aware that the client may develop hypovolemic shock during burn management. Which of the following are early manifestations of hypovolemic shock? Select all that apply. 1. Tachycardia 2. Cold and clammy skin 3. Decreased urine output 4. Bradycardia 5. Hyperactive bowels sounds 6. Polyuria 7. Hypoactive bowel sounds

Tachycardia Cold and clammy skin Decreased urine output Hypoactive bowel sounds Rationale: Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. The body shunts blood from organs such as the skin, kidney, and GI tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the patient's skin is cold and clammy, bowel sounds are hypoactive, and urine output decreases.

A 65-year-old diabetic male client has an A-V fistula. The following are important nursing considerations in taking care of this client, except: 1. Auscultate for a bruit 2. Palpate for a thrill 3. Monitor for infection at the insertion site 4. Take blood pressures only on the arm with the fistula

Take blood pressures only on the arm with the fistula Rationale: Blood pressure should never be taken on the arm with AV fistula.

The client is scheduled for lower abdominal surgery. As the nurse administers a tapwater enema prior to the procedure, the client begins to complain of abdominal cramping. Which of the following actions should the nurse implement first? 1. Tell the client to relax, and continue infusing the enema 2. Stop infusing the enema, and allow the client to evacuate the fluid 3. Temporarily stop the infusion until the cramping subsides 4. Turn the client onto the other side, and continue infusing the enema

Temporarily stop the infusion until the cramping subsides Rationale: When the client initially begins to complain of abdominal cramping during an enema, it is usually most appropriate to temporarily stop the infusion until the cramping subsides. If on resuming the flow of enema fluid the client continues to complain of cramping or inability to retain further fluid, the nurse should discontinue the enema.

The patient admitted to the Medical-Surgical Department has a history of Myasthenia Gravis. Which of the following diagnostic tests should the nurse note with the doctor's advise? Select all that apply. 1. Tensilon Test 2. Nerve conduction studies 3. Lumbar tap 4. Electroencephalogram 5. EMG

Tensilon Test, Nerve conduction studies , and EMG Rationale: Myasthenia Gravis produces weakness and abnormal fatigue in skeletal muscles. The Tensilon test confirms the diagnosis by temporarily improving muscle function after an IV injection of edrophonium or neostigmine. Nerve conduction studies test for receptor antibodies. Lumbar puncture is a test used to diagnose multiple sclerosis, meningitis etc. An EEG is a test used to diagnose multiple sclerosis, a result of progressive demyelination of the white matter of the brain and spinal cord. Electromyography helps differentiate nerve disorders from muscle disorders.

The nurse is caring for a client who is prescribed a subcutaneous administration of medication. Which of the following factors would be the most important consideration in selecting the needle length to use for the subcutaneous injection of the drug? 1. The diameter of the needle 2. The amount of medication to be administered 3. The amount of adipose tissue at the administration site 4. The viscosity of the solution to be injected

The amount of adipose tissue at the administration site Rationale:The amount of adipose tissue at the administration site is the most important factor to consider in selecting the needle length to use for the subcutaneous injection of the drug.

The wife of a 40-year-old male client with schizophrenia questions the nurse about the cause of her husband's disorder. Which response by the nurse is most accurate? 1. The disorder is thought to result from altered dopamine transmission in the brain. 2. The disorder is thought to result from disturbed family relations 3. The disorder is thought to result from brain alterations in the frontal lobe. 4. The disorder is thought to result from a combination of biologic, genetic, and psychosocial factors.

The disorder is thought to result from a combination of biologic, genetic, and psychosocial factors. Rationale: As with many psychiatric disorders, a combination of factors contributes to the cause of schizophrenia.

Which factor is least important in the decision regarding whether a victim of family violence can safely remain in the home? 1. The availability of appropriate community shelters 2. The non-abusing caretaker's ability to intervene on the client's behalf 3. The client's possible response to relocation 4. The family's socioeconomic status

The family's socioeconomic status Rationale: Socioeconomic status is not a reliable predictor of abuse in the home, so it would be least important consideration in deciding issues of safety for the victim of family violence.

Select all the information the nurse manager should include when developing an educational session for her nursing staff regarding informed consent components. 1. Refusing a treatment or procedure is prohibited once they are already initiated. 2. All the information about treatment and procedures are the nurse's obligation to provide. This includes complications and risks that are involved. 3. If the client has questions about the treatment or procedure, the nurse is still the main person expected to obtain the signature on an informed consent form. 4. The nurse is obligated to inform the client about possible outcomes if a treatment or procedure is refused. 5. Documentation on the informed consent form is imperative. It is important to include the name/s of the persons performing the treatment or procedure. 6. Discomforts that are to be expected, possible complications that may arise and associated risks of the treatment or procedure are to be explained to the client.

The nurse is obligated to inform the client about possible outcomes if a treatment or procedure is refused, Documentation on the informed consent form is imperative. It is important to include the name/s of the persons performing the treatment or procedure, Discomforts that are to be expected, possible complications that may arise and associated risks of the treatment or procedure are to be explained to the client. Rationale: The principle of informed consent is entrenched in common law and nursing standards. Informed consent is granted permission in the knowledge of the possible risks, benefits, and consequences. It is the physician's responsibility to obtain consent by providing necessary and relevant information regarding the treatment or procedure. Nurses are expected to secure the signature on the form once the physician has communicated the information and it has been established that the client understands fully the facts laid out. Informed consent requires the following factors:(1) A complete explanation of the treatment or procedure to be performed.(2) Name/s of persons performing and assisting in the treatment or procedure.(3) Discomforts associated with the procedure, as well as complications and risks.(4) A consequence of treatment refusal even after it has started.(5) Alternative therapies may be substituted for the proposed treatment or procedure.

A female patient has a Hemoglobin level of 10.8 and Hematocrit level of 30%. She is being prepared for blood transfusion. Which is correct regarding blood transfusion procedures? 1. Monitor the patient for 1 hour after starting the transfusion. 2. The procedure is done until 2 hours. 3. The transfusion should be started within 30 minutes from the blood bank. 4. Half normal saline solution is the only solution used for blood transfusion.

The transfusion should be started within 30 minutes from the blood bank. Rationale: The transfusion should be started within 20-30 minutes of removing the blood or blood components from the blood bank.Staying with the patient at least 15 minutes after the start of the transfusion is required. The transfusion needs to be completed within 4 hours,not 2 hours. The only solution that should be added to blood or blood components is 0.9% sodium chloride (Normal saline solution).

When assessing a 5-year-old child brought by his mother to the clinic for a routine checkup, which of the following would the nurse expect the child to be able to do? 1. Ride a tricycle 2. Tie his shoe laces 3. Kick a ball forward 4. Use blunt scissors

Tie his shoe laces Rationale: Tying shoe-laces is a behavior to be expected of a 5-year-old. A 2-year-old usually can kick a ball forward. Riding a tricycle is characteristic of a 3-year-old. Using blunt scissors is characteristic of a 3-year-old.

The nurse is teaching a client with COPD how to do pursed-lip breathing. The primary reason for clients with COPD to use pursed-lip breathing is: 1. To increase dyspnea 2. To increase oxygenation 3. To prolong exhalation 4. To prevent respiratory infection

To prolong exhalation Rationale: The primary reason for instructing clients with COPD how to pursed-lip to breathe is to prolong exhalation. Prolonging exhalation helps to prevent bronchiolar collapse and the trapping of air.

The nurse instructs the client receiving chemotherapy to avoid which of the following to reduce the risks associated with thrombocytopenia? 1. Being near individuals with upper respiratory infection 2. Keeping fresh flowers and plants in the home. 3. Shaving with an electric razor. 4. Trimming nails with a nail clipper.

Trimming nails with a nail clipper. Rationale: A client with thrombocytopenia should avoid activities that could result in injury and bleeding. For this reason, the client should avoid trimming the nails with a nail clipper and should use a nail file instead.

An adolescent male client is having a tonic-clonic/Grandmal Seizure. Which of the following should the nurse do FIRST? 1. Assess breathing 2. Turn the client's head to the side 3. Insert a tongue depressor in the client's mouth 4. Restrain the client.

Turn the client's head to the side Rationale: In the neonate, the fontanels will bulge and become firm in the presence of increased intracranial pressure.

A client with peritonitis has a Salem sump that is connected to low suction. Nursing plan for this client should include? 1. Irrigating the nasogastric tube with sterile water through the blue opening 2. Measuring nasogastric drainage daily 3. Turning the client from side to side every 4 hours 4. Increasing the suction control to high if no drainage appears

Turning the client from side to side every 4 hours Rationale: Turning the client will aid suctioning. For the nasogastric tube to be effective, the blue opening should remain open and clear of solution or secretions. Drainage is measured every 8 hours. Increasing the suction control to high may cause gastric mucosal damage.

In reviewing the client's chart, the nurse notes that the client has a diagnosis of borderline personality disorder. Which behaviors would the nurse anticipate in this client? 1. Grandiose thinking, over-acting behavior 2. Lack of self-confidence, clingy 3. Odd ideas and mannerisms 4. Unstable moods and impulsive behaviors

Unstable moods and impulsive behaviors Rationale: The client with borderline personality disorder typically demonstrates unstable moods and impulsive behaviors.

The nurse administering oral care on a client with thrombocytopenia. Which of the following is the most appropriate for this client? 1. Limiting floss to once a day. 2. Use an alcohol-based mouthwash to prevent infection. 3. Use swabs to administer oral care. 4. Encourage tooth brushing at least once a shift.

Use swabs to administer oral care. Rationale: Clients with thrombocytopenia should be protected from injury that will result in bleeding. An oral swab is least likely to cause tissue injury to the oral cavity during the performance of oral care.

Abruptio placenta manifests with which of the following symptoms? Select all that apply. 1. Painless vaginal bleeding 2. Uterine tenderness 3. Strong and regular contractions 4. Non-reassuring fetal heart patterns 5. Uterine irritability 6. Abdominal pain radiating to the lower back

Uterine tenderness Non-reassuring fetal heart patterns , Uterine irritability , Abdominal pain radiating to the lower back Rationale: Abruptio placenta is the premature separation of the normally implanted placenta from the uterus before the fetus is born. It occurs when there are bleeding and formation of a hematoma on the maternal side of the placenta. This typically presents with painful vaginal bleeding, aching and dull abdominal pain radiating to the lower back, uterine irritability with frequent low-intensity contractions, uterine tenderness, and a high uterine resting tone identified by the use of an intrauterine pressure catheter. Nonreassuring fetal heart rate patterns, hypovolemic signs, and fetal death are also additional signs of abruption placenta.

A confused client in a skilled nursing facility is found lying on the bathroom floor on his own pool of urine. The client is taken care of and the nurse in charge of the client is completing an incident report. Which of the following statements written by the nurse are correct to include in an incident report: 1. Vital signs: blood pressure 122/76; pulse 69 bpm and regular; respirations 14 cpm and regular; temperature 98.8 °F. 2. A bleeding wound approximately 7 cm in diameter is noted on the patient's left hip. 3. The client ambulated to the washroom to urinate yet wasn't able to reach the toilet before urinating. 4. The client is oriented to person but not to place and time. He verbalized, "I do not remember what I was doing in the bathroom." 5. Seeing that both the side rails are up when the client was in the bathroom, it was obvious that the client climbed over the side rails. 6. The physician was alerted immediately of the situation and was told that the client was confused and was found on the bathroom floor.

Vital signs: blood pressure 122/76; pulse 69 bpm and regular; respirations 14 CPM and regular; temperature 98.8 °F, A bleeding wound approximately 7 cm in diameter is noted on the patient's left hip, The client is oriented to person but not to place and time. He verbalized, "I do not remember what I was doing in the bathroom.", The physician was alerted immediately of the situation and was told that the client was confused and was found on the bathroom floor. Rationale: In accord with the agency's policies, nurses are required to file incident reports when a situation arises that could or did cause client harm. When filing an incident report, the nurse should state only the facts surrounding the incident. The nurse should only describe the event and record the date, time, location, factual findings, actions taken and people involved in the incident. The nurse's opinions of conclusions about the incident are not to be documented. Since the client is already found lying on the bathroom floor, the nurse did not witness the client climbing over the side rails and ambulating to the washroom; therefore, these statements should not be included in the incident report.

The patient has been diagnosed with Hepatitis B. Which of the following is appropriate care? 1. Use HEPA Filter mask for airborne contamination. 2. Wear gloves and gown when handling client secretions and specimens. 3. Wear surgical mask. 4. Provide a negative pressure room for the client.

Wear gloves and gown when handling client secretions and specimens. Rationale: Chronic hepatitis B carriers should follow standard hygienic practices to ensure that close contacts are not directly contaminated by his or her blood or other body fluids. The best nursing care for this client involves earing of gloves and gown when handling patient's secretions or fluids.

A 86-year-old woman is diagnosed with a cerebrovascular accident of the left cerebral hemisphere. During the nursing assessment, the client speaks in a rambling manner and is unable to repeat words spoken to her. The area of the brain that is most likely affected is the? 1. Wernicke's area 2. Brodmann's area 3. Broca's area 4. Precentral gyrus

Wernicke's area Rationale: The client is displaying signs of Receptive aphasia, This is caused by damage to the Wernicke's aphasia. Receptive aphasia is the inability to comprehend written and spoken words. In this type of aphasia, the client has fluent speech however it is rapid, can be rambling and not making any sense. They are also unable to repeat words and phrases and have difficulty following instructions because they can't understand it.

The nurse, who has several primary concerns in caring for the client with pericarditis, must be alert to the possibility of cardiac tamponade. Nursing assessment skills are key to anticipating and identifying symptoms of cardiac tamponade, which include the following, except: 1. Falling arterial pressure 2. Rising venous pressure 3. Distant heart sounds 4. Widening pulse pressure

Widening pulse pressure Rationale: One of the objectives of management for clients with pericarditis is being alert for cardiac tamponade, which is a life-threatening condition. The signs and symptoms of cardiac tamponade begin with falling arterial pressure. Usually, the systolic pressure falls while the diastolic pressure remains stable; hence, the pulse pressure narrows. Heart sounds may progress from being distant to being imperceptible. Neck vein distention and other signs of rising central venous pressure are observed.

The nurse is caring for a post-operative pediatric client complaining of nausea. Compazine 2.5 mg suppository per rectum was ordered by the physician. Available stock of Compazine is 5mg/suppository. How much should the nurse give? 1. 1/2 suppository 2. 1 suppository 3. 1 1/2 suppository 4. 2 suppositories

½ suppository Rationale: Ratio and proportion 5 mg : 1 supp :: 2.5 mg : xx = 0.5 or ½ suppository