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Mental Health The nurse is developing a plan of care for a client who believes the unit's food is being poisoned. Which strategy should the nurse plan to implement that will encourage the client to discuss feelings? 1.) Use open-ended questions and silence 2.) Encourage the client's family to bring in food 3.) Focus on the fact that the client's beliefs are untrue 4.) Instruct the client about the need for adequate nutrition
Answer: 1 Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their feelings. None of the remaining options attempt to encourage communication with the client.
Adult Health The nurse is preparing to care for a client receiving peritoneal dialysis. Which should be included in the nursing plan of care to prevent the major complication associated with peritoneal dialysis? 1.) Maintain strict aseptic technique 2.) Add heparin to the dialysate solution 3.) Change the catheter site dressing daily 4.) Monitor the client's level of consciousness
Answer: 1 Rationale: The major complication of peritoneal dialysis is peritonitis. Strict aseptic technique is required in caring for the client receiving this treatment. Although changing the catheter site dressing daily may assist in preventing infection, this option relates to an external site. Adding heparin to the dialysate solution and monitoring the client's level of consciousness are unrelated to the major complication of peritoneal dialysis.
Pharmacology math The provider orders fluid maintenance at a rate of 10 mL/kg/hr. The client weighs 145 lbs. How many mL per minute will the client be receiving? 1.) 11 mL/minute 2.) 10 mL/hour 3.) 659 mL/hour 4.) 65.9 ml/minute
Answer: 1 Since there are 2.2 kg in a pound, 145 lbs/2 = 65.9 kg. 10 mL per 65.9 kg is 659 mL per hour. Since there are 60 minutes in an hour, 659/60 = 10.98 mL per minute. Round to the nearest tenth to get the answer, which is 11 mL per minute.
Maternity The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply. 1.) "The ductus arteriosus allows blood to bypass the fetal lungs." 2.) "One vein carries oxygenated blood from the placenta to the fetus. 3.) "The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy." 4.) "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 5.) "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."
Answer: 1, 2, 4 Rationale: The ductus arteriosus is a unique fetal circulation structure that allows the nonfunctioning lungs to receive only a minimal amount of oxygenated blood for tissue maintenance. Oxygenated blood is transported to the fetus by one umbilical vein. The normal fetal heart tone range is considered to be 110 to 160 beats per minute. Arteries carry deoxygenated blood and waste products from the fetus, and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries.
Maternity A pregnant woman tests positive for the hepatitis B virus (HBV). The woman asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which response by the nurse is most appropriate? 1.) "Breast-feeding can start 6 months after delivery" 2.) "Breast-feeding is allowed after the baby has been vaccinated with immune globulin" 3.) "Breast-feeding is not advised, and you should seriously consider bottle-feeding the baby" 4.) "Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery"
Answer: 2 Rationale: Although HBV is transmitted in breast milk, after scheduled newborn vaccines and immune globulin have been administered to the newborn, the woman may breast-feed without risk to the newborn. The remaining options are incorrect responses.
Mental Health A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? 1.) "Do you think that having asthma will kill you?" 2.) "You seem very distressed over learning you have asthma." 3.) "Asthma is a treatable condition when medications are taken properly, so let's practice with your inhalant." 4.) "It will be difficult to work with you if you can't view this a challenge rather than 'a nail in your coffin'."
Answer: 2 Rationale: Clients who have learned that they have a chronic illness may exhibit denial, anger, or sarcasm because of fear associated with the chronic illness. It is important for the nurse to convey an accepting attitude to enhance mutual respect and trust. Eliminate options that are sarcastic or punitive. The only correct option is the one that respectfully addresses the concern presented by the client.
Pharmacology What is the most important thing for the nurse to teach a patient who is switching allergy medications from diphenhydramine to loratadine? 1.) Loratadine can potentially cause dysrhythmias 2.) Loratadine has fewer sedative effects 3.) Loratadine has increased bronchodilating effects 4.) Loratadine causes less gastrointestinal upset
Answer: 2 Rationale: Loratadine does not affect the central nervous system and therefore is non-sedating. There is insufficient evidence to indicate that loratadine can cause dysrhythmias, can act as a bronchodilator, or cause gastrointestinal upset than other comparable medications.
Pharmacology A patient complains of worsening nasal congestion despite the use of oxymetazoline nasal spray every 2 h. What is the nurse's most appropriate response? 1.) "Oxymetazoline is not an effective nasal decongestant" 2.) "Overuse of nasal decongestants results in rebound congestion" 3.) "You are probably displaying an unexpected reaction to oxymetazoline" 4.) "Oxymetazoline should be administered every hour for severe congestion"
Answer: 2 Rationale: Oxymetazoline is an effective nasal decongestant, but overuse results in worsening or "rebound" congestion. It should not be used more than every 4 h. To avoid future rebound congestion with nasal sprays, it is recommended that they be used for no more than 3-5 days.
Fundamentals A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? 1.) Adding a dose of heparin sodium 2.) Holding the next dose of warfarin 3.) Increasing the next dose of warfarin 4.) Administering the next dose of warfarin
Answer: 2 Rationale: The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). The normal INR is 2 to 3 for standard warfarin therapy, which is used for the treatment of atrial fibrillation, and 3 to 4.5 for high-dose warfarin therapy, which is used for clients with mechanical heart valves. A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the values of 35 seconds and 3.5 are high, the nurse should anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect.
Pharmacology math A nurse receives an order to administer norepinephrine IV to a client at a rate of 30 mL/hr. The nurse receives the medication in a 500 mL bag of D5W that contains 40 mg of the drug. How many mcg/min will the client receive? 1.) 80 mcg/min 2.) 40 mcg/min 3.) 20 mcg/min 4.) 60 mcg/min
Answer: 2 To calculate this result, the nurse should first calculate the amount of mg/hour. To do this, the nurse takes the rate and divides it by the volume in the bag:30 mL/hr divided by 500 mL = 0.06 hr/mlThis is then multiplied by the dose available:0.06 x 40 mg (in the bag) = 2.4 mg/hrThe dose is then converted from mg/hr to mcg/min:2.4 mg/hr divided by 60 minutes = 0.04 x 1000 = 40 mcg/min
Pediatrics The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? 1.) Enteric 2.) Contact 3.) Droplet 4.) Neutropenic
Answer: 3 Rationale: A major priority in nursing care for a child with suspected meningitis is to administer the appropriate antibiotic as soon as it is prescribed. The child will be placed in a private room, with droplet transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when the client has a low neutrophil count.
Management, Prioritization and Delegation Which person is displaying behaviors that most strongly suggest the need for additional screening for possible substance abuse? 1.) Person with cancer progressively needs more pain medication to achieve relief 2.) College student reports occasionally smoking marijuana during semester break 3.) Stay-at-home mom reports drinking while her kids are in school and after they go to bed 4.) Person with a fractured leg reports taking opioids and tapering off when pain subsides
Answer: 3 Rationale: A woman who is drinking when her children are out of sight is displaying substance use that is not based on medical needs or social norms. The college student is using an illegal substance, but at this point, the frequency does not suggest that it is a compulsive problem. Person with cancer and person with a fracture are using medications for pain as indicated.
Management, Prioritization and Delegation A patient is displaying muscle spasms of the tongue, face, and neck, and his eyes are locked in an upward gaze. He has been prescribed haloperidol. What is the priority action by the nurse? 1.) Maintain eye contact and stay with him until the spasms pass 2.) Place the patient on aspiration precautions until the spasms subside 3.) Obtain an order for intramuscular or IV diphenhydramine 4.) Obtain an order for and administer an antiseizure medication
Answer: 3 Rationale: IV administration of diphenhydramine will rapidly alleviate the symptoms. The patient is experiencing medication side effects. This condition is frightening and uncomfortable for the patient, but it is not usually harmful. Swallow precautions will not harm the patient, but waiting for the spasms to pass delays the most appropriate intervention.
Fundamentals The nurse is reviewing the client's results of preadmission laboratory studies for a complete blood count, electrolytes, coagulation studies, and creatinine before a surgical procedure. Which laboratory result should the nurse report immediately to the surgeon? 1.) Platelet count 210,000 mm3 2.) Serum creatinine level 0.8 mg/dL 3.) Hemoglobin level 8.9 g/dL 4.) Serum sodium level 141 mEq/L
Answer: 3 Rationale: Routine screening tests include a complete blood count, coagulation studies, and serum electrolyte and creatinine levels. The complete blood count includes the Hgb analysis. All of these values are within normal range except for the Hgb level. If a client has a low Hgb level, the surgery could likely be postponed by the surgeon.
Pediatrics The nurse caring for a child who has sustained a head injury in an automobile crash is monitoring the child for signs of increased intracranial pressure (ICP). For which early sign of increased ICP should the nurse monitor? 1.) Increased systolic blood pressure 2.) Abnormal posturing of extremities 3.) Significant widening pulse pressure 4.) Change in level of consciousness
Answer: 4 Rationale: An altered level of consciousness is an early sign of increased intracranial pressure (ICP). Late signs of increased ICP include tachycardia leading to bradycardia, apnea, systolic hypertension, widening pulse pressure, and posturing.
Adult Health The spouse of a client with acute kidney injury secondary to heart failure asks the nurse how a heart problem can affect the kidneys. The nurse should formulate a response using what fact about the kidneys? 1.) The kidneys get fatigued from having to filter too much fluid 2.) The kidneys can react adversely to moderate doses of furosemide 3.) The kidneys will shut down easily if serum levels of digoxin are high 4.) The kidneys generally require and receive about 20% to 25% of the resting cardiac output
Answer: 4 Rationale: Heart failure is referred to as a prerenal cause of acute kidney injury because heart failure results in decreased blood flow to the kidneys. The kidneys normally receive about 20% to 25% of the cardiac output and require adequate perfusion to function properly. With a significant or prolonged decrease in blood supply, the kidneys can fail. Options 1 and 3 are incorrect. As for option 2, large doses of furosemide resulting in severe dehydration may lead to decreased kidney perfusion, but moderate doses of furosemide do not cause prerenal acute kidney injury, and furosemide may be used to treat acute kidney injury.