AHHHHHHHHHHHH

At which point during the physical examination should a child with asthma be assessed for the presence or absence of intercostal retractions? A. Inspiration B. Coughing C. Apneic episodes D. Expiration

Inspiration Intercostal retractions result from respiratory effort to draw air into restricted airways. The retractions will not be noticeable when air is expelled from the lungs, such as when the client is coughing or expiring. During apnea, the client is not attempting to draw air into the airways. Apnea indicates that the respiratory effort is absent.

The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? A. Potassium level, 3.9 mEq/dL B. Creatinine level, 1.1 mg/dL C. Sodium level, 125 mEq/L D. Calcium level, 9 mg/dL

Sodium level, 125 mEq/L The normal serum sodium level is 135 to 145 mEq/L. This value indicates hyponatremia. Symptoms of hyponatremia include nausea and vomiting, headache, confusion, and seizures, which can be severe and need immediate attention. Options A, B, and D are all within normal parameters.

The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.) A. 0.2 mL B. 0.8 mL C. 1.25 mL D. 2.0 mL

(1 mL × 4 mg)/5 mg = 0.8 mL

Which behavior indicates to the nurse that a client with paranoid ideas is improving? A. Arrives on time for all activities B. Talks more openly about plans to protect his possessions C. Aggressively uses the punching bag in the gym D. Discusses his feelings of anxiety with the nurse

Discusses his feelings of anxiety with the nurse Anxious feelings increase paranoid ideation. If the client is able to discuss these feelings, then the client is improving because of fewer paranoid ideas. Option A would indicate that a client with depression or one who is passive-aggressive is improving. Option B indicates feelings of paranoia. Option C indicates the release of anger, and "anger turned inward" is sometimes used as a definition for depression.

The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up? A. Urine specific gravity of 1.03 B. Frothy, tea-colored urine C. Clay-colored stools D. Elevated serum amylase and lipase levels

Elevated serum amylase and lipase levels Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels indicate pancreatic injury. Option A is a normal finding. Options B and C are expected findings related to jaundice.

A 4-year-old child has cystic fibrosis. Which stage of Erikson theory of psychosocial development is the nurse addressing when teaching inhalation therapy? A. Autonomy B. Industry C. Trust D. Initiative

Initiative Children 4 to 5 years of age are in the "Initiative vs. Guilt" stage of Erikson theory of psychosocial development. They enjoy being active and participating in role playing. "Autonomy vs. Shame and Doubt" occurs at 1 to 3 years of age. "Industry vs. Inferiority" occurs at 6 to 11 years; "Trust vs. Mistrust" occurs from birth to 1 year of age.

The health care provider prescribes carbamazepine for a child whose tonic-clonic seizures have been poorly controlled. The nurse informs the mother that the child must have blood tests every week. The mother asks why so many blood tests are necessary. Which complication is assessed through frequent laboratory testing that the nurse should explain to this mother? A. Nephrotoxicity B. Ototoxicity C. Myelosuppression D. Hepatotoxicity

Myelosuppression Myelosuppression is the highest priority complication that can potentially affect clients managed with carbamazepine therapy. The client requires close monitoring for this condition by weekly laboratory testing. Hepatic function may be altered, but this complication does not have as great a potential for occurrence as option C. Options A and B are not typical complications of carbamazepine therapy.

The nurse walks into the room and observes the client experiencing a tonic-clonic seizure. Which intervention should the nurse implement first? A. Restrain the client to protect from injury. B. Flex the neck to ensure stabilization. C. Use a tongue blade to open the airway. D. Turn client on the side to aid ventilation.

Turn client on the side to aid ventilation. Maintaining the airway during a seizure is the priority for safety. Options A, B, and C are contraindicated during a seizure and may cause further injury to the client.

A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows that he is not. Which response is best for the nurse to make? A. "Did you really believe you were Jesus Christ?" B. "I think you're getting well." C. "Others have had similar thoughts when under stress." D. "Why did you think you were Jesus Christ?"

"Others have had similar thoughts when under stress." Option C offers support by assuring the client that others have experienced similar situations. Option A is belittling. Option B is making an inappropriate judgment. You may have narrowed your choices to options C and D. However, you should eliminate option D because it is a "why" question, and the client does not know why.

Zolpidem tartrate, 1.75 mg PRN at bedtime, is prescribed for rest. The scored tablets are labeled 3.5 mg per tablet. How many tablets should the nurse plan to administer? A. ½ tablet B. 1 tablet C. 1½ tablets D. 2 tablets

1.75 is ordered. 3.5 is available. 1.75/3.5 time one tab equlas 05. Or one half tablet. Options B, C, and D are incorrect.

The nurse prepares to administer amoxicillin clavulanate potassium (Augmentin) to a child weighing 15 kg. The prescription is for 15 mg/kg every 12 hours by mouth. How many milliliters should the nurse administer when supplied as below? A. 0.5 mL B. 0.5 mL C. 5 mL D. 9 mL

15 mg/kg × 15 kg = 225 mg to be administered Supply = 125 mg/5 mL (5 mL/125 mg) × 225 mg = 9 mL or (225 mg/125 mg) × 5 mL = *9 mL*

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate? A. "Weigh the baby daily, and if she is gaining weight, she is getting enough to eat." B. "Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." C. "Offer the baby extra bottled milk after her feeding and see if she still seems hungry." D. "If you're concerned, you might consider bottle feeding so that you can monitor intake."

"Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of adequate nutrition, most home scales do not measure this accurately, and the suggestion will likely make the mother anxious. Option C causes nipple confusion and diminishes the mother's milk production. Option D does not address the client's question.

Amoxicillin, 500 mg PO every 8 hours, is prescribed for a client with an infection. The drug is available in a suspension of 125 mg/5 mL. How many milliliters should the nurse administer with each dose? A. 10 B. 15 C. 20 D. 25

500 mg/x mL = 125 mg/5 mL 125x = 2500 x = 20 mL

A 12-year-old boy complains to the nurse that he is "short" (4′5″ [53 inches]). His twin sister is 5 inches taller than he is (4′10″ [58 inches]). Based on these findings, what conclusion should the nurse reach? A. The boy is not growing as normally expected. B. The girl is experiencing a period of unexpected growth. C. A normal growth spurt occurs in girls 1 to 2 years earlier than boys. D. Male-female twins are not identical; therefore, their growth cannot be compared.

A normal growth spurt occurs in girls 1 to 2 years earlier than boys. Girls experience a growth spurt at 9.5 to 14.5 years of age and boys at 10.5 to 16 years of age. There are insufficient data to support; growth trends must be assessed to reach such a conclusion. Option B is not unexpected. The fact that the children are twins has less to do with their growth than the fact that they are male and female.

The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding warrants immediate intervention by the nurse? A. A unilateral pupil that is dilated and nonreactive to light B. Client cries out when awakened by a verbal stimulus C. Client demonstrates a loss of memory of the events leading up to the injury D. Onset of nausea, headache, and vertigo

A unilateral pupil that is dilated and nonreactive to light Any change in pupil size and reactivity is an indication of increasing intracranial pressure and should be reported to the health care provider immediately. Option B is a normal response to being awakened. Options C and D are common manifestations of head injury and are of less immediacy than option A.

Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical treat-ments for dehydration in a 36-month-old child? (Select all that apply.) A. Record wet diapers. B. Assess for sunken fontanels C. Examine skin turgor. D. Observe mucous membranes. E. Record dietary intake

A. Record wet diapers. C. Examine skin turgor. D. Observe mucous membranes. E. Record dietary intake All these interventions can be used to evaluate fluid status in children and are helpful assessment functions (A, C, D, E), but the age of the child makes a fontanel check impractical (B). The posterior fontanel closes at 2 months and the anterior fontanel closes at 18 months of age.

The health care provider prescribes ipratropium for a client. An allergic reaction to which other medication would cause the nurse to question the prescription for? A. Albuterol B. Theophylline C. Metaproterenol D. Atropine sulfate

Atropine sulfate Clients who have experienced allergic reactions to atropine sulfate and belladonna alkaloids may also be allergic to ipratropium, so the prescription for Atrovent should be questioned. Allergies to options A, B, and C would not cause the nurse to question a prescription for ipratropium.

A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide? A. Avoid using the breast pump. B. Breastfeed the infant every 2 hours. C. Reduce fluid intake for 24 hours. D. Skip feedings to let the sore breasts rest

Breastfeed the infant every 2 hours. The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. If the infant does not feed adequately and empty the breast, using a breast pump helps extract the milk and relieve some of the discomfort. Dehydration irritates swollen breast tissue. Skipping feedings may cause further engorgement and discomfort.

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad B. Broiled fish, green beans, and an apple C. Pork chops, macaroni and cheese, and grapes D. Avocado salad, milk, and angel food cake

Broiled fish, green beans, and an apple Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as option B. Option A is a high-protein diet, and options C and D contain high-fat foods, which are contraindicated for this client.

A 26-year-old primigravida client is experiencing increasing discomfort and anxiety during the active phase of labor. She requests something for pain. Which analgesic should the nurse anticipate administering? A. Butorphanol B. Hydromorphone C. Morphine sulfate D. Codeine sulfate

Butorphanol is a mixed agonist-antagonist analgesic resulting in good analgesia but with less respiratory depression, nausea, and vomiting compared with opioid agonist analgesics.

Following the administration of sublingual nitroglycerin, which assessment finding indicates that the medication was effective? A. Decrease in level of chest pain B. Clear bilateral breath sounds C.Increase in blood pressure D. Increase in urinary output

Decrease in level of chest pain Nitroglycerin reduces myocardial oxygen consumption, which decreases ischemia and reduces chest pain. Options B, C, and D are not expected outcomes of sublingual nitroglycerin.

The nurse is caring for a client who is experiencing severe pain. The expected outcome the nurse writes for the client reads, "The client will state my pain is <2 within 45 minutes after pain medication has been administered." Formulating the expected outcome is an example of which step in the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

Planning Planning allows the nurse to set goals for care and elicit the expected outcome by identifying appropriate nursing actions. Assessment, implementation, and evaluation are part of the care for the client but are not the appropriate actions for formulating the expected outcome.

The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal? A. Psychomotor agitation B. Restlessness and hyperactivity C. Detachment from reality and drowsiness D. Distorted perceptions and hallucinations

Psychomotor agitation During cocaine withdrawal, the nurse should expect option A and a pattern of withdrawal symptoms similar to those of one who uses amphetamines. Options B, C, and D are signs and symptoms of a person who is high on cocaine rather than one who is experiencing withdrawal from cocaine.

Which data obtained during a respiratory assessment for a 78-year-old client is most important to report to the primary health care provider? A. Auscultation of vesicular breath sounds B. Pulse oximetry reading of 89% C. Arterial PaO2 of 86% D. Resonance on percussion of the lungs

Pulse oximetry reading of 89% An oxygen saturation lower than 90% indicates hypoxia. Options A, C, and D are all normal findings.

The nurse is preparing to administer amphotericin B IV to a client. What laboratory data is most important for the nurse to assess before initiating an IV infusion of this medication? A. Serum potassium level B. Platelet count C. Serum creatinine level D. Hemoglobin level

Serum potassium level The nurse should obtain baseline potassium levels prior to beginning drug therapy because amphotericin B changes cellular permeability, allowing potassium to escape from the cell, which could lead to a decrease in the serum potassium level and severe hypokalemia. Options B, C, and D are helpful laboratory values, but they do not have the importance of option A in determining if amphotericin B can be administered safely via IV infusion.

Which vital sign in a pediatric client is most important to report to the primary health care provider? A. Newborn with a heart rate of 140 beats/min B. Three-year-old with a respiratory rate of 28 breaths/min C. Six-year-old with a heart rate of 130 beats/min D. Twelve-year-old with a respiratory rate of 16 breaths/min

Six-year-old with a heart rate of 130 beats/min The normal heart rate for a 6- to 10-year-old is 70 to 110 beats/min. Options A, B, and D are all within normal range for those ages.

The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A. Stay with the client while the client is standing. B. Record the findings on the graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm. D. Record changes in the client's pulse rate.

Stay with the client while the client is standing. Although all these measures are important, option A is most important because it helps ensure client safety. Option B is necessary but does not have the priority of option A. Options C and D are important measures to ensure accuracy of the recording but are of less importance than providing client safety.

What is the most important nursing priority for a client who has been admitted for a possible kidney stone? A. Reducing dairy products in the diet B. Straining all urine C. Measuring intake and output D. Increasing fluid intake

Straining all urine Straining all urine is the most important nursing action to take in this case. Encouraging fluid intake is important for any client who may have a kidney stone, but it is even more important to strain all urine. Straining urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery. Option C is not the highest priority action. Option A is usually not recommended until the stone is obtained and the content of the stone is determined. Even then, dietary restrictions are controversial.

A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first? A. Support the client to a sitting position. B. Ask the client to walk slowly back to the room. C. Administer a sublingual nitroglycerin tablet. D. Provide oxygen via nasal cannula.

Support the client to a sitting position. The nurse should safely assist the client to a resting position and then perform options C and D. The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher.

In caring for a client with acute diverticulitis, which assessment data warrants immediate nursing intervention? A. The client has a rigid hard abdomen and elevated WBC. B. The client has left lower quadrant pain and an elevated temperature. C. The client is refusing to eat any of the meal and is complaining of nausea. D. The client has not had a bowel movement in 2 days and has a soft abdomen.

The client has a rigid hard abdomen and elevated WBC. A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is a medical emergency and should be reported to the health care provider immediately. Options B and C are expected clinical manifestations of diverticulitis. Option D does not warrant immediate intervention.

When assessing safety for the older adult, which of the following is of highest priority to the nurse? A. The client has a cataract in the right eye. B. The client is not married and lives alone. C. The client lives in a two-story building. D. The client reports a history of repeated falls.

The client reports a history of repeated falls. Risk assessment for falls is a critical element in caring for the older adult. Options A, B, and C are important components in assessing client risk, but a history of prior falls puts the older client at very high risk for falling again.

A client with hepatic failure tells the nurse about recent use of acetaminophen. How should the nurse respond to this client's statement? A. Bleeding precautions should be implemented. B. Tylenol is indicated for minor aches and pains. C. Acetaminophen reduces inflammation. D. The drug is hepatotoxic and contraindicated

The drug is hepatotoxic and contraindicated Acetaminophen is hepatotoxic and can cause further complications for a client with impaired liver function, so its use is contraindicated. Although bleeding is a risk in clients with liver disease caused by decreased production of clotting components, this drug significantly increases this risk and is contraindicated. Although option B is an indicated use for this drug, it remains contraindicated in clients with hepatic failure. Option C is inaccurate.

The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the when planning activities for the group? A. Each resident's length of stay at this nursing home B. A brief description of each resident's family life C. The age and medication regimen of each group member D. The usual activity patterns of each group member

The usual activity patterns of each group member An older person's level of activity is a determining factor in adjustment to aging as described by the activity theory of aging. All the information described in options A, B, and C might be useful to the nurse but is not as helpful during the initiation of the socialization group. The most useful initial information would be an assessment of each individual's adjustment to the aging process.

A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing pressure ulcers. Which physical characteristic of aging puts the client at risk? A. 16% increase in overall body fat B. Reduced melanin production C. Thinning of the skin, with loss of elasticity D. Calcium loss in the bones

Thinning of the skin, with loss of elasticity Thin nonelastic skin is an important factor in pressure formation. The proportion of body fat to lean mass increases with age and might help decrease ulcer tendency. Option B causes gray hair. Option D can contribute to broken bones, but it is probably not a factor in pressure ulcer formation.

A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? A. This feeling occurs during feeding with a breast infection. B. This sensation occurs as breast milk moves to the nipple. C. The baby does not have good latch-on. D. The infant is not positioned correctly.

This sensation occurs as breast milk moves to the nipple. When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation in their nipples when let-down occurs. Options A, C, and D provide inaccurate information.

A client mumbles out loud whether anyone is talking to her or not, and the client also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which intervention should the nurse implement? A. Respond to the client's feelings rather than the illogical thoughts. B. Identify beliefs and thoughts about what the client is experiencing. C. Provide the client with hope that the voices will eventually go away. D. Ask the client how she has previously managed the voices.

Ask the client how she has previously managed the voices. The nurse should promote symptom management and determine how the client previously managed the voices. Options A and B are interventions that are useful with clients who are experiencing delusions. Option C is important, but the most important intervention is to promote symptom management.

The client with which fasting plasma glucose level needs the most immediate intervention by the nurse? A. 50 mg/dL B. 80 mg/dL0 C 110 mg/dL D. 140 mg/dL

50mg/dl The normal fasting plasma glucose level ranges from 70 to 105 mg/dL. A client with a low level, such as 50 mg/dL, requires the most immediate intervention to prevent loss of consciousness. Normal (such as 80 mg/dL) and slightly elevated levels, such as 110 or 140 mg/dL, do not require immediate intervention.

A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection? A. A 17-year-old who is sexually active with numerous partners B. A 45-year-old lesbian who has been sexually active with two partners in the past year C. A 30-year-old cocaine user who inhales the drug and works in a topless bar D. A 34-year-old male homosexual who is in a monogamous relationship

A 17-year-old who is sexually active with numerous partners Option A is at greatest risk for contracting sexually transmitted diseases, including HIV, because the greater the number of sexual partners, the greater the risk for contracting an STD. Option B comprises the group of lowest infected persons because there is little transfer of body fluid during sexual acts. Option C, who free-bases, would not be sharing needles, so contracting an STD is not necessarily a risk. A male homosexual in a monogamous relationship has a decreased risk of contracting HIV as long as both partners are monogamous and neither is infected.

The nurse is reviewing a client's laboratory results before a procedure in which a neuromuscular blocking agent is prescribed. Which finding should the nurse report to the health care provider? A. Hypokalemia B. Hyponatremia C. Hypercalcemia D. Hypomagnesemia

A. Hypokalemia Low potassium levels enhance the effects of neuromuscular blocking agents, so the health care provider should be informed of the client's hypokalemia. Options B, C, and D are of concern but do not enhance the effects of neuromuscular blocking agents.

A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? A. Save the next urine sample. B. Restrict oral fluid intake. C. Strain all voided urine. D. Reduce physical activity.

A. Save the next urine sample. The nurse should instruct the client to save the next urine sample for observation of its appearance and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary tract infection. Increased fluid intake should be encouraged, unless contraindicated. Option C is only necessary if a calculus (stone) is suspected. Option D is not indicated by this client's symptoms.

A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he is being treated for dissociative disorder. Which data are consistent with this diagnosis? (Select all that apply.) A. Sleepwalking B. Unable to remember who he is C. Has recurrent intrusive obsessions D. Acute attack of anxiety E. Exhibits multiple personalities

A. Sleepwalking B. Unable to remember who he is E. Exhibits multiple personalities Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness and are consistent with a diagnosis of dissociative disorder (A,B,E). (C) is consistent with obsessive-compulsive disorder. (D) is associated with neuro-cognitive disorders.

A couple expresses concern and fear prior to having an amniocentesis to determine fetal lung maturity. To assist them in coping with this situation, which intervention is best for the nurse to implement? A. Explain that harm to the fetus is highly unlikely. B. Answer all their questions regarding the procedure. C. Encourage them to verbalize their feelings. D. Show them a video about the procedure.

Answer all their questions regarding the procedure. The nurse should allay their concerns by providing information about the procedure and answering questions. This action assists the couple in coping with the situation. Option A may offer false reassurance. Option C alone does not resolve the couple's fears. Although option D may be helpful, it is a passive activity, and the nurse's availability to answer questions is likely to be most helpful in calming their fears.

Which class of antineoplastic chemotherapy agents resembles the essential elements required for DNA and RNA synthesis and inhibits enzymes necessary for cellular function and replication? A. Alkylating agents B. Antimetabolites C. Antitumor antibiotics D. Plant alkaloids

Antimetabolites Antimetabolites exert their action by inhibiting the enzymes necessary for cellular function and replication. Options A, C, and D have a different mechanism of action.

Which medication is useful in treating digoxin toxicity? A. Atropine sulfate B. Isoproterenol C. Xylocaine D. Digoxin immune Fab

Digoxin immune Fab Digibind is useful in treating this type of drug toxicity because it is an antibody that binds antigenically to unbound serum digoxin or digitoxin, resulting in renal excretion of the bound complex. Options A, B, and C are not used to treat digitoxin toxicity.

When caring for a client in labor, which finding is most important to report to the primary health care provider? A. Maternal heart rate, 90 beats/min B. Fetal heart rate, 100 beats/min C. Maternal blood pressure, 140/86 mm Hg D. Maternal temperature, 100.0°F

Fetal heart rate, 100 beats/min A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress because the average FHR at term is 140 beats/min, and the normal range is 110 to 160 beats/min. Options A, C, and D are normal findings for a woman in labor.

A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best? A. "We aren't torturing you. These treatments are necessary to prevent a terrible infection." B. "I know these treatments must seem like torture to you, but we want to help you recover." C. "You have so much to live for, and all of your family members want you to live." D. "Would you like me to call the chaplain so that you can discuss your feelings privately?"

"I know these treatments must seem like torture to you, but we want to help you recover." Options B offers an empathetic response without sounding patronizing. Options A is not empathetic and is actually somewhat argumentative. The client is not asking for information as much as pleading for understanding. Option C appears as scolding and places blame on the client for wanting to die and possibly hurting the client's family members as a result. Option D might be appropriate if the nurse simply asks the client if a chaplain's visit is desired, but the nurse is dismissing the client's needs by not addressing them at the moment.

The nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression? A. "I'm not very pretty or likeable." B. "I've lost 20 pounds in the past month." C. "I like to keep things to myself." D. "I think everyone is out to get me."

"I'm not very pretty or likeable." Feelings of hopelessness are characteristics of one who is depressed. Although option B might be indicative of depression, further assessment would be required to rule out an organic cause before attributing the statement to depression. Options C and D are indicative of a paranoid personality.

During a health fair, a male client with emphysema tells the nurse that he fatigues easily. Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest diameter. Which instruction is best to provide the client? A. "Pace your activities and schedule rest periods." B. "Increase the amount of oxygen you use at night." C. "Obtain medical evaluation for antibiotic therapy." D. "Reduce your intake of fluids containing caffeine."

"Pace your activities and schedule rest periods." Manifestations of emphysema include an increase in AP diameter (referred to as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to promote energy management, such as pacing activities and scheduling rest periods. Option B may result in a decreased drive to breathe. The client is not exhibiting any symptoms of infection, so option C is not necessary. Option D is less beneficial than option A.

One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond? A. "You may not have enough energy before long to hold a big party." B. "Do you mean to say that you want to plan your funeral and wake?" C. "Planning a party and thinking about all your friends sounds like fun." D. "You should be thinking about spending your last days with your family."

"Planning a party and thinking about all your friends sounds like fun." Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party. Option B puts words in the client's mouth that may not be accurate. The nurse should support the client's goals rather than telling the client how to spend her time.

A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary? A. "I will avoid coughing, sneezing, and forceful nose blowing." B. "Swimming can begin on the tenth postoperative day." C. "Any mild discomfort can be managed with acetaminophen." D. "Drainage from my ears is expected after the surgery."

"Swimming can begin on the tenth postoperative day." The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the client should be reeducated if the client swims or allows water to enter the external ear. Options A, C, and D reflect correct responses.

The nurse enters the examination room of a client who has been told by her health care provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client? A. "I know many women who have survived ovarian cancer." B. "Let's talk about the treatments of ovarian cancer." C. "In my opinion I would suggest getting a second opinion." D. "Tell me about what you are feeling right now."

"Tell me about what you are feeling right now." The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings. Giving false reassurance or personal suggestions are not therapeutic communication for the client.

A client is ordered 22 mg of gentamicin by IM injection. The drug is available in 20 mg/2 mL. How many milliliters should be administered? A. 1.8 B. 2.0 C. 2.4 D. 2.2

(22 mg/20 mg) × (x mL/2 mL) = 22x = 40 x = 2.2 mL

Which assessment findings should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.) A. Steatorrhea B. Obesity C. Foul-smelling stools D. Delayed growth E. Pulmonary congestion

A. Steatorrhea C. Foul-smelling stools D. Delayed growth E. Pulmonary congestion Options A, C, D, and E are all common assessment findings in the client with cystic fibrosis. Weight loss, not weight gain, is associated with cystic fibrosis.

The family of a male adult with schizophrenia does not want the client to be involved in decisions regarding his treatment. The nurse should inform the family that the client has a right to be involved in his treatment planning based on which law? A. Social Security Act of 1990 B. American with Disabilities Act of 1990 C. Medicaid Act of 1965 D. Mental Health Act of 1946

American with Disabilities Act of 1990 The Americans with Disabilities Act guarantees the client the right to participate in treatment planning. Option A is a federal insurance program that provides benefits to retired persons, the unemployed, and the disabled. Option C is a program for eligible individuals and/or families with low income and resources. Option D provides for public education regarding psychiatric illnesses.

A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, has been terminated from her job, and has not left the house since that time. This client is displaying symptoms of which disorder? A. Claustrophobia B. Acrophobia C. Agoraphobia D. Necrophobia

Agoraphobia Agoraphobia is the fear of crowds or of being in an open place. Option A is the fear of being in closed places. Option B is the fear of high places. Option D is an abnormal fear of death or bodies after death. A phobia is an unrealistic fear associated with severe anxiety.

Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate (Mexate) therapy? A. Increase in rheumatoid factor B. Decrease in hemoglobin level C. Increase in blood glucose level D. Decrease in erythrocyte sedimentation rate (ESR; sed rate)

Decrease in hemoglobin level Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in the hemoglobin level. Option A indicates disease progression but is not a side effect of the medication. Option C is not related to methotrexate. Option D indicates that inflammation associated with the disease has diminished.

The nurse is caring for a client who develops ventricular fibrillation. Which action should the nurse take first? A. Administer epinephrine. B. Defibrillate immediately. C. Give a bolus with isotonic fluid. D. Notify the health care provider.

Defibrillate immediately. Defibrillation is the first and most effective emergency treatment for ventricular fibrillation. Options A, C, and D may follow the first action.

A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression? A. Implementation of the goal should be deferred until further data can be gathered. B. The depression will dissipate once the client becomes accustomed to retirement. C. Depressed clients may be unaware of guilt feelings and should be encouraged to increase self-awareness. D. Nursing goals should be approved by the treatment team before they are initiated.

Depressed clients may be unaware of guilt feelings and should be encouraged to increase self-awareness. Depression is associated with feelings of guilt, and clients are often not aware of these feelings. Awareness is the first step in dealing with guilt (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings. Although a goal may be changed based on an evaluation of interventions to meet the goal, a goal should never be ignored. Option B dismisses the client's symptoms as age-related. Setting goals for the nursing care plan is a function of the nurse, although the nurse can collaborate with the treatment team.

A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client? A. Determine if all employees have had the hepatitis B vaccine series. B. Explain that this type of hepatitis can be transmitted when feeding the client. C. Assure the employees that they cannot contract hepatitis B when providing direct care. D. Tell the employees that wearing gloves and a gown are required when providing care.

Determine if all employees have had the hepatitis B vaccine series. Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination. There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, option C is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact.

The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement? A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea.

Determine if pain is causing the client's tachypnea. Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. Option B can increase the client's carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be offered instead. Option C could increase respiratory congestion in a client with a poorly functioning cardiopulmonary system, placing the client at risk of fluid overload.

A 6-year-old child is admitted to the emergency department with status epilepticus. His parents report that his seizure disorder has been managed with phenytoin, 50 mg PO bid, for the past year. Which drug should the nurse plan to administer in the emergency department? A. Phenytoin B. Diazepam C. Phenobarbital D. Carbamazepine

Diazepam is the drug of choice for treatment of status epilepticus. Options A, C, and D are used for the long-term management of seizure disorders but are not as useful in the emergency management of status epilepticus.

A 77-year-old female client is admitted to the hospital with confusion and anorexia of several days' duration. She has symptoms of nausea and vomiting and is currently complaining of a headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to which medication? A. Warfarin B. Ibuprofen C. Nitroglycerin D. Digoxin

Digoxin Older persons are particularly susceptible to the buildup of cardiac glycosides, such as digoxin or digitoxin (medications derived from digitalis), to a toxic level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Options A, B, and C are unlikely to result in the symptoms described.

A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff? A. Encourage staff to participate in online in-service education. B. Assign staff to make sure that all equipment is thoroughly cleaned. C. Ask which staff members would like to go home for the remainder of the day. D. Notify the supervisor that the staff needs additional assignments.

Encourage staff to participate in online in-service education. Online educational programs are available around the clock, so staff can engage in continuing education programs when the opportunity arises, such as during periods of low census. Option B is not the responsibility of the nursing staff. Option C is not the best use of staff and does not use the extra time provided by the low census. The charge nurse should use the time to improve the unit, and requesting additional assignments is not necessary.

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A. Client will not demonstrate cross addiction. B. Codependent behaviors will be decreased. C. Excessive CNS stimulation will be reduced. D. The client will demonstrate an increased level of consciousness.

Excessive CNS stimulation will be reduced. Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal. Options A, B, and D are all appropriate outcome statements for the client described but do not have the priority of option C.

A client with type 2 diabetes has a plantar foot ulcer. When developing a teaching plan regarding foot care, what information should the nurse obtain first from the client? A. How the client examines her feet B. Which hypoglycemic medication she takes C. Who lives in the home with her D. How long she has had diabetes mellitus

How the client examines her feet Option A specifically relates to foot care. Options B, C, and D provide worthwhile information to obtain but do not have the importance of option A.

The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine he is currently following.

Ask the client to describe the routine he is currently following. The nurse should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information than the client's written diary. The nurse can then determine which changes need to be made. The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient.

A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client? A. Sublimation B. Identification C. Introjection D. Repression

B. Identification Identification is an attempt to be like someone or emulate the personality traits of another. Option A is substituting an unacceptable feeling with one that is more socially acceptable. Option C is incorporating the values or qualities of an admired person or group into one's own ego structure. Option D is the involuntary exclusion of painful thoughts or memories from one's awareness.

The charge nurse reviews the charting of a graduate nurse. Which indicates a need for further education on documentation? A. Uses descriptive words such as "gurgling" to describe breath sounds. B. Records temperature 30 minutes before and after giving acetaminophen. C. Charts some actions in advance of performing them. D. Includes the client's response to an intervention.

Charts some actions in advance of performing them. Charting actions prior to implementing them is an example of fraudulent charting, and the graduate nurse should receive further education. Options A, B, and D are appropriate charting examples.

Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? A. States having difficulty with color perception B. Presents with opacity of the lens upon assessment C. Complains of seeing a cobweb-type structure in the visual field D. Reports the need to use a magnifying glass to see small print

Complains of seeing a cobweb-type structure in the visual field Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment. Distorted color perception, opacity of the lens, and gradual vision loss are expected signs and symptom of cataracts but do not need immediate attention.

While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the client's health care provider is on the telephone. What action should the nurse instruct the unit secretary to implement? A. Transfer the call into the room of the client. B. Instruct the secretary to explain the reason for the call. C. Ask another nurse to take the phone call. D. Ask the health care provider to see the client on the unit.

Ask another nurse to take the phone call. Another nurse should be asked to take the phone call, which allows the nurse to stay at the bedside to complete the assessment of the client's chest pain. Options A and B should not be done during an acute change in the client's condition. Requesting the health care provider to come to the unit is premature until the nurse completes assessment of the client's status.

When caring for a hospitalized child with type 1 diabetes mellitus, which intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Teach the signs and symptoms of hypoglycemia. B. Assess for polydipsia, polyphagia, and polyuria. C. Check the blood glucose level every 4 hours. D. Evaluate the need for a snack between meals.

Check the blood glucose level every 4 hours. Checking the blood glucose level is a low-risk task that can be safely delegated to the UAP in most circumstances. Teaching, assessment, and evaluation are all within the scope of practice of the RN and should not be delegated to the UAP.

Which assessment datum indicates to the nurse that a dose of granisetron administered IV prior to chemotherapy has had the desired effect? A. Oral mucosa pink and intact B. Scalp intact without alopecia C. Client denies nausea D. Client denies pain

Client denies nausea Granisetron is an antiemetic administered before chemotherapy to prevent chemotherapy-induced nausea and vomiting. Chemotherapy can cause oral sores, but granisetron does not prevent this problem. Granisetron does not affect option B or D.

Dopamine in the central nervous system is increased. A. Maintain respiratory isolation precautions. B. Increase daily fluids to 2000 to 4000 mL/day. C. Administer with meals to decrease gastric irritation. D. Assess for signs of severe liver dysfunction.

Increase daily fluids to 2000 to 4000 mL/day. Increasing fluid intake during treatment prevents precipitation of the drug in the renal tubules, which could lead to obstructive problems that impair kidney function. Acute glomerulonephritis is a possible complication of acyclovir sodium therapy. Options A, C, and D are unrelated interventions for treatment with acyclovir sodium.

The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.) A. Confusion B. Peripheral edema C. Crackles in the lungs D. Dyspnea E. Distended neck veins

Confusion Crackles in the lungs Dyspnea Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion. Options B and E are associated with right-sided heart failure.

The nurse administers levothyroxine to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.) A. Increase in T3 and T4 B. Decrease in heart rate C. Increase in TSH D. Decrease in urine output E. Decrease in periorbital edema

Increase in T3 and T4 Decrease in periorbital edema Levothyroxine is a thyroid replacement drug that increases thyroid hormone levels (T3 [triiodothyronine] and T4 [thyroxine]) and decreases periorbital edema, a symptom of hypothyroidism (A and E). Decrease in heart rate and an increased level of thyroid-stimulating hormone (TSH) are not therapeutic results from taking levothyroxine (B and C). Levothyroxine does not affect urine output (D).

A client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of 8 ectopic beats/min. Which action should the nurse take based on this observation? A. Assess for bilateral jugular vein distention. B. Increase oxygen flow via nasal cannula. C. Administer PRN furosemide (Lasix). D. Auscultate for a pleural friction rub.

Increase oxygen flow via nasal cannula. This client should have the oxygen flow immediately increased to promote oxygenation of the myocardium. Ventricular ectopy, characterized by multiple PVCs, is often caused by myocardial ischemia exacerbated by hypokalemia. The nurse would expect the client in congestive heart failure to have some degree of option A, which does not exacerbate the ectopy. Option C could create a more severe hypokalemia, which could increase the ectopy. The client is not exhibiting signs of option D.

When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse to report to the primary health care provider? A. Ascending numbness from the feet to the knees B. Decrease in cognitive status of the client C. Blurred vision and sensation changes D. Persistent unilateral headache

Decrease in cognitive status of the client A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist the client with mechanical ventilation. A primary health care provider will need to be contacted immediately. Options A, C, and D are findings associated with Guillain-Barré syndrome that should also be reported but are not as critical as the client's hypoxic status.

A client with viral influenza is receiving vitamin C, 1000 mg PO daily, and acetaminophen elixir, 650 mg PO every 4 hours PRN. The nurse calls the health care provider to report that the client has developed diarrhea. Which change in prescriptions should the nurse anticipate? A. Change the acetaminophen to ibuprofen. B. Change the elixir to an injectable route. C. Decrease the dose of vitamin C. D. Begin treatment with an antibiotic.

Decrease the dose of vitamin C. Diarrhea is an adverse effect of high doses of vitamin C, so the nurse should anticipate a reduction in the dose of vitamin C. Acetaminophen does not cause diarrhea and is not available in an injectable form. Because the client has a viral infection, option D will not be beneficial.

The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention? A. Ecchymosis over the right elbow area B. Deep unrelenting pain in the right arm C. An edematous right elbow D. The presence of crepitus in the right elbow

Deep unrelenting pain in the right arm Compartment syndrome is a condition involving increased pressure and constriction of the nerves and vessels within an anatomic compartment, causing pain uncontrolled by opioids and neurovascular compromise. Option A is an expected finding. Option C related to compartment syndrome cannot be seen, and any visible edema is an expected finding related to the injury. Option D is an expected finding.

In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect? A. Irregular respiration and heart rate B. Gagging C. Blue feet and hands D. Diminished femoral pulses

Diminished femoral pulses Diminished femoral pulses could indicate coarctation of the aorta. In the normal transition period, options A and B occur during the 4 to 6 hours after birth (second period of reactivity). Option C is a normal finding in the newborn.

The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time.

Discuss the client another time. The best nursing action is to discuss the client another time. Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details can identify the client when referring to the client by gender or age, even when not using the client's name.

A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? A. Orange juice has vitamin C that deters bacterial growth. B. Apple juice is the most useful in acidifying the urine. C. Cranberry juice stops pathogens' adherence to the bladder. D. Grapefruit juice increases absorption of most antibiotics.

Cranberry juice stops pathogens' adherence to the bladder .Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective as cranberry juice in preventing UTIs.

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A. Herpes B. Trichomonas C. Gonorrhea D. Syphilis

Gonorrhea Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not effective against option A, B, or D.

A child is being treated with mebendazole for pinworms. Which type of diet should the mother be instructed to feed the child while the child is receiving this medication? A. Lactose-free foods B. High-fat diet C. Vitamin C-enriched foods D. High-fiber diet

High-fat diet A high-fat diet increases the absorption of mebendazole, which boosts the effectiveness of the medication in eliminating the pinworms. Options A, C, and D are not related to the administration of this medication.

Upon assessing a newborn male, the nurse finds the urethral meatus opens on ventral side of penis behind the glans. The nurse would recognize this finding is consistent with which finding? A. Cryptorchidism B. Priapism C. Hypospadias D. Episapdias

Hypospadias In hypospadias, there is a congenital defect of urethral meatus in males and the urethra opens on ven-tral side of penis behind the glans. Answer A, B, and D are consistent with other conditions.

The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement? A. Advise the client that food from the meal tray should not be shared with others. B. Leave the room and discuss the incident privately with the staff member. C. Objectively document the situation as observed on a variance report. D. Call the nurse-manager to the client's room immediately.

Leave the room and discuss the incident privately with the staff member. Discussing the incident privately promotes open communication between the charge nurse and staff member. The client is free to share unwanted food with family or friends, but the employee should not ask for the client's food. Option C is not necessary, and the charge nurse can respond to this situation without implementing option D.

Which preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? A. Monitor for signs of metabolic acidosis. B. Estimate the quantity of diarrhea stools. C. Place in a supine position after feeding. D. Observe for projectile vomiting.

Observe for projectile vomiting. Projectile vomiting, the classic sign of pyloric stenosis, contributes to metabolic alkalosis. Metabolic acidosis is the opposite imbalance from alkalosis and is not an expected finding. An antidiarrheal agent is not indicated. Option C is dangerous because of the potential for aspiration with frequent vomiting.

A female client is receiving tetracycline for acne. Which client teaching should the nurse include? A. Oral contraceptives may not be effective. B. Drinking cranberry juice will promote healing. C. Breast tenderness may occur as a side effect. D. The urine will turn a red-orange color.

Oral contraceptives may not be effective. Certain antibiotics, such as tetracycline, decrease the effectiveness of oral contraceptives. Options B, C, and D do not convey accurate information related to client teaching about this medication.

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority? A. Place the client on NPO status. B. Assess the client's temperature. C. Obtain a stool specimen. D. Administer IV fluids.

Place the client on NPO status. A client with acute severe diverticulitis is at risk for peritonitis and intestinal obstruction and should be made NPO to reduce risk of intestinal rupture. Options B, C, and D are important but are less of a priority than option A, which is implemented to prevent a severe complication.

A client receiving a continuous infusion of heparin IV starts to hemorrhage from an arterial access site. Which medication should the nurse anticipate administering to prevent further heparin-induced hemorrhaging? A Vitamin K1 B. Protamine sulfate C. Warfarin sodium D. Prothrombin

Protamine sulfate Protamine sulfate is the antagonist for heparin and is given for episodes of acute hemorrhage. Options A, C, and D are not heparin antagonists.

Which intervention should be included in the plan of care for a client admitted to the hospital with ulcerative colitis? A. Administer stool softeners. B. Place the client on fluid restriction. C. Provide a low-residue diet. D. Add a milk product to each meal.

Provide a low-residue diet. A low-residue diet will help decrease symptoms of diarrhea, which are clinical manifestations of ulcerative colitis. Options A, B, and D are contraindicated and could worsen the condition .

When bathing an uncircumcised boy older than 3 years, which action should the nurse take? A. Remind the child to clean his genital area. B. Defer perineal care because of the child's age. C. Retract the foreskin gently to cleanse the penis. D. Ask the parents why the child is not circumcised.

Retract the foreskin gently to cleanse the penis. The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria. The child's cognitive development may not be at the level at which option A would be effective. Perineal care needs to be provided daily regardless of the client's age. Option D is not indicated and may be perceived as intrusive.

The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food items chosen by the client indicate understanding of the teaching? (Select all that apply.) A. White bread B. Salmon C. Broccoli D. Whole milk E. Banana

Salmon Broccoli Banana Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains, and low-fat dairy products. All are recommended by the American Diabetes Association (ADA) and are a part of the My Plate guidelines recommended by the U.S. Department of Agriculture (USDA). Whole milk is high in fat and is not recommended by the ADA. White bread is milled, a process that removes the essential nutrients. It should be avoided for weight loss and is a poor choice for the client with diabetes.

After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse implement? A. Complete an incident report. B. Select another sterile needle. C. Disinfect the needle with an alcohol swab. D. Notify the supervisor of the department immediately.

Select another sterile needle. After a needle stick, the needle is considered used, so the nurse should discard it and select another needle. Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report or notify the occupational health nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards for safe practice and infection control.

When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse-manager implement? A. Speak privately with the nurse. B. Hold a staff meeting to discuss this issue. C. Review the nurse's current salary. D. Nominate the nurse for employee of the month.

Speak privately with the nurse. The nurse-manager should speak privately with the nurse to assess the nurse's motives and to discuss allowing other team members the opportunity to be on call for the day shift. Option B might become confrontational. Option C is irrelevant. Option D is not warranted.

During the initial nursing assessment history, a client tells the nurse that he is taking tetracycline hydrochloride for urethritis. The nurse is most concerned if the client reports taking which medication concurrently? A. Sucralfate B. Hydrochlorothiazide C. Acetaminophen D. Phenytoin

Sucralfate Sucralfate is used to treat duodenal ulcers and will bind with tetracycline hydrochloride, inhibiting this antibiotic's absorption. Options B, C, and D have no drug interaction properties that prohibit concurrent use with tetracycline hydrochloride.

The nurse knows that certain antipsychotic drugs cause extrapyramidal symptoms. Which extrapyramidal symptom is a permanent and irreversible adverse effect of long-term phenothiazine administration? A. Dystonia B. Akathisia C. Pseudoparkinsonism D. Tardive dyskinesia

Tardive dyskinesia is a permanent effect of long-term phenothiazine administration. TD causes stiff, jerky movements of your face and body that you can't control. Options A, B, and C are side effects of phenothiazines but do not have the characteristics of being permanent and irreversible.

A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain? A. The client's usual sleeping pattern B. Whether the client smokes C. How much liquid the client consumes before bedtime D. The amount of caffeine that the client consumes during the day

The client's usual sleeping pattern The first thing to determine is the client's usual sleeping pattern and how it has changed to become what the client describes as insomnia. Options B, C, and D provide additional information after option A is ascertained.

The nurse administers atropine sulfate ophthalmic drops preoperatively to the right eye of a client scheduled for cataract surgery. Which response by the client indicates that the drug was effective? A. The pupils become equal and reactive to light. B. The right pupil constricts within 30 minutes. C. Bilateral visual accommodation is restored. D. The right pupil dilates after drop instillation.

The right pupil dilates after drop instillation. Atropine is a mydriatic drug which causes pupil dilation and paralysis in preparation for surgery or examination. Options A, B, and C do not describe the therapeutic effects of atropine sulfate ophthalmic drops prior to cataract surgery.

Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence? A. Adjustment of orthodontic appliances or braces B. Loss of deciduous teeth (baby teeth) C. Urinary catheterization D. Insect bites

Urinary catheterization Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage. Of the choices listed, only urinary catheterization is an invasive procedure. Options A, B, and D are not invasive and do not require administration of prophylactic antibiotics.

Which of the following cardiac rhythms is represented in the image? A. Normal sinus rhythm B. Sinus tachycardia C. Ventricular fibrillation D. Atrial fibrillation

Ventricular fibrillation is a life-threatening arrhythmia characterized by irregular undulations of varying amplitudes. Options A, B, and D are not represented in the image.

A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement? A. Place a wedge under the client's left side. B. Determine cervical dilation and effacement. C. Administer 10 L of oxygen via facemask. D. Increase the rate of the oxytocin (Pitocin) infusion.

Increase the rate of the oxytocin (Pitocin) infusion. The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal examination places the client at risk for infection and should be performed when the client exhibits signs of progressing labor, which is not indicated at this time.

Which question should the nurse ask a client prior to the initiation of treatment with IV infusions of gentamicin sulfate? A. "Are you having difficulty hearing?" B. "Have you ever been diagnosed with cancer?" C."Do you have any type of diabetes mellitus?" D. "Have you ever had anemia?"

"Are you having difficulty hearing?" Complications of gentamicin sulfate therapy include ototoxicity, nephrotoxicity, and neurotoxicity. Determining if the client is hard of hearing prior to initiation of this aminoglycoside will be helpful as the treatment progresses and ototoxicity is identified as a possible complication. Options B, C, and D are important elements of any medical history, but they do not have the priority of option A when assessing for complications of aminoglycoside therapy.

When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse? A. Sodium level, 137 mEq/L B. Potassium level, 5.5 mEq/L C. Blood urea nitrogen (BUN) level, 18 mg/dL D. Calcium level, 10 mEq/L

Potassium level, 5.5 mEq/L Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia. Options A, C, and D are normal findings.

When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly.

Put bed rails up on the side of bed opposite from the nurse. Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails.

The nurse initiates neurologic checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neurologic function? A. Change in level of consciousness B. Increasing muscular weakness C. Changes in pupil size bilaterally D. Progressive nuchal rigidity

Change in level of consciousness A decrease or change in the level of consciousness is usually the first indication of neurologic deterioration. Options B and C may also occur but are much less likely to be the first sign of neurologic compromise. Option D is often a sign of meningitis.

A client with non-Hodgkin lymphoma has been prescribed cyclophosphamide IV for therapy. Which assessment finding would need to be reported immediately to the oncologist? A. Sores on the mouth or tongue B. Chills, fever, and sore throat C. Loss of appetite or weight with diarrhea D. Changes in color of fingernails or toenails

Chills, fever, and sore throat Cyclophosphamide is an immunosuppressive drug used to treat lymphoma and puts the client at risk for infection. Signs and symptoms of an infection should be reported to the oncologist immediately. Options A and C are expected signs and symptoms of non-Hodgkin lymphoma. Option D is a normal side effect of cyclophosphamide.

A client experiencing dysrhythmias is given quinidine, 300 mg PO every 6 hours. The nurse plans to observe this client for which common side effect associated with the use of this medication? A. Diarrhea B. Hypothermia C. Seizures D. Dysphagia

Diarrhea The most common side effects associated with quinidine therapy are gastrointestinal complaints, such as diarrhea. Options B, C, and D are not usually associated with quinidine therapy.

Dopamine is administered to a client who is hypotensive. Which finding should the nurse identify as a therapeutic response? A. Gain in weight B. Increase in urine output C. Improved gastric motility D. Decrease in blood pressure

Increase in urine output Intropin activates dopamine receptors in the kidney and dilates blood vessels to improve renal perfusion, so an increase in urine output indicates an increase in glomerular filtration caused by increased arterial blood pressure. Option A is related to fluid retention but is not an indicator of a therapeutic response to dopamine therapy. Option C is not related to the vasopressor effect of dopamine therapy. Dopamine increases cardiac output, which increases a client's blood pressure, not option D.

Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A. Hypokalemia B. Microalbuminuria C. Elevated serum lipid levels D. Ketonuria

Microalbuminuria Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not option A, is associated with end-stage renal disease caused by diabetic nephropathy. Option C may be elevated in end-stage renal disease. Option D may signal the onset of diabetic ketoacidosis (DKA).

A lidocaine IV infusion at 4 mg/min via infusion pump is prescribed for a client having premature ventricular contractions (PVCs). The available premixed infusion contains 2 mg/mL of D5W. How many milliliters per hour should the nurse program the pump to deliver to this client? A. 20 B. 24 C. 60 D. 120

Option D is the correct calculation; 120 mL/hr = 1 mL/2 mg × 4 mg/min × 60 min/hr.

Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers.

Maintain standard precautions. The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B is not necessary unless the client has an infection. Option C increases the risk of infection. Option D does not reduce the risk of infection.

A client receives an antihypertensive agent daily. Which action is most important for the nurse to implement prior to administering the medication? A. Verify the expiration date. B. Obtain the client's blood pressure. C. Determine the client's history of adverse reactions. D. Review the client's medical record for a change in drug route.

Obtain the client's blood pressure. To determine the most accurate response to antihypertensive therapy, baseline blood pressures should be obtained before an antihypertensive drug is administered and should be compared with orthostatic vital signs to determine whether any side effects are occurring. Although options A, C, and D are required nursing actions prior to giving any drug, the therapeutic response should be determined before another dose is administered.

Alteration of which laboratory finding represents the achievement of a therapeutic goal for heparin administration? A. Prothrombin time (PT) B. Fibrin split products C. Platelet count D. Partial thromboplastin time (PTT)

Partial thromboplastin time (PTT) Heparin therapy is guided by changes in the partial thromboplastin time (PTT). Options A, B, and C are not used to track the therapeutic effect of heparin administration.

In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? A. Sodium B. Phosphate C. Potassium D. Glucose

Potassium Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium; hypokalemia; hypertension is the most prominent and universal sign. The serum sodium level is normal or elevated, depending on the amount of water resorbed with the sodium. Option B is influenced by parathyroid hormone (PTH). Option D is not affected by primary aldosteronism.

The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first? A. Recommend mental health counseling. B. Review the medication actions and interactions. C. Assess for the client's daily activity level. D. Provide information regarding a support group.

Review the medication actions and interactions. Interferon-alfa-2a and ribavirin combination therapy can cause severe depression; therefore, it is most important for the nurse to review the medication effects and report these to the health care provider. Options A, C, and D might be implemented after the physiologic aspects of the situation have been assessed.

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? A. Tinnitus, vertigo, and hearing difficulties B. Sudden, stabbing, severe pain over the lip and chin C. Unilateral facial weakness and paralysis D. Difficulty in chewing, talking, and swallowing

Sudden, stabbing, severe pain over the lip and chin Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V). Option A would be characteristic of Ménière syndrome (cranial nerve VIII). Option C would be characteristic of Bell palsy (cranial nerve VII). Option D would be characteristic of disorders of the hypoglossal (cranial nerve XII).

A 3-year-old boy is admitted to the emergency department after ingesting an unknown amount of phenobarbital elixir prescribed for his brother's seizure disorder. Which nursing intervention should the nurse implement first? A. Administer syrup of ipecac. B. Take the child's vital signs. C. Draw a blood specimen for a phenobarbital level. D. Teach the mother safe medication storage practices.

Take the child's vital signs. Phenobarbital causes respiratory depression, so the priority intervention is assessment of vital signs. Options A, C, and D are actions that may all be used in the treatment of this child, but they do not have the priority of option B.

A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to continue further assessment of the infant? A. Two-month-old who is unable to roll from back to abdomen B. Ten-month-old who cannot sit without support C. Nine-month-old who cries when his mother leaves the room D. Eight-month-old who has not yet begun to speak words

Ten-month-old who cannot sit without support As a developmental milestone, infants should sit unsupported by 8 months. The milestone of rolling over is achieved at 5 to 6 months for most infants. Stranger anxiety is common from 7 to 9 months. Speaking a few words is expected at about 12 months.

A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? A. Oral hygiene should be performed before the medication. B. Antifungal medications are available in tablet, suppository, and liquid forms. C. Candida albicans is the organism that causes the white lesions in the mouth. D. The dietary intake of dairy and spicy foods should be limited.

Oral hygiene should be performed before the medication. HIV infection causes depression of cell-mediated immunity that allows an overgrowth of C. albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral liquids should be consumed and oral hygiene performed before swishing the liquid Nystatin. Options B and C provide the client with additional information about the pathogenesis and treatment of opportunistic infections, but option A allows the client to participate in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort associated with stomatitis, but restriction of dairy products is not indicated.

A 45-year-old female client is receiving alprazolam for anxiety. Which client behavior would indicate that the drug is effective? A. Personal hygiene is maintained by the client for the first time in a week. B. The client has an average resting heart rate of 120 beats/min. C. The staff observes the client sitting in the day room reading a book. D. The nurse records that the client lost 2 lb of body weight in the past week.

The staff observes the client sitting in the day room reading a book. The ability to sit and concentrate on reading indicates decreased anxiety. Options A, B, and D are not related to the use of alprazolam for anxiety.

A client with chronic gouty arthritis is talking allopurinol, 100 mg PO daily. Which laboratory serum level should the nurse report to the health care provider to determine the therapeutic outcome? A. Prothrombin time B. Uric acid level C. White blood cell count D. Creatinine level

Uric acid level The primary therapeutic outcome associated with allopurinol therapy is reduced serum uric acid levels with a lower frequency of acute gouty attacks, so option B should be reported to the health care provider. Options A, C, and D are not related to the effectiveness of allopurinol.

The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN? A. A client with an admitting diagnosis of menorrhagia who is now 24 hours' post-vaginal hysterectomy B. A client admitted with a myocardial infarction 4 days ago who was transferred from the intensive care unit (ICU) the previous day C. A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) D. A 4-year-old admitted the previous evening with gastrointestinal rotavirus who is receiving IV fluids and a clear liquid diet

A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) Option C requires communication skills and assessment skills beyond the educational level of a PN or UAP. Establishing a therapeutic, one-on-one relationship with a depressed client is beyond the scope of practice for a PN. In addition, Tylenol is extremely hepatotoxic, and careful assessment is essential. Options A, B, and D could all be cared for by a PN under the supervision of the RN.

During therapy with isoniazid, it is most important for the nurse to monitor which laboratory value closely? A. Liver enzyme levels B. Blood urea nitrogen (BUN) level C. Serum electrolyte levels D. Complete blood count (CBC)

Liver enzyme levels The client receiving isoniazid is at risk for the development of hepatitis; therefore, liver function test results should be monitored carefully during drug therapy. Options B, C, and D are not specific indicators of liver function, so they are not monitored closely during isoniazid therapy.

Which intervention is most important when caring for a client immediately after electroconvulsive therapy (ECT)? A. Reorient the client to surroundings. B. Assess blood pressure every 15 minutes. C. Determine if muscle soreness is present. D. Maintain a patent airway.

Maintain a patent airway. The client is typically unconscious immediately following ECT, and nausea is a common side effect. The nurse should take measures to prevent aspiration and maintain a patent airway. Clients may be confused after ECT, but reorientation is not as high a priority as the airway. Although vital signs should be assessed, the airway is a higher priority. Muscle soreness is an expected finding after ECT.

A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. What action should the nurse immediately take to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg? A. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow. B. Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding. C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. D. Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.

Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. Placing the client in a supine position reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound. Option A compromises diaphragmatic expansion and inhibits pressoreceptor activity. Option B places the client at risk of evisceration of the abdominal wound and increased bleeding. Option D will not stop internal bleeding in the liver and spleen caused by the gunshot wound.

A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome? A. Presence of a systolic murmur B. New onset of patchy alopecia C. Complaints of long bone pain D. Recent projectile vomiting

Presence of a systolic murmur Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most common heart defects associated with this congenital anomaly. Options B, C, and D are not recognized as common complications of trisomy 21.

On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorders? A. Dissociative disorders B. Personality disorders C. Anxiety disorders D. Psychotic disorders

Psychotic disorders Delusions are false beliefs characteristic of psychosis. Delusions are generally not characteristic of options A, B, and C.

A client on the psychiatric unit, diagnosed with bipolar disorder, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take? A. Have the staff escort the client to his room. B. Tell the client that his behavior will be documented in his record. C. Redirect the client by offering an activity such as playing card games. D. Review the medication record for an antipsychotic drug.

Redirect the client by offering an activity such as playing card games. Distracting the client, or redirecting him toward a constructive activity, prevents further escalation of the inappropriate behavior. Option A could result in escalating the abuse and might unnecessarily involve another staff member in the abusive situation. Option B may be more threatening to the client. Option D may be indicated if the behavior escalates, but at this time the best initial action is option C.

The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge? A. Tries to interact with a few peers and staff. B. Reports feeling better and less depressed. C. Sits attentively with peers in group therapy. D. Easily awakens for morning medications.

Reports feeling better and less depressed. The client is experiencing symptoms of depression, and the outcome by discharge for this client would be that the client reports feeling better and less depressed. The client may interact with peers and staff and sit attentively in groups without any improvement in depression. Difficulty awakening is usually caused by the medication regimen for depression, so awakening is not an indication of improvement.

The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly? A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt.

Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. His wife is most likely to lean toward the weak side and needs extra support on that side and from the back to prevent falling. Options A, C, and D provide less security for her.

When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching A. Recommend that the client carry suction equipment at all times. B. Instruct the client to have writing materials with him at all times. C. Tell the client to carry a medical alert card that explains his condition. D. Caution the client not to travel outside the United States alone.

Tell the client to carry a medical alert card that explains his condition. Neck breathers carry a medical alert card that notifies health care personnel of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth to mouth resuscitation will not establish a patent airway. Options A and D are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence on writing messages is probably the least effective.

A five year old is in Bryant's traction for intervention for a fractured femur. Which finding by the nurse would require intervention? A. The parents are at the bedside reading a book with the child. B. The child's hips are in 90-degree flexion. C. The child's hips are gently resting on the bed. D. The child is consuming 120 mL of grape juice.

The child's hips are gently resting on the bed. The In Bryant's traction, the buttocks should be elevated off the bed not resting on the mattress. Drinking grape juice with a volume of 120 mL is acceptable and the family should be incorporated into the child's plan of care.

An older client calls the clinic and complains of feeling very weak and dizzy. Further assessment by the nurse indicates that the client self-administered an enema of 3 L of tap water because of constipation. What is the most likely cause of the client's symptoms? A. Mucosal bleeding B. Sodium retention C. Fluid volume depletion D. Water intoxication

Water intoxication Tap water is a hypotonic fluid that can leave the intestine and enter the interstitial fluid by osmosis, ultimately causing systemic water intoxication. This is manifested by weakness, dizziness, pallor, diaphoresis, and respiratory distress. Excessive use of enemas can cause mucosal irritation, which might result in some bleeding, but the client would not experience weakness and dizziness unless she was hemorrhaging. Options B and C can occur with the use of a hypertonic rather than hypotonic solution.

The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN? A. Assess skeletal pins for infection. B. Assist the client with toileting. C. Establish thrombus prevention care. D. Evaluate pain management plan.

assist the client with toileting The PN can implement nursing care, such as option B. The PN assists the RN in the development of a teaching plan and reinforces information to the client according to the plan. Options A, C, and D are outside the scope of PN practice, but the PN can assist the RN in gathering data, implementing nursing care, and contributing to the plan of care under the supervision of the RN.

A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next? a. Flex the hips and knees and align the knees with the client's knees for safety. b. Allow the client to sit on the side of the bed for a few minutes before transferring. c. Place the client's weight-bearing or strong leg forward and the weak foot back. d. Grasp the transfer belt at the client's sides to provide movement of the client.

b. Allow the client to sit on the side of the bed for a few minutes before transferring. A client who has been immobile may be weak and dizzy and develop orthostatic hypotension (a drop in blood pressure on rising), so allowing the client to sit for a few minutes before transferring from the bedside to the wheelchair provides time for the client to gain equilibrium and allows dependent blood in the lower extremities to return to the heart. Next, positioning the legs under the client's center of gravity reduces back strain and stabilizes the client to stand. To ensure a safe transfer for a client with hemiparesis (unilateral muscle weakness), a transfer belt provides a secure hold to prevent sudden falls.

The nurse recognizes which behaviors in a client as warning signs of an impending suicide attempt? (Select all that apply.) a. Reports feelings of sadness. b. Mood changes from depressed to happy. c. Begins giving away possessions. d. Becomes compliant with medication regimen. e. Independently joins a support group

b. Mood changes from depressed to happy. c. Begins giving away possessions Feelings of elation and giving away possessions are common characteristics of those who have made a plan to commit suicide. Feelings of sadness are signs of depression but not impending suicide. Options D and E are not typically indicative of impending suicide.

The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which resulted in burned areas. Which expected outcome statement has the highest priority? A. The child will be protected from further harm. B. The family's cultural values will be respected. C. The parents will express regret at harming their child. D. The parents will demonstrate an ability to care for burn wounds.

The child will be protected from further harm. The nurse's highest priority is to ensure that no further harm befalls the child. Options B, C, and D are also important objectives but are secondary to option A.

A client being treated for an acute myocardial infarction is to receive the tissue plasminogen activator alteplase. The nurse would be correct in providing which explanation to the client regarding the purpose of this drug? A. This drug is a nitrate that promotes vasodilation of the coronary arteries. B. This drug is a clot buster that dissolves clots within a coronary artery. C. This drug is a blood thinner that will help prevent the formation of a new clot. D. This drug is a volume expander that improves myocardial perfusion by increasing output.

This drug is a clot buster that dissolves clots within a coronary artery. t-PA, or tissue plasminogen activator, is a coronary-specific fibrinolytic agent that dissolves clots within the coronary arteries. This drug is not a calcium channel blocker or nitrate, which would promote vasodilation of the coronary arteries. This medication is not an anticoagulant, such as warfarin or heparin, which would prevent new clot formation. Volume expansion is not provided by an infusion of t-PA and would not necessarily improve myocardial perfusion caused by an increased cardiac output in a client with coronary artery disease.

The health care provider prescribes cisplatin to be administered in 5% dextrose and 0.45% normal saline with mannitol added. Which assessment parameters would be most helpful to the nurse in evaluating the effectiveness of the therapy? A. Oral temperature B. Blood cultures C. Urine output D. Liver enzyme levels

Urine output The effectiveness of the diuresis is best measured by urine output. Mannitol, an osmotic diuretic, is given during cisplatin therapy to promote diuresis and reduce the risk of nephrotoxicity and ototoxicity associated with this chemotherapeutic agent. Options A, B, and D do not provide information about the risk for nephrotoxicity and ototoxicity related to cisplatin administration.

Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk." C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk." D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings."

"Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method. Option B is incorrect because alcohol can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk. Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings.

The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You"

"Decreasing Cholesterol Levels Through Diet" A health promotion brochure about decreasing cholesterol is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Option A does not address the underlying causes of arteriosclerosis. Options B and D are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol.

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult."

"How will this affect your present sexual activity?" Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement.

The antigout medication allopurinol is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? A. "I take aspirin for my pain." B. "I frequently eat fruit and drink fruit juices." C. "I drink a great deal of water, so I have to get up at night to urinate." D. "I observe my skin daily to see if I have an allergic rash to the medication."

"I take aspirin for my pain." The client should be taught to avoid aspirin because the ingestion of aspirin or diuretics can precipitate an attack of gout. Options B, C, and D are all appropriate for the treatment of gout. The client's urinary pH can be increased by the intake of alkaline ash foods, such as citrus fruits and juices, which will help reduce stone formation. Increasing fluids helps prevent urinary calculi (stone) formation and should be encouraged, even if the client must get up at night to urinate. Allopurinol has a rare but potentially fatal hypersensitivity syndrome, which is characterized by a rash and fever. The medication should be discontinued immediately if this occurs.

A middle-aged client tells the clinic nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." Which is the best response for the nurse to make? A. "Describe in more detail your feelings about being overwhelmed." B. "Why don't you give up some of your commitments?" C. "What has worked for you in the past?" D. "I know, but it is important to take time for yourself."

"What has worked for you in the past?" A nurse can help the client solve problems by identifying past coping mechanisms that could be transferred into current situations that the client finds to be overwhelming. The client has already expressed some degree of hopelessness (overwhelmed and anxious), so option A is redundant. Option B is advice giving and may not be possible for the person, and this response does not encourage the client to employ known methods of coping. Option D is also considered advice giving, with an implied value judgment.

The nurse anticipates administering Rho(D) immune globulin (RhoGAM) to which individuals? (Select all that apply.) A. An Rh-negative woman who has had a miscarriage at 24 weeks B. The father of a baby of an Rh-positive fetus C. An Rh-negative mother after delivery of an Rh-positive infant with a negative direct Coombs test D. An Rh-positive infant within 72 hours after birth E. An Rh-negative mother with a negative antibody titer at 28 weeks

-An Rh-negative woman who has had a miscarriage at 24 weeks -An Rh-negative mother after delivery of an Rh-positive infant with a negative direct Coombs test -An Rh-negative mother with a negative antibody titer at 28 weeks (A, C, and E) are all candidates for RhoGAM. RhoGAM should never be given to an infant or father (B and D).

The nurse assesses a woman in the emergency room who is in her third trimester of pregnancy. Which finding(s) is(are) indicative of abruptio placentae? (Select all that apply.) A. Dark red vaginal bleeding B. Rigid boardlike abdomen C. Soft abdomen on palpation D. Complaints of severe abdominal pain E. Painless bright red vaginal bleeding

-Dark red vaginal bleeding -Rigid boardlike abdomen -Complaints of severe abdominal pain These are all signs of abruptio placentae (A, B, and D). The others are signs of placenta previa (C and E).

The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a client who has had an appendectomy. The IV tubing being used delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is necessary, round to the nearest whole drop.)

1000 ml D5W / 8 hours = 125 ml/hr x 15 gtt/60 = 31.2 gtt/min. or *31* gtt/min.

Dopamine, 5 mcg/kg/min, is prescribed for a client who weighs 105 kg. The nurse mixes 400 mg of dopamine in 250 mL D5W for IV administration via an infusion pump. What is the hourly rate that the nurse should set on the pump? A. 5 mL/hr B. 10 mL/hr C 15 mL/hr D. 20 mL/hr

20 mL/hr 400 mg/250 mL equals 1.6 mg/mL, or 1600 mcg/mL. The prescription for 5 mcg/kg/min would result in 31,500 mcg/hr. Delivery of that dose would be achieved by administering 20 mL/hr, which would deliver 5.07 mcg/kg/min. Options A, B, and C are not accurate hourly rates for this infusion.

The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign? A. 3 B. 4 C. 5 D. 8

5 The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0, and a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a total score of 5. Options A, B, and D are not accurate.

The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 lb. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available 150 mg/5 mL. What is the correct dosage as indicated on the figure. A. 30 mL B. 15 mL C. 10 mL D. 5 mL

66 lb/(2.2 kg/lb) = 30 kg 30 kg × (15 mg/kg) = 450 mg (5 mL/150 mg) × 450 mg = 15 mL or (450 mg/150 mg) × 5 mL = *15 mL*

In caring for a pregnant woman with gestational diabetes, the nurse should be alert to which finding? A. A consistent fasting blood sugar level between 80 and 85 mg/dL B. A 2-hour postprandial level >120 mg/dL C. Client reports taking a 30-minute walk after dinner D. Client describes eating pattern of four to six meals daily

A 2-hour postprandial level >120 mg/dL Two-hour postprandial levels >120 mg/dL may indicate the need for the initiation of insulin to maintain adequate blood glucose levels; consequently, a value >120 mg/dL should be assessed further. Fasting blood sugars between 80 and 85 mg/dL are normal. Options C and D are healthy behaviors for a woman with gestational diabetes.

Which client is best to assign to a graduate PN who is being oriented to a renal unit? A. A client who is 1 day postoperative after placement of an arteriovenous (AV) shunt B. A client who is receiving continuous ambulatory peritoneal dialysis C. A client with continuous bladder irrigation for hematuria D. A client with renal calculi whose urine needs to be strained

A client with renal calculi whose urine needs to be strained The client with renal calculi (kidney stones) is the most stable client for a PN who is being oriented. Straining urine and the administration of pain medication are tasks that can be safely performed with minimal risk of problems. Options A, B, and C require careful assessment from an experienced nurse because of the potential for significant complications.

A male client with prostatic carcinoma has arrived for his scheduled dose of docetaxel chemotherapy. What symptom would indicate a need for an immediate response by the nurse prior to implementing another dose of this chemotherapeutic agent? A. A cough that is new and persistent B. Persistent nausea and vomiting C. Fingernail and toenail changes D. Increasing weakness and neuropathy

A cough that is new and persistent Option A is an adverse effect that is immediately life threatening. Severe fluid retention can cause pleural effusion (requiring urgent drainage), dyspnea at rest, cardiac tamponade, or pronounced abdominal distention (caused by ascites). Options B, C, and D are all adverse effects from chemotherapy and need to be monitored consistently.

The nurse is preparing a teaching plan for a group of healthy adults. Which individual is most likely to maintain optimum health? A. A teacher whose blood glucose levels average 126 mg/dL daily with oral antidiabetic drugs B. An accountant whose blood pressure averages 140/96 mm Hg and who says he does not have time to exercise C. A stock broker whose total serum cholesterol level dropped to 290 mg/dL with diet modifications D. A recovering IV heroin user who contracted hepatitis more than 10 years ago

A teacher whose blood glucose levels average 126 mg/dL daily with oral antidiabetic drugs The diabetic teacher has assumed responsibility for self-care, so among those listed, he or she is the most likely to maintain optimum health. Option B has expressed a lack of interest in health promotion. Option C continues to demonstrate a high-risk cholesterol level despite a reported attempt at dietary modifications. Previous IV drug use and a history of hepatitis make this individual a health risk despite the fact that the individual is in recovery.

The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first? A. An 18-year-old woman who had a positive pregnancy test and wants advice on how to tell her parents B. A woman with type 1 diabetes who has just discovered she is pregnant and is worried about her fingerstick glucose C. A women at 24 weeks of gestation crying about painful genital lesions on the vulva and urinary frequency D. A women at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn

A women at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn The women with epigastric pain should be called first. One of the cardinal signs of eclampsia, a life-threatening complication of pregnancy, is epigastric pain. Options A, B, and C are less serious and should be called after option D.

A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? A. Americans with Disabilities Act of 1990 B. ANA Code of Ethics with Interpretative Statements C. ANA's Scope and Standards of Nursing Practice D. Patient's Bill of Rights of 1990

ANA's Scope and Standards of Nursing Practice The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to direct the philosophy and standards of psychiatric nursing practice. Options A and D define the client's rights. Option B provides ethical guidelines for nursing.

A nurse performs an initial admission assessment of a 56-year-old client. Which factor(s) would indicate that the client is at risk for metabolic syndrome? (Select all that apply.) A. Abdominal obesity B. Sedentary lifestyle C. History of hypoglycemia D. Hispanic or Asian ethnicity E. Increased triglycerides

Abdominal obesity Sedentary lifestyle Hispanic or Asian ethnicity Increased triglycerides Metabolic syndrome is a name for a group of risk factors that increase the risk for coronary artery disease, type 2 diabetes, and stroke (A, B, D, and E). Hypoglycemia is not a risk factor for metabolic syndrome (C).

A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take? A. Administer the prescribed dose at the scheduled time. B. Hold the dose and contact the health care provider. C. Hold the dose and recheck the blood pressure in 1 hour. D. Check the health care provider's prescription to clarify the dose.

Administer the prescribed dose at the scheduled time. The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered. Options B and C would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, option D is not necessary.

A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond? A. Ask him to rate his pain on a scale of 1 to 10. B. Encourage him to wait until bedtime so the pill can help him sleep. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct him in the use of deep breathing exercises for pain control.

Ask him to rate his pain on a scale of 1 to 10. Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be used as an adjunct to pain medication, not instead of medication.

A female client with trichomoniasis (Trichomonas vaginalis) receives a prescription for metronidazole. Which instruction is most important for the nurse to include in this client's teaching plan? A. Avoid alcohol consumption. B Complete the medication regimen. C Use a barrier contraceptive method. D. Treat partner(s) concurrently.

Avoid alcohol consumption. Clients should be instructed to avoid alcohol and products containing alcohol while taking metronidazole because of the possibility of a disulfiram-like reaction. Option B helps prevent the development of metronidazole-resistant T. vaginalis. To prevent reinfection, clients should abstain from sexual contact or use a barrier contraceptive while taking metronidazole, and their partner(s) should be treated concurrently. The most important instruction for client well-being is option A.

The nurse is correct in withholding an older adult client's dose of nifedipine if which assessment finding is obtained? A. Blood pressure of 90/56 mm Hg B. Apical pulse rate of 68 beats/min C. Potassium level of 3.3 mEq/L D. Urine output of 200 mL in 4 hours

Blood pressure of 90/56 mm Hg Nifedipine is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male. A pulse rate <60 beats/min is an indication to withhold the drug. A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia. Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200-mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose.

A comatose client is admitted to the critical care unit, and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids? A. Pain scale B. Vital signs C. Breath sounds D. Level of consciousness

Breath sounds Before administering IV fluids through a central line, the nurse must first ensure that the catheter did not puncture the vessel or lungs. A chest radiograph should be obtained STAT, and the nurse should auscultate the client's breath sounds. Options A, B, and D are important assessment data but are not specifically related to insertion of a central venous catheter.

Which instruction should the nurse include in the teaching plan for a client who is receiving phenytoin for seizure control? A. Maintain consistent sodium intake. B. Use sunscreen when outdoors. C. Return for monthly urinalysis. D. Brush and floss teeth daily.

Brush and floss teeth daily. Brushing and flossing the teeth daily prevent gingival hyperplasia (gum disease) that is common with long-term phenytoin therapy. Options A, B, and C are not indicated for client instruction regarding phenytoin.

The charge nurse is reviewing the admission history and physical data for four clients newly admitted to the unit. Which client is at greatest risk for adverse reactions to medications? A. 30-year-old man with a fracture B. 7-year-old child with an ear infection C. 75-year-old woman with liver disease D. 50-year-old man with an upper respiratory tract infection

C. 75-year-old woman with liver disease Impaired hepatic metabolic pathways for drug and chemical degradation place option C at greatest risk for adverse reactions to medications based on advancing age and liver disease. Options A and D have no predisposing factors, such as genetics, pathophysiologic dysfunction, or drug allergies, that would increase the risk for cumulative toxicity or adverse drug reactions. Option B is at risk for dose-related adverse reactions but is at less risk than option C.

Which factor is most important to ensure compliance when planning to teach a client about a drug regimen? A. Genetics B. Client age C. Client education D. Absorption rate

Client education The client's educational level is the most important factor when planning teaching to ensure a client's compliance with taking a prescribed drug. Options A and D are physiologic responses that do not relate to a client's compliance. Although maturity level and age contribute to compliance, the client's basic understanding of instructions, which is best indicated by educational level, is more significant.

An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A. Leukocytosis and febrile B. Polycythemia and crackles C. Pharyngitis and sputum production D. Confusion and tachycardia

Confusion and tachycardia The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate. Options A, B, and C are often absent in the older client with bacterial pneumonia.

The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take? A. Reapply the external transducer. B. Insert the intrauterine pressure catheter. C. Discontinue the oxytocin infusion. D. Continue to monitor labor progress.

Continue to monitor labor progress. The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress and document the findings in the client's record. There is no reason to reapply the external transducer if the FHR tracings are being captured. Options B and C are not indicated at this time.

The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention? A. Cross-country skiing B. Scuba diving C. Horseback riding D. Kayaking

Cross-country skiing Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the activities listed, cross-country skiing includes the most weight-bearing, whereas options B, C, and D involve less.

When developing a written nursing care plan for a client receiving chemotherapy for treatment of cancer, the nurse writes, "Assess each voiding for hematuria." The administration of which type of chemotherapeutic agent would prompt the nurse to add this intervention? A. Vincristine B. Bleomycin sulfate C. Chlorambucil D. Cyclophosphamide

Cyclophosphamide Hemorrhagic cystitis is the characteristic adverse reaction of cyclophosphamide. Administration of options A, B, and C does not typically cause hemorrhagic cystitis.

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide formula for the infant until he becomes calm, and then offer the breast again.

Encourage the mother to stop feeding for a few minutes and comfort the infant. The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful. Options A and D would cause nipple confusion. Option B would only cause the infant to be more resistant, resulting in the mother and infant becoming more frustrated.

A client who has been hospitalized for 2 weeks for paranoia reports continuously to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take based on the client's complaints? A. Enroll the client in an exercise class to promote positive activities. B. Place a lock on the client's closet to allay the client's concerns. C. Promote extinction of the ideation by ignoring the client. D. Explain to the client that these suspicions are certainly false.

Enroll the client in an exercise class to promote positive activities. Diverting the client's attention from paranoid ideation and encouraging the client to engage in positive activities can be helpful in assisting to develop a positive self-image. Option B actually supports paranoid ideation. Option C may lower self-esteem. The nurse should not argue with the client about the delusions (option D).

A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A. Assess for signs of jugular venous distention. B. Obtain the needed intravenous solution. C. Flush the line with heparinized solution. D. Flush the line with normal saline.

Flush the line with normal saline. Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin. Option A will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than option B.

A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family? A. Follow exposure precautions. B. Encourage regular meals. C. Collect all urine. D. Avoid touching the client.

Follow exposure precautions. Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others. Option B is a good suggestion to promote adequate nutrition but is not as important as option A. Option C is unnecessary. Contact with the client is permitted but should be brief to limit radiation exposure.

The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor.

Gently lower the client to the floor. Option D is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. Option A is important but should be done after the client is in a safe position. Because the client is not supporting himself, option B is impractical. Option C is likely to cause chaos on the unit and might alarm the other clients.

The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment? A. Hearing acuity B. Immunization history C. Weight and length D. Head circumference

Immunization history The Centers for Disease Control and Prevention indicates that vaccines are among the most widely used, effective, and safe medical products in use today. Assessing the infant immunization histories in clients from disadvantaged socioeconomic groups is the most effective method for determining these infants' susceptibilities to vaccine-preventable diseases. Assessment of options A, C, and D provides valuable information but does not supply information about infants' susceptibilities to vaccine-preventable diseases, which are major causes of infant mortality and morbidity.

The health care provider prescribes 1000 mL of Ringer's lactate solution with 30 units of oxytocin (Pitocin) to infuse over 4 hours for a client who has just delivered a 10-lb infant by cesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse should set the flow rate at how many gtt/min? A. 42 B. 83 C. 125 D. 250

1000 mL of LR with oxytocin 30 mg/4 hours = 250 ml/hr x 20 gtt/60 = 83.3 or *83* ml/hr

A client at 32 weeks of gestation is hospitalized with preeclampsia, and magnesium sulfate is prescribed to control the symptoms. Before the next dose of MgSO4 is given, which assessment finding indicates that the client is at risk for toxicity? A. Deep tendon reflexes-decrease to 2+ B. 100 mL of urine output in 4 hours C. Respiratory rate decreases to 16 breaths/min D. Serum magnesium level, 7.5 mg/dL

100 mL of urine output in 4 hours The minimum urine output expected for a repeat dose of magnesium sulfate is 30 mL/hr, so 100 mL of urine in 4 hours can lead to poor excretion of magnesium, with a possible cumulative effect. Magnesium sulfate, a central nervous system (CNS) depressant, helps prevent seizures, so option A is a positive sign that the medication is having a desired effect. A decreased respiratory rate indicates that the drug is effective. A respiratory rate below 12 breaths/min indicates toxic effects. The therapeutic level of magnesium sulfate for a PIH client is 4 to 8 mg/dL.

The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? A. 14 B. 16 C. 17 D. 28

16 The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled. Options A, C, and D are inaccurate recordings.

The nurse prepares to administer ophthalmic drops to a client prior to cataract surgery. List the steps in the order that they should be implemented from first step to final step. 1. Drop prescribed number of drops into conjunctival sac. 2. Wash hands and apply clean gloves. 3. Place dominant hand on the client's forehead. 4. Ask the client to close the eye gently.

2, 3, 1, 4 Washing hands and applying gloves prior to procedure initiation prevents the spread of infection (2). Placing the dominant hand on the client's forehead (3) stabilizes the hand so the nurse can hold the dropper 1 to 2 cm above the conjunctival sac and drop the prescribed number of drops (1); asking the client to close the eye gently helps distribute the medication (4).

The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider? A. Ammonia odor is noted when the catheter is emptied. B. 240 mL of urinary output is produced in 12 hours. C. A 16-French catheter was used for an adult female. D. Drainage system is hanging below the level of the bladder.

240 mL of urinary output is produced in 12 hours. An expected finding is between 400 and 750 mL in 12 hours = average of 30 mL/hr. Ammonia odor is an expected finding. Size 14- to 18-French catheters are common sizes used in the adult female. Below the level of the bladder is the correct position for the drainage bag.

The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last. 1. Gently insert the catheter without suction using sterile technique. 2. Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). 3. Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. 4. Apply suction intermittently while withdrawing the catheter.

3, 2, 1, 4 Equipment should be set up and adjusted prior to beginning the procedure. Hyperoxygenation using an MRB should be completed prior to inserting the catheter. After preoxygenation, the catheter can be inserted and suction can be applied intermittently.

The nurse is administering the early morning dose of insulin aspart, 5 units subcutaneously, to a client with diabetes mellitus type 1. The client's fingerstick serum glucose level is 140 mg/dL. Considering the onset of insulin aspart, when should the nurse ensure that the client's breakfast be given? A. 5 minutes after subcutaneous administration B. 30 minutes after subcutaneous administration C. 1 to 2 hours after administration D. At any time because of a flat peak of action

5 minutes after subcutaneous administration Insulin aspart is a very rapidly acting insulin, with an onset of 5 to 15 minutes. Insulin aspart should be administered when the client's tray is available. Insulin aspart peaks in 45 minutes to 1½ hours and has a duration of 3 to 4 hours. The client should have eaten to ensure absorption of the meal so that serum glucose levels will coincide with the peak. Insulin glargine has a flat peak of action and is usually given at bedtime.

A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric amount does this child need? A. 400 calories/day B. 500 calories/day C. 600 calories/day D. 700 calories/day

600 calories/day An infant requires 108 calories/kg/day. The first step is to change 10 lb 15 oz to 10.9 lb. Then convert pounds to kilograms by dividing pounds by 2.2, which is 10.9/2.2 = 4.954 kg, rounded to 5 kg. The second step is to multiply 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because of the 1° F temperature elevation. Ten percent of 540 (calories/day) is 54, and 540 + 54 = 594. This infant will require approximately 600 calories/day. Options A, B, and D are incorrect.

A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse? A. A primigravida who is 8 cm dilated after 14 hours of labor B. A client scheduled for a repeat cesarean birth at 38 weeks' gestation C. A client being induced for fetal demise at 20 weeks' gestation D. A multiparous client who is dilated 5 cm and 50% effaced

A multiparous client who is dilated 5 cm and 50% effaced The new nurse should be assigned the least complicated client to gain experience and confidence, as well as protect client safety. Of the clients available for assignment, option D is progressing well and is the least complicated. Options A, B, and C have actual or potential complications and should be assigned to a more experienced nurse.

A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. Take a vitamin supplement tablet once a day. B. Change positions in the chair at least every hour. C. Increase daily intake of water or other oral fluids. D. Purchase a newer model wheelchair.

Change positions in the chair at least every hour. The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an intervention of last resort because this will be very expensive for the client.

When caring for an 80-year-old client with pneumonia, which finding is of most concern to the nurse? A. Decrease in level of consciousness B. BUN level, 20 mg/dL; creatinine level, 1.0 mg/dL C. Reports of a dry mouth and lips D. Fine crackles auscultated in lung bases

Decrease in level of consciousness A decrease in level of consciousness is a sign of decreased oxygenation and requires immediate intervention. Options B, C, and D are expected findings.

A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide? A. Decrease intake of fluids after the evening meal. B. Drink a glass of cranberry juice every day. C. Drink a glass of warm decaffeinated beverage at bedtime. D. Consult the health care provider about a sleeping pill.

Decrease intake of fluids after the evening meal. Nocturia is urination during the night. Option A is helpful to decrease the production of urine, thus decreasing the need to void at night. Option B helps prevent bladder infections. Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result in urinary incontinence if the client is sedated and does not awaken to void.

The nurse is preparing a child for transport to the operating room for an emergency appendectomy. The anesthesiologist prescribes atropine sulfate, IM STAT. What is the primary purpose for administering this drug to the child at this time? A. Decrease the oral secretions. B. Reduce the child's anxiety. C. Potentiate the opioid effects. D. Prevent possible peritonitis.

Decrease the oral secretions. Atropine sulfate, an anticholinergic agent, is given to decrease oral secretions during a surgical procedure. Options B, C, and D are not actions of anticholinergic agents.

Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome? A. "Get immunization against human papillomavirus (HPV)." B. "Change your tampon frequently." C. "Empty your bladder after intercourse." D. "Obtain a yearly flu vaccination."

"Change your tampon frequently." Certain strains of Staphylococcus aureus produce a toxin that can enter the bloodstream through the vaginal mucosa. Changing the tampon frequently reduces the exposure to these toxins, which are the primary cause of toxic shock syndrome. Option A helps prevent cervical cancer, not toxic shock syndrome. Option C can lessen the incidence of urinary tract infection. Option D can help prevent some individuals from contracting the flu and pneumonia, but no relationship to toxic shock syndrome has been proven.

In conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma? A. "Have you ever been told that you have hardening of the arteries?" B. "Do you frequently experience eye pain?" C. "Do you have high blood pressure or kidney problems?" D. "Does anyone in your family have glaucoma?"

"Does anyone in your family have glaucoma?" Glaucoma has a definite genetic link, so clients should be screened for a positive family history, especially an immediate family member. Options A and C are not related to glaucoma. Glaucoma rarely causes pain, which is why screening is so important.

A client in an acute psychiatric setting asks the nurse if their conversations will remain confidential. How should the nurse respond? A. "The Health Insurance Portability and Accountability Act (HIPAA) prevents me from repeating what you say." B. "You can be assured that I will keep all of our conversations confidential because it is important that you can trust me." C. "For your safety and well-being, it may be necessary to share some of our conversations with the health care team." D. "I am legally required to document all of our conversations in the electronic medical record."

"For your safety and well-being, it may be necessary to share some of our conversations with the health care team." Some information, such as a suicide plan, must be shared with other team members for the client's safety and optimal therapy. HIPAA does not prevent a member of the health care team from repeating all conversations, particularly if safety is an issue. Ensuring a client that a conversation will remain confidential puts the nurse at risk, particularly if safety is an issue. Although pertinent information should be documented, the nurse is not legally required to document all conversations with a client.

Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with otitis externa? A. "Has your child been swimming recently?" B. "Has you child had a recent sore thorat?" C. "Does your child drink from a sippy cup?" D. "Is anyone else in the home ill?"

"Has your child been swimming recently?" Otits externa is an external ear infection and often due to swimming and the retention of fluid in the ear. Options B and C are not relative to otitis. Otitis externa is not contagious, so option D is not relevant.

The nurse is completing an admission interview for a client with Parkinson disease. Which question will provide additional information about manifestations that the client is likely to experience? A. "Have you ever experienced any paralysis of your arms or legs?" B. "Do you have frequent blackout spells?" C. "Have you ever been frozen in one spot, unable to move?" D. "Do you have headaches, especially ones with throbbing pain?"

"Have you ever been frozen in one spot, unable to move?" Clients with Parkinson disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move. Parkinson disease does not typically cause option A, B, or D.

The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A. "Hold the medication in your mouth for a few minutes before swallowing it." B. "Do not drink or eat milk products for 1 hour prior to taking this medication." C. "Dilute the medication with juice to reduce the unpleasant taste and odor." D. "Take the medication before meals to promote increased absorption."

"Hold the medication in your mouth for a few minutes before swallowing it." Nystatin suspension is prescribed for *fungal infections of the mouth.* The client should swish the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness. Option D is not necessary.

The Milwaukee brace is designed to slow the progression in spinal curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed a total of 1 hour a day for hygiene. There are no specific exercises for increasing the range of motion in the back that should be performed. A T shirt should be worn next to the body and the brace put on over the T shirt to protect the skin. The brace will not cure the spinal curvature but should slow the progression of the scoliosis. A. "I will give her a baby aspirin every 4 hours as needed for fever." B. "I will call the clinic if her cry becomes high-pitched or unusual." C. "I know I can expect her to be irritable over the next 2 days." D. "I will exercise her legs regularly to decrease the soreness."

"I will give her a baby aspirin every 4 hours as needed for fever." Although fever may occur, non-aspirin-containing medications should be used because of the risk of Reye syndrome. Option B indicates a severe reaction, whereas option C is a common side effect. Option D decreases soreness in the thigh injection site.

A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond? A. "Let's play some dominoes for a few minutes." B. "I don't think the violence means the world is ending." C. "The news makes you have upsetting thoughts." D. "Listening to the news seems to be frightening you."

"Listening to the news seems to be frightening you." A client's delusional statements are best addressed by identifying the feeling associated with the delusion. Option A may be helpful but ignores the feelings that the client is experiencing. Delusional clients often argue with statements that contradict their belief system. The client is unlikely to understand the relationship between the news and the thoughts experienced.

The nurse is preparing a teaching plan for a client who has received a new prescription for levothyroxine sodium. Which instruction should be included? A. "Take this medication with a high-protein snack at bedtime." B. "You may change at any time to a less expensive generic brand." C. "Take your pulse daily, and if it exceeds 100 beats/min, contact the health care provider." D. "Return to the clinic weekly for serum blood glucose testing."

"Take your pulse daily, and if it exceeds 100 beats/min, contact the health care provider." Levothyroxine sodium should be withheld if the pulse is over 100 beats/min. To prevent insomnia, the daily dose should be taken early in the morning before breakfast, not at bedtime. Product brands should not be changed without consulting the health care provider because the intended effects and side effects of different formulations of the medication can vary. The serum glucose level is not affected by thyroid preparations, so option D is not required.

The nurse has completed diabetic teaching for a client who has been newly diagnosed with diabetes mellitus. Which statement by this client would indicate to the nurse that further teaching is needed? A. "Regular insulin can be stored at room temperature for 30 days." B. "My legs, arms, and abdomen are all good sites to inject my insulin." C. "I will always carry hard candies to treat hypoglycemic reactions." D. "When I exercise, I should plan to increase my insulin dosage."

"When I exercise, I should plan to increase my insulin dosage." Exercise helps facilitate the entry of glucose into the cell, so increasing insulin doses with exercise would place the client at high risk for a hypoglycemic reaction. Options A, B, and C reflect accurate statements about the use of insulin and management of hypoglycemic reactions.

The nurse administers regular insulin (human), 8 units subcutaneously, to a client at 8:00 am, 30 minutes before breakfast. At what time is the client most at risk for a hypoglycemic reaction? A. 9:30 am B. 10:30 am C. 12:00 pm D. 3:00 pm

10:30 am Regular insulin is short-acting and peaks between 2 and 3 hours after administration. The client is most at risk for a hypoglycemic reaction during the peak times. Options A, C, and D are not high-risk times for the client to experience hypoglycemia because they do not fall within the peak time.

The nurse calls the primary health care provider to report the status of a postsurgical client. Place the statements in the correct SBAR communication format. 1. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P 150/88, HR 90, and RR 26, with an O2 sat of 95%." 2. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital." 3. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain control with his current medication regimen since the surgery." 4. "Would you like to make a change in his pharmacologic regimen?"

2, 3, 1, 4 SBAR: S = Situation and includes introduction of the nurse and client/setting (option B). B = Background and includes the presenting complaint and relevant history (option C). A = Assessment and includes current vital signs and other information (option A). R = Recommendations and includes an explanation of why you are calling or a suggestion about which action should be taken (option D).

According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults? A. A 60-year-old man who tells the nurse that he is feeling fine and really does not need any help from anyone B. A 78-year-old widower who has come to the mental health clinic for counseling after the recent death of his wife C. An 81-year-old woman who states that she enjoys having her grandchildren visit but is usually glad when they go home D. A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years

A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years The older woman who wishes she could change the choices she has made in her lifetime is expressing despair and is still searching for integrity. The nurse uses Erikson stages of development over the lifespan to assess an older client's adjustment to aging and plans teaching strategies to assist the client to attain integrity versus despair. Options A, B, and C are normal developmental tasks of older adults.

The blood pressure should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and who have chronic hypertension are at increased risk. Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. Options B, C, and D can be done if the blood pressure is normal. A. A client who is 2 days postoperative with a right total knee replacement B. A client who is scheduled for a sigmoid colostomy surgery today C. A client who has a surgical abdominal wound with dehiscence D. A client who is 1 day postoperative following a right-sided mastectomy

A client who is 2 days postoperative with a right total knee replacement Option A is the least critical client and should be assigned to the RN with the least experience. A client with a knee replacement is probably ambulating and able to perform self-care, and a physical therapist is likely to be assisting with the client's care. Option B will require a high level of nursing care when returned from surgery. Option C means that there is a separation or rupture of the wound, which requires an experienced nurse to provide care. Option D requires extensive teaching and should be assigned to a more experienced nurse.

Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A. A stage III sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B. Pneumonia, with a sputum culture of gram-negative bacteria C. Urinary tract infection, with positive blood cultures D. Culture of a diabetic foot ulcer shows gram-positive cocci

A stage III sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) The client with colonized MRSA is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy, which makes recovery very difficult. Positive blood cultures indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer at high risk for poor healing and bone infection.

The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.) A. Monitor maternal vital signs for hemorrhage. B. Instruct the woman to report any contractions. C. Ensure that the woman has a full bladder prior to beginning. D. Monitor fetal heart rate for 1 hour after the procedure. E. Place the client in a side-lying position.

A. Monitor maternal vital signs for hemorrhage. B. Instruct the woman to report any contractions. D. Monitor fetal heart rate for 1 hour after the procedure. These are safe measures to implement during an amniocentesis to monitor for and prevent complications (A, B, and D). During late pregnancy the bladder should be emptied so that it will not be punctured, but during early pregnancy the bladder must be full to push the uterus upward (C). The woman should be placed in a supine position with her hands across her chest (E).

Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.) A. Importance of adherence to medication regimen B. Current treatment measures for substance abuse C. Signs and symptoms of an exacerbation D. Prevention of criminal activity E. Behavior modification for aggression F. Chronic grief associated with long-term illness

A. Importance of adherence to medication regimen C. Signs and symptoms of an exacerbation F. Chronic grief associated with long-term illness Medication adherence is an important component of successful rehabilitation (A). Clients and their families also need to know the signs and symptoms of an exacerbation or relapse of the disease (C), which is frequently associated with poor medication compliance. Acknowledging the chronic sorrow associated with severe and persistent mental illness (F) helps individuals negotiate the grieving process. (B, D, and E) are not universal problems associated with schizophrenia.

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A. Mode of transmission B. Portal of entry C. Reservoir D. Portal of exit

A. Mode of transmission The contaminated gloves serve as the mode of transmission from the portal of exit of the reservoir to a portal of entry.

A 4-year-old child is receiving chemotherapy for acute lymphocytic leukemia. Which laboratory result should the nurse examine to assess the child's risk for infection? A. Neutrophil count B. Platelet count C. Reticulocyte count D. Lymphocyte count

A. Neutrophil count During chemotherapy, granulocytes are significantly suppressed. Because neutrophils comprise 60% to 70% of the granulocyte count, these levels are the most useful laboratory results of the options presented to determine the child's risk for infection. Options B, C, and D are not as useful as option A in determining risk of infection.

When planning care for the client undergoing electroconvulsive therapy (ECT), which equipment should the nurse make available? (Select all that apply.) A. Oxygen B. Suction equipment C. Continuous passive range-of-motion (CPM) machine D. Crash cart E. Chest tube drainage system

A. Oxygen B. Suction equipment D. Crash cart Because aspiration is a potential complication, emergency equipment such as oxygen, suction, and a crash cart should be available (A, B, and D). The client is only unconscious for a short period; therefore, there is no need for a CPM machine (C). ECT does not put the client at risk for a pneumothorax; therefore, a chest tube drainage system is not needed (E).

The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately? A. Reactivity of deep tendon reflexes, comparing upper with lower extremities B. Vital sign readings, excluding blood pressure if needed equipment is unavailable C. Memory of events that occurred before and after the blow to the head D. Ability to open the eyes spontaneously before any tactile stimuli are given

Ability to open the eyes spontaneously before any tactile stimuli are given The level of consciousness (LOC) should be established immediately when a head injury has occurred. Spontaneous eye opening is a simple measure of alertness that indicates that arousal mechanisms are intact. Option A is not the best indicator of LOC. Although option B is important, vital signs are not the best indicators of LOC and can be evaluated after the client's LOC has been determined. Option C can be assessed after LOC has been established by assessing eye opening.

Which parameter is most important for the nurse to check prior to administering a subcutaneous injection of heparin? A. Heart rate B. Urinary output C. Activated partial thromboplastin time (aPTT) D. Prothrombin time (PT) and international normalized ratio (INR)

Activated partial thromboplastin time (aPTT) The laboratory value that measures heparin's therapeutic anticoagulation time is the aPTT. Option A should be checked before the administration of digoxin. Option B is valuable information but not a parameter measured for heparin therapy. Option D is evaluated during anticoagulation therapy using sodium warfarin.

A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the right lateral abdominal area. Which drug should the nurse expect to administer to treat this condition? A. Levofloxacin B. Acyclovir sodium C. Fluconazole D. Esomeprazole

Acyclovir sodium The clinical manifestations listed are consistent with herpes zoster (shingles). Acyclovir sodium is an antiviral used to treat herpes zoster or shingles. Levofloxacin is an antibiotic and may be used to treat pneumonia or other infections in the HIV client. Fluconazole is an antifungal and is used to treat candidiasis in the HIV client. Esomeprazole is a protein pump inhibitor used for gastroesophageal reflux disease.

A client who is prescribed chlorpromazine HCl for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most important? A. Administer a dose of benztropine mesylate PRN. B. Determine if the client has increased photosensitivity. C. Provide comfort measures for sore muscles. D. Assess the client for visual and auditory hallucinations.

Administer a dose of benztropine mesylate PRN. Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with chlorpromazine. It is most important for the nurse to administer an anticholinergic such as benztropine mesylate to reverse these effects. Options B, C, and D may be appropriate interventions but are not as urgent as option A.

Which intervention(s) should the nurse implement when administering a new prescription of amitriptyline HCl to a client with a depressive disorder? (Select all that apply.) A. Explain that therapeutic effects should be achieved within 1 to 3 days. B. Administer at bedtime to minimize sedative effects. C. Give 1 hour after the administration of isocarboxazid (Marplan). D. Take blood pressure prior to and after administration. E. Assess for adverse reactions such as dry mouth and blurred vision.

Administer at bedtime to minimize sedative effects. Take blood pressure prior to and after administration. Assess for adverse reactions such as dry mouth and blurred vision. The drug causes sedation, so it should be given at bedtime (B). Cardiovascular adverse reactions include orthostatic hypotension; therefore, the blood pressure should be assessed (D). This drug can cause anticholinergic effects such as dry mouth, blurred vision, constipation, and urinary retention (E). The drug takes 2 to 6 weeks to achieve therapeutic effects (A). All monoamine oxidase (MAO) inhibitors such as isocarboxazid should be discontinued 1 to 3 weeks prior to the administration of amitriptyline HCl(C).

Which interventions should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.) A. Provide a low-fiber diet. B. Administer mineral oil daily. C. Decrease the daily fluids. D. Eliminate dairy products. E.Initiate consistent toileting routine.

Administer mineral oil daily. Eliminate dairy products. Initiate consistent toileting routine. Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining with mineral oil, eliminating dairy products, and initiating a regular toileting routine. A high-fiber diet, not option A, and increased daily fluids, not option C, are components of care for a child with encopresis.

The nurse prepares to administer digoxin, 0.125 mg PO, to an adult client with heart failure and notes that the digoxin serum level in the laboratory report is 1 ng/mL. Which action should the nurse take? A. Discontinue the digoxin. B. Notify the health care provider. C. Administer the digoxin. D. Reverify the digoxin level.

Administer the digoxin. A therapeutic range for digoxin is 0.5 to 2 ng/mL. The digoxin should be continued to maintain a therapeutic range. Options A, B, and D are not indicated for a therapeutic range.

The nurse performs a client assessment prior to the administration of a prescribed dose of dipyridamole and aspirin PO. The nurse notes that the client's carotid bruit is louder than previously assessed. Which action should the nurse implement? A. Administer the prescribed dose as scheduled. B. Hold the dose until the health care provider is contacted. C. Advise the client to take nothing by mouth until further assessment is completed. D. Elevate the head of the bed and apply oxygen by nasal cannula.

Administer the prescribed dose as scheduled. A carotid bruit reflects the degree of blood vessel turbulence, which is typically the result of atherosclerosis. Aspirin is prescribed to reduce platelet aggregation and should be administered to this client, who is at high risk for thrombus occlusion. Options B, C, and D are not necessary interventions at this time.

The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure? A. Dilute each of the medications with sterile water prior to administration. B. Mix the medications in one syringe before opening the feeding tube. C. Administer water between the doses of the two liquid medications. D. Withdraw any fluid from the tube before instilling each medication.

Administer water between the doses of the two liquid medications. Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube and should be administered separately, with water instilled between each medication.

The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs? A.Place the child's head flat, with the knees on pillows above the level of the heart. B. Have the child lie on the right side, with the head elevated on one pillow. C. Allow the child to assume a knee-chest position, with the head and chest slightly elevated. D. Encourage the child to sit up at a 45-degree angle, drink cold water, and take deep breaths.

Allow the child to assume a knee-chest position, with the head and chest slightly elevated. Assuming a knee-chest position with the head and chest slightly elevated will help restore hemodynamic equilibrium. Options A and B are incorrect positions and may hinder the child's condition. Option D may cause chest pain or a vasovagal response, with resulting hypotension.

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? A. Wash the cord frequently with mild soap and water. B. Cover the cord with a sterile dressing. C. Allow the cord to air-dry as much as possible. D. Apply baby lotion after the baby's daily bath.

Allow the cord to air-dry as much as possible. Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process. Options A, B, and D are incorrect because they promote moisture and increase the potential for infection.

When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A. A young adult with bacterial meningitis with recent seizures B. An older adult client with pneumonia and viral meningitis C. A female client in isolation with meningococcal meningitis D. A male client 1 day postoperative after drainage of a brain abscess

An older adult client with pneumonia and viral meningitis The most stable client is option B. Options A, C, and D are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care.

The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding? A. Myocardial infarction 2 months ago B. Anorexia and vomiting for the past 2 days C. Recently diagnosed type 2 diabetes mellitus D. Skeletal traction for a right hip fracture

Anorexia and vomiting for the past 2 days The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys in filtering waste from the blood. Dehydration, which could be caused by vomiting, would cause an increased BUN level. Option A would affect serum enzyme levels, not the BUN level. Option C would primarily affect the blood glucose level; renal failure that could increase the BUN level would be unlikely in a client newly diagnosed with type 2 diabetes. Effects of option D might affect the complete blood count (CBC) but would not directly increase the BUN level.

The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which medication prescription should the nurse question? A. Antianginal with a therapeutic effect of vasodilation B. Anticholinergic with a side effect of pupillary dilation C. Antihistamine with a side effect of sedation D. Corticosteroid with a side effect of hyperglycemia

Anticholinergic with a side effect of pupillary dilation Clients with angle-closure glaucoma should not take medications that dilate the pupil because this can precipitate acute and severely increased intraocular pressure. Options A, C, and D do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.

Which clinical manifestation in the client with hyperthyroidism is most important to report to the health care provider? A. Nervousness B. Increased appetite C. Apical heart rate of 130 beats/min D. Insomnia

Apical heart rate of 130 beats/min The apical heart rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac disorders. Options A, B, and D are all expected findings that should also be reported but are not as critical.

One day after a Billroth II surgery, a male client suddenly grabs his right chest and becomes pale and diaphoretic. Vital signs are assessed as blood pressure 100/80 mm Hg, pulse 110 beats/min, and respirations 36 breaths/min. Which action is most important for the nurse to take? A. Provide a paper bag for his hyperventilation. B. Administer a prescribed PRN analgesic. C. Have the client drink a glass of sweetened fruit juice. D. Apply oxygen at 2 L via nasal cannula.

Apply oxygen at 2 L via nasal cannula. Pulmonary embolism and pneumothorax are risks associated with major abdominal surgery. The nurse should immediately provide oxygen while performing further assessment. A rapid respiratory rate should not be treated as hyperventilation. Option B should not be administered until more ominous causes are ruled out or treated. There is no evidence that the client is hypoglycemic.

During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings, what action should the nurse take? A. No action is required because this is an expected finding for a school-aged child. B.Ask if the child has had a cold, runny nose, or any ear pain lately. C. Send a note home advising parents to have the child evaluated by a health care provider. D. Call the parents and have them take the child home from school for the rest of the day.

Ask if the child has had a cold, runny nose, or any ear pain lately. More information is needed to interpret these findings. The tympanic membrane is normally pearly gray, not bulging, and moves when a client blows against resistance or when a small puff of air is blown into the ear canal. Because these findings are not completely normal, further assessment of history and related signs and symptoms are needed to interpret the findings accurately. Based on the data obtained from the otoscope examination, options A, C, and D are not indicated.

During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns.

Ask the client to talk about specific concerns. Option D provides an opportunity for the client to verbalize her concerns and provides the nurse with more assessment data. Options A and B may not be related to her current concern, assume that obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the concerns she is having.

A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse's response? A. Telling the client and her partner that the labor process is often unpredictable B. Informing the client that this means she will give birth sooner than expected C. Asking the client and her partner if they would like the nurse to stay in the room D. Affirming that the fetal heart rate is remaining within normal limits

Asking the client and her partner if they would like the nurse to stay in the room Offering to remain with the client and her partner offers support without providing false reassurance. The length of labor is not always predictable, but options A and B do not offer the client the support that is needed at this time. Option D may be reassuring regarding the fetal heart rate but does not provide the client the emotional support she needs at this time during the labor process.

Which nursing intervention has the highest priority during IV administration of mechlorethamine HCl and actinomycin? A.Assess for extravasation at the IV site during infusion. B. Premedicate with antiemetics 30 to 60 minutes before infusion. C. Monitor cardiac rate and rhythm during the IV infusion. D. Check the granulocyte count daily for the presence of neutropenia.

Assess for extravasation at the IV site during infusion. Mechlorethamine HCl and actinomycin are vesicants; therefore, assessment for blister formation and/or tissue sloughing that can occur with leakage of these agents into surrounding subcutaneous tissues is essential to ensure client safety during the IV infusion. Options B, C, and D do not have the priority of option A during the administration of vesicants.

When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16 weeks of gestation B. At 20 weeks of gestation C. At 24 weeks of gestation D. At 30 weeks of gestation

At 30 weeks of gestation Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child. Option D is closest to the time when parents would be ready for such classes. Options A, B, and C are not the best times during a pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her significant others.

Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns? A. Midnight census B. Oncoming shift census C. Average daily census D. Hourly census

Average daily census An average daily census is determined by trend data and takes into account seasonal and daily fluctuations, so it is the best method for determining staffing needs. Options A and B provide data at a certain point in time, and that data could change quickly. It is unrealistic to expect to obtain an hourly census, and such data would only provide information about a certain point in time.

The nurse is preparing to apply a surface anesthetic agent for a client. Which action should the nurse implement to reduce the risk of systemic absorption? A. Apply the anesthetic to mucous membranes. B. Limit the area of application to inflamed areas. C. Avoid abraded skin areas when applying the anesthetic. D. Spread the topical agent over a large surface area.

Avoid abraded skin areas when applying the anesthetic. To minimize systemic absorption of topical anesthetics, the anesthetic agent should be applied to the smallest surface area of intact skin. Application to the mucous membranes poses the greatest risk of systemic absorption because absorption occurs more readily through mucous membranes than through the skin. Inflamed areas generally have an increased blood supply, which increases the risk of systemic absorption, so option B should be avoided. A large surface area increases the amount of topical drug that is available for transdermal absorption, so the smallest area should be covered, not option D.

Which nursing interventions are therapeutic when caring for a hospitalized toddler? (Select all that apply.) A. Require parents to leave the room when performing invasive procedures. B. Allow the toddler to choose a colored Band-Aid after an injection. C. Give brief but simple explanations to the child before procedures. D. Insert a urinary catheter if bedwetting occurs during hospitalization. E. Do not allow any toys to be brought in from the child's home.

B. Allow the toddler to choose a colored Band-Aid after an injection. C. Give brief but simple explanations to the child before procedures. Giving the toddler a choice may increase autonomy in the hospitalized setting. Brief but simple explanations are beneficial with the toddler. Separation from the parent can cause emotional distress. Regression is expected, and bedwetting is not an indication for a urinary catheter. The nurse should encourage age-appropriate toys to be brought in from home.

An older client is receiving a water-soluble drug that is more than the average dose for a young adult. Which action should the nurse implement first? A. Obtain a prescription for lower medication dosages. B. Determine the drug's serum levels for toxicity. C. Start IV fluids to decrease the serum drug levels. D. Hold the next dosage and notify the health care provider.

B. Determine the drug's serum levels for toxicity. Older clients usually have a decline in lean body mass and total body water that causes water-soluble drugs to become distributed in fluid compartments, resulting in an increased concentration, so determining the drug's serum level for toxicity should be implemented first. Although options A, C, and D may be indicated, an increased plasma drug level should be the determining factor to consider when water-soluble drugs warrant a reduced dosage in the older client.

The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac disease? A. Turkey salad, milk, and oatmeal cookies B. Baked chicken, coleslaw, soda, and frozen fruit dessert C. Tuna salad sandwich on whole wheat bread, milk, and ice cream D. Turkey sandwich on rye bread, orange juice, and fresh fruit

Baked chicken, coleslaw, soda, and frozen fruit dessert A child with celiac disease is managed on a gluten-free diet, which eliminates food products containing oats, wheat, rye, or barley.

After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing chronic complications of diabetes? A. Blood pressure, 159/98 mm Hg B. Hemoglobin A1C (HbA1C), 6% C. Creatinine level, 1.0 mg/dL D. Chronic sciatica

Blood pressure, 159/98 mm Hg A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or stroke. Options B and C are within defined parameters, and Option D is not a recognized chronic complication of diabetes.

For which clients should the nurse withhold the initial dose of a cyclooxygenase 2 (COX-2) inhibitor until notifying the health care provider? (Select all that apply.) A A middle-aged adult with a history of tinnitus while taking aspirin B. A middle-aged adult with a history of polycystic ovarian disease C. An older adult with a history of a skin rash while taking glyburide (DiaBeta) D. An adolescent with a history of an anaphylactic reaction to penicillin E. An older adult with a history of gastrointestinal upset while taking naproxen sodium (Naprosyn) F. An adolescent at 34 weeks of gestation experiencing 1+ pitting edema

C. An older adult with a history of a skin rash while taking glyburide (DiaBeta) D. An adolescent with a history of an anaphylactic reaction to penicillin F. An adolescent at 34 weeks of gestation experiencing 1+ pitting edema COX-2 inhibitors are contraindicated for those who are allergic to sulfa drugs (C), aspirin, and nonsteroidal antiinflammatory drugs (NSAIDs). Drug safety for adolescents (D and F) is not yet established, and COX-2 inhibitors, as well as NSAIDs, are contraindicated during the third trimester of pregnancy (F) because they can cause a premature closure of the patent ductus arteriosus. Tinnitus, an adverse reaction of aspirin (A), and ovarian disease (B) are not contraindications for the use of COX-2 inhibitors. Gastrointestinal upset is a common adverse reaction of NSAIDs (E) but is not a contraindication for the use of a COX-2 inhibitor.

A 55-year-old client was diagnosed with schizophrenia 5 years earlier. Numerous hospitalizations have occurred since the diagnosis because of noncompliance with the prescribed medication regimen. Which drug might work best for this particular client? A. Chlorpromazine HCl B. Lithium carbonate C. Fluphenazine decanoate D. Diazepam

C. Fluphenazine decanoate Fluphenazine, an antipsychotic drug that can be given IM, has a rapid onset (1 to 2 hours) and a long duration of action (up to 3 or 4 weeks), so it would be the drug of choice for a noncompliant psychotic client. Option A is an antipsychotic drug used to treat schizophrenia and is usually administered PO (IM doses are short-acting). The client must be compliant in taking this drug for it to be effective. Option B is most effective with manic and depressive bipolar affective disorders. Option D is an antianxiety drug and would not be effective for a psychotic disorder.

After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond? A. Ask the client to remain quiet so the procedure can be performed safely. B. Concentrate on completing the insertion as efficiently as possible. C. Calmly reassure the client that the discomfort will be temporary. D. Tell the client a joke as a means of distraction from the procedure.

Calmly reassure the client that the discomfort will be temporary. The nurse should respond with a calm demeanor to help reduce the client's apprehension. After responding calmly to the client's apprehension, the nurse may implement to ensure safe completion of the procedure.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line? A. Cephalhematoma, which is caused by forceps trauma B. Subarachnoid hematoma, which requires immediate drainage C. Molding, which is caused by pressure during labor D. Subdural hematoma, which can result in lifelong damage

Cephalhematoma, which is caused by forceps trauma Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery, and is a common variation of the newborn. Options B and D both involve intracranial bleeding and could not be detected by physical assessment alone.

A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A. Replace the stoma appliance every day. B. Use warm tap water to irrigate the ileostomy. C. Change the bag when the seal is broken. D. Measure and record the ileostomy output.

Change the bag when the seal is broken. A seal must be maintained to prevent leakage of irritating liquid stool onto the skin. Option A is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so option B is not necessary. Option D is not needed.

The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?' A. Apply a warm compress proximal to the site. B. Check for kinks in the tubing and raise the IV pole. C. Adjust the tape that stabilizes the needle. D. Flush with normal saline and recount the drop rate.

Check for kinks in the tubing and raise the IV pole. The nurse should first check the tubing and height of the bag on the IV pole, which are common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often responds to warmth over the vessel, but the nurse should first adjust the IV pole height. The nurse may need to adjust the stabilizing tape on a positional needle or flush the venous access with normal saline, but less invasive actions should be implemented first.

The nurse is planning a community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program? A. Parents of children with spina bifida B. High school girls in a health class C. Class of people interested in having children D. Postpartum women attending a baby care class

Class of people interested in having children Folic acid is needed early in pregnancy to prevent neural tube defects; the group most likely to be considering pregnancy is option C. Parents with children who already have a neural tube defect such as spina bifida are not as invested in the content as option C. High school age students may have interest in the topic but as a group are less likely to anticipate the likelihood that problems could occur in their lives than option C. Option D may be interested if planning future pregnancies, but have higher learning priorities during the postpartum period.

A client is receiving pyridostigmine bromide to control the symptoms of myasthenia gravis. Which client behavior would indicate that the drug therapy is effective? A. Decreased oral secretions B. Clear speech C. Diminished hand tremors D. Increased ptosis

Clear speech is the result of increased muscle strength. Muscle weakness characteristic of myasthenia gravis often first appears in the muscles of the neck and face. Options A and D are symptoms of multiple sclerosis that would persist if the medication was ineffective. Hand tremors are not typical symptoms of the disease.

A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior? A. Move all medical equipment away from the client's bedside. B. Allay fears by teaching the client about the causes of the disease. C. Cluster care to allow for brief rest periods during the day. D. Encourage visitation by the client's family members, including the client's young children.

Cluster care to allow for brief rest periods during the day. The best intervention is to organize care so that the client can experience rest periods. The critical care unit contains many lifesaving treatment modalities that offer clients an array of auditory, visual, and even painful stimuli. These stressors can result in isolation and confusion. Option A is not practical because the client may need assistance from medical equipment to survive. The client is too ill to receive teaching (Option B). Although option D may be supportive, young children are routinely prohibited from critical care units because of increased risk of infectious disease transmission.

A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A. Come to the clinic today for an ultrasound. B. Go immediately to the emergency department. C. Lie on your left side for about 1 hour and see if the bleeding stops. D. Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI).

Come to the clinic today for an ultrasound. Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound. Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which is life threatening to the mother and fetus. If those symptoms were described, option B would be appropriate. Option C does not address the cause of the symptoms. The client is not describing symptoms of a UTI.

The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which actions should the nurse expect to implement? (Select all that apply.) A. Administer aspirin with tissue plasminogen activator (t-PA). B. Complete the National Institute of Health Stroke Scale (NIHSS). C. Assess the client for signs of bleeding during and after the infusion. D. Start t-PA within 6 hours after the onset of stroke symptoms. E. Initiate multidisciplinary consult for potential rehabilitation.

Complete the National Institute of Health Stroke Scale (NIHSS). Assess the client for signs of bleeding during and after the infusion. Initiate multidisciplinary consult for potential rehabilitation. Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contrain-dicated with t-PA because it increases the risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).

A client with bipolar disorder is seen in the mental health clinic for evaluation of a new medication regimen that includes risperidone. The nurse notes that the client has gained 30 lb in the past 3 months. Which assessment is most important for the nurse to obtain? A. Compliance with medication regimen B. Current thyroid-stimulating hormone (TSH) level C. Occurrence of mania or depression D. A 24-hour diet and exercise recall

Compliance with medication regimen Medication compliance is most important for the treatment of psychotic disorders, and because Risperidone is associated with weight gain, it is probable that the client is complying with the treatment plan. The TSH level indicates thyroid function, which regulates basal metabolic rate and influences weight. It is important to obtain information about occurrences of mania and depression since the last visit, but if the client is compliant with the medication regimen, these symptoms are likely to have been controlled. Diet and exercise should also be assessed, but weight gain is a likely indicator of medication compliance.

When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as ebola and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse-manager to take? A. Make it clear that no one who is afraid to care for clients with rare disorders will be permitted to work on the unit. B. Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. C. Introduce the staff to the family of a client who has been treated for SARS and ask the staff to share their fears with this family. D. Assign staff based on the needs of the unit, providing peer counseling for those staff members who express fear.

Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. Fear is often related to a lack of knowledge and an education program about the relevant disorders would be appropriate, but after the education program, the nursing staff should be reassessed regarding their willingness to work with these clients. Option A is too authoritarian and does not permit education to play a role in reducing fears. Option C is likely to be intrusive to the family member. Arbitrary staffing without education does not reduce staff fears, even with the provision of peer counseling.

A nurse is planning client care and wants to verify the steps for a specific client procedure. Which action should the nurse take? A. Review the plan and the steps in performing the procedure with another nurse. B. Look up the specific procedure in a medical-surgical nursing text on the unit. C. Discuss the client's prescribed procedure with an available health care provider. D. Consult the agency's policies and procedures manual and follow the guidelines.

Consult the agency's policies and procedures manual and follow the guidelines. The agency's policies and procedures manual should be consulted to verify the agency's approved protocol for the client's procedure, which is adapted to follow current standards of care. Options A and B may be resources, but client care should be implemented according to the agency's published policies and procedures. Option C is not practical.

The nurse hears a series of long-duration, discontinuous, low-pitched sounds on auscultation of a client's lower lung fields. Which documentation of this finding is correct? A. Fine crackles B. Wheezes C. Course crackles D. Stridor

Course crackles Course crackles are caused by air passing through airways that are intermittently occluded by mucus. Fine crackles are a series of short-duration, discontinuous, high-pitched sounds. Wheezes are continuous, high-pitched, musical or squeaking-type sounds. Stridor is a continuous croupy sound of constant pitch and indicates partial obstruction of the airway.

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.) A. Cramping with bright red spotting B. Extreme tenderness of the breast C. Lack of tenderness of the breast D. Increased amounts of discharge E. Increased right-side flank pain

Cramping with bright red spotting Lack of tenderness of the breast Increased right-side flank pain Options A and C are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. Option E could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. Options B and D are normal signs during the first trimester of a pregnancy.

The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important reason to minimize this child's crying during the recovery period? A. Tear formation increases salivation. B. This behavior increases respirations. C. Excessive hysteria can lead to vomiting. D. Crying stresses the suture line.

Crying stresses the suture line. Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair. Although crying also causes options A, B, and C, these conditions do not create a problem for the child with a cleft lip repair.

In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible? A. Daily black, sticky stool B. Daily dark brown stool C. Firm brown stool every other day D. Soft light brown stool twice a day

Daily black, sticky stool Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. Option C indicates constipation, which is a lesser priority. Options B and D are variations of normal.

The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A. Increased serum albumin level B. Decreased serum creatinine C. Decreased serum ammonia level D. Increased liver function test results

Decreased serum ammonia level The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood.

A client is experiencing an adverse effect of the gastrointestinal stimulant metoclopramide HCl. Which assessment finding would require immediate intervention by the nurse? A. Reports dizziness when first getting up. B. Describes an unpleasant metallic taste in the mouth. C. Demonstrates Parkinson-like symptoms, such as cogwheel rigidity. D. Refuses to drive after 6 pm because of an inability to see well at night.

Demonstrates Parkinson-like symptoms, such as cogwheel rigidity. Metoclopramide HCl blocks dopamine receptors in the brain, which can cause the extrapyramidal symptoms associated with Parkinson disease. Reglan has been associated with hypertension, not option A. Option B is often associated with metronidazole, not metoclopramide HCl. Option D, and other vision problems, have not been associated with metoclopramide HCl.

A female client with myasthenia gravis is taking a cholinesterase inhibitor and asks the nurse what can be done to remedy her fatigue and difficulty swallowing. What action should the nurse implement? A. Explore a plan for development of coping strategies for the symptoms with the client. B. Explain to the client that the dosage is too high, so she should skip every other dose of medication. C. Advise the client to contact her health care provider because of the development of tolerance to the medication. D. Develop a teaching plan for the client to self-adjust the dose of medication in response to symptoms.

Develop a teaching plan for the client to self-adjust the dose of medication in response to symptoms. Maintaining optimal dosage for cholinesterase inhibitors can be challenging for clients with myasthenia gravis. Clients should be taught to recognize signs of overmedication and undermedication so that they can modify the dosage themselves based on a prescribed sliding scale. Options A, B, and C do not adequately address the client's concerns.

The health care provider prescribes the anticonvulsant carbamazepine for an adolescent client with a seizure disorder. The nurse should instruct the client to notify the health care provider if which condition occurs A. Experiences dry mouth. B. Experiences dizziness. C. Develops a sore throat. D. Develops gingival hyperplasia.

Develops a sore throat. Blood dyscrasias (aplastic anemia, leukopenia, anemia, and thrombocytopenia) can be an adverse effect of carbamazepine. Flulike symptoms, such as pallor, fatigue, sore throat, and fever, are indications of such dyscrasias. Options A and B are expected reactions. Option D is a side effect of phenytoin, not carbamazepine.

The nurse expects a 2-year-old child to exhibit which behavior? A Build a house with blocks. B. Ride a small tricycle 6 feet. C. Display possessiveness with toys. D. Look at a picture book for 15 minutes.

Display possessiveness with toys. Two-year-old children are egocentric and unable to share with other children. Options A, B, and D are behaviors of a preschooler.

The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents.

Do not give the medication and document the reason. The nurse should not give the medication and should document the reason because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent or a health care provider's permission, unless conditions are met to justify coerced treatment. Option D is not necessary unless the medication had previously been administered.

The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the health care provider.

Document that the client responds to painful stimulus. The client has demonstrated a purposeful response to pain, which should be documented as such. Response to painful stimulus is assessed after response to verbal stimulus, not before. There is no indication for placing the client on seizure precautions. Reporting decorticate posturing to the health care provider is nonpurposeful movement.

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A. Perform cough and deep breathing exercises hourly. B. Turn from side to side in bed at least every 2 hours. C. Dorsiflex and plantarflex the feet 10 times each hour. D. Drink approximately 4 ounces of water every hour.

Dorsiflex and plantarflex the feet 10 times each hour. To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion. Options A, B, and D are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than option C.

A client is being discharged with a prescription for sulfasalazine to treat ulcerative colitis. Which instruction should the nurse provide to this client prior to discharge? A Maintain good oral hygiene. B. Take the medication 30 minutes before a meal. C. Discontinue use of the drug gradually. D. Drink at least eight glasses of fluid a day.

Drink at least eight glasses of fluid a day. Adequate hydration is important for all sulfa drugs because they can crystallize in the urine. If possible, the drug should be taken after eating to provide longer intestinal transit time. Option A is important for other medications, such as phenytoin, because of the incidence of gingival hyperplasia, and option C is important for steroid administration, but option D is most important to stress with this client.

Which disaster management intervention by the nurse is an example of primary prevention? A. Emergency department triage B. Follow-up care for psychological problems C. Education of rescue workers in first aid D. Treatment of clients who are injured

Education of rescue workers in first aid Primary prevention is aimed at preventing disease or injury. Training rescue workers prior to a disaster is an example of minimizing or preventing injury. Option A is an example of secondary prevention. Option B is an example of tertiary prevention. Option D is an example of secondary prevention.

The nurse assesses a client who is taking indomethacin (Indocin) for arthritic pain. Which of the following is most important to report to the primary health care provider? A. Takes medication with milk. B. Blood pressure, 104/64 mm Hg. C. Elevated liver enzyme levels. D. Hemoglobin level, 13 g/dL.

Elevated liver enzyme levels. Indomethacin is an antiinflammatory drug and can cause liver damage. Elevated liver enzyme levels indicate a complication with the drug. This medication should be taken with food or milk to reduce gastrointestinal (GI) side effects. Options B and D are normal findings.

The therapeutic range for theophylline is 10 to 20 mcg/mL, so the theophylline dose should be held for fear of causing toxicity. Options B, C, and D are not indicated actions based on the reported theophylline level. A. Electrocardiogram (ECG) B. Arterial blood gases (ABGs) C. Serum cholesterol level D. Pelvic ultrasound

Electrocardiogram (ECG) Baseline cardiac function studies are required to monitor the irreversible cardiotoxic effects of doxorubicin HCl. Option B assesses disturbances of acid-base balance. Option C is not affected by this chemotherapeutic agent. Option D is used to detect pelvic abnormalities such as tumors but is not specific for the administration of doxorubicin HCl.

When assessing a 38-year-old client with tuberculosis who is taking rifampin, which finding would be most important to report to the primary health care provider immediately? A. Orange-colored urine B. Potassium level, 4.9 mEq/L C. Elevated liver enzyme levels D. Blood urea nitrogen (BUN) level, 12 mg/dL.

Elevated liver enzyme levels Rifampin can cause hepatotoxicity, so elevated liver enzyme levels need to be closely monitored and reported to the health care provider. Orange discoloration of the urine is an expected side effect of this medication. The potassium level is normal. A BUN level of 12 mg/dL is within defined parameters.

An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which she is convinced are going to cause her to have a heart attack. What action should the nurse take? A. Take the client's blood pressure and reassure her that questioning will not cause a heart attack. B. Explain that treatment is based on information obtained in the assessment. C. Encourage the client to relax so that she can provide the information requested. D. Empower the client to share her story of why she is here at the mental health clinic.

Empower the client to share her story of why she is here at the mental health clinic. The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and selective inattention. Option D is the best method for addressing this client's level of anxiety by creating a shared understanding of the client's concerns. Although assessment of her blood pressure might be a worthwhile intervention, reassuring her that questioning will not cause a heart attack is argumentative. Option B suggests that treatment cannot be provided without the information, which is manipulative. Asking the client to relax is likely to increase her anxiety.

When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? A. Encourage the client to turn from side to side every 2 hours. B. Elevate the foot of the client's bed at least 6 inches. C. Encourage the client to ambulate every 3 hours. D. Teach the client how to perform leg exercises while in bed

Encourage the client to ambulate every 3 hours. Ambulation is the best way to increase peripheral vascular activity. Options A, B, and D will increase peripheral vascular activity but are not as effective as ambulation.

After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of Internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C. Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or health care provider if any questions arise.

Encourage the client to call the clinic nurse or health care provider if any questions arise. To ensure safe medication use, the nurse should encourage the client to call the nurse or health care provider if any questions arise. Options A, B, and C may all include useful information, but these sources of information cannot evaluate the nature of the client's questions and the follow-up needed.

After administration of a 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A. Ensure that the client receives breakfast within 30 minutes. B. Remind the client to have a midmorning snack at 1000. C. Discuss the importance of a midafternoon snack with the client. D. Explain that the client's capillary glucose will be checked at 1130.

Ensure that the client receives breakfast within 30 minutes. Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction. Options B, C, and D are also important nursing actions but are of less immediacy than option A.

The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. Which action should the nurse perform? A. Examine for clamp closures. B. Irrigate with a larger syringe. C. Assess for signs of infection. D. Flush the line with heparin.

Examine for clamp closures. Thrombus formation, closed clamp, or crystallized medication can cause resistance while flushing a central line, so the line should be assessed for closed clamps first. Irrigation with a larger syringe will not alleviate the cause for the resistance and can rupture the line. A central line infection should not cause resistance while flushing the line. The CVC should be flushed with normal saline or a diluted solution of heparin (10 to 100 U/mL) after option A is completed, if necessary.

The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the health care provider? A. Sits or squats frequently when playing outdoors B. Exhibits a sudden and unexplained weight gain C.Is not completely toilet-trained and has some accidents D. Demonstrates irritation and fatigue 1 hour before bedtime

Exhibits a sudden and unexplained weight gain Sudden and unexplained weight gain can indicate fluid retention and is a sign of congestive heart failure. Option A is used by the child to reduce chronic hypoxia, especially during exercise. Option C is common; 2-year-olds are not expected to be toilet-trained. Option D is normal.

An older client who resides in a long-term care facility is hearing-impaired. How should the nurse modify interventions for this client? A. Turn off the client's television and speak very loudly. B. Communicate in writing whenever it is possible. C. Speak very slowly while exaggerating each word. D. Face the client and speak in a normal tone of voice.

Face the client and speak in a normal tone of voice. A hearing-impaired client frequently relies on lip reading and body language to determine what is being said, so option D should be implemented. Options A and C may distort the sounds and facial expressions, which alters the client's ability to interpret the verbal message. Communicating in writing is another option that could be used if verbal or body language is ineffective.

A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test? A. Failure to collect all urine specimens during the period of the study will invalidate the test. B. Blood is collected to measure the amount of creatinine and determine the glomerular filtration rate (GFR). C. Dialysis is started when the GFR is lower than 5 mL/min. D. Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours.

Failure to collect all urine specimens during the period of the study will invalidate the test. Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the study or the results will be inaccurate. As renal function decreases, the creatinine level will decrease in the urine. Dialysis is usually started when the GFR is 12 mL/min. There is no need to record the frequency and amount of each voiding during the time span of urine collection.

A client who is hypertensive receives a prescription for hydrochlorothiazide. When teaching about the side effects of this drug, which symptoms are most important for the nurse to instruct the client to report? A. Fatigue and muscle weakness B. Anxiety and heart palpitations C. Abdominal cramping and diarrhea D. Confusion and personality changes

Fatigue and muscle weakness Thiazide diuretics, such as HCTZ, cause potassium wasting in the urine, so the client should be instructed to report fatigue and muscle weakness, which are characteristic of hypokalemia. Although options B, C, and D should be reported, they are not indicative of hypokalemia, which is a side effect of hiazides that can cause cardiac dysrhythmias.

In developing a nursing care plan for a 9-month-old infant with cystic fibrosis, the nurse writes a nursing diagnosis of alteration in nutrition: less than body requirements, related to inadequate digestion of nutrients. Which intervention would best meet this child's needs? A. Give aluminum hydroxide and magnesium hydroxide after meals. B. Give pancrelipase capsule mixed with applesauce before each meal. C. Administer cholestyramine resin before each meal and at bedtime. D. Administer omeprazole for gastroesophageal reflux.

Give pancrelipase capsule mixed with applesauce before each meal. Pancreatic enzyme replacement with pancrelipase is a major component of cystic fibrosis nutritional management. Aluminum hydroxide and magnesium hydroxide may be given before meals with enzymes to reduce gastric acidity and prevent enzyme destruction but are ineffective when used alone to promote enzyme replacement. Options C and D are used to treat steatorrhea in cystic fibrosis.

A client exhibits symptoms of alcohol intoxication. The blood alcohol level is 200 mg (0.2%). Which measurement tool is best for the nurse to use during the initial assessment of this client? A. CAGE questionnaire for alcoholism B. Addiction Severity Index C. Glasgow Coma Scale D. DSM multiaxial evaluation

Glasgow Coma Scale Evaluation of level of consciousness, which is the purpose of the Glasgow Coma Scale, has the highest priority. Option A is useful in helping clients recognize their alcoholism. Options B and D are comprehensive assessments that should be completed after the acute phase is resolved.

A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following? A. Fever, elevated white blood count, elevated platelets B. Fatigue, weight loss and anorexia, elevated red blood cells C. Hyperplasia of the gums, elevated white blood count, weakness D. Hypocellular bone marrow aspirate, fever, decreased hemoglobin level

Hyperplasia of the gums, elevated white blood count, weakness Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia. Options A, B, and D state incorrect information for symptoms of leukemia.

A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A. Hypophosphatemia B. Hypocalcemia C. Hyponatremia D. Hypokalemia

Hypocalcemia Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not option A. Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with option C or D.

A primigravida at 34 weeks of gestation is admitted to labor and delivery in preterm labor. She is started on a terbutaline sulfate continuous IV infusion via pump. This therapy is ineffective, and the baby is delivered vaginally. For which complication should the nurse monitor in this infant during the first few hours after delivery? A. Hypokalemia B. Hypermagnesia C. Hypoglycemia D. Hypernatremia

Hypoglycemia Hypoglycemia may occur in the neonate because a side effect of terbutaline sulfate is increased maternal serum glucose levels. Although monitoring for imbalances in options A, B, and D is important, option C is the priority following the maternal administration of terbutaline sulfate.

The nurse on a medical-surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain? A. If suctioning will be needed for drainage of the wound B. If the family would prefer a private or semiprivate room C. If the client also has a Hemovac in place D. If the client's wound is infected

If the client's wound is infected The fact that the client has a Penrose drain should alert the nurse to the possibility that the surgical wound is infected. Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. To avoid contamination of another postoperative client, it is most important to place any client with an infected wound in a private room. A Penrose drain does not require option A. Although option B is helpful information, it does not have the priority of option D. A Hemovac is used to drain fluid from a dead space and is not a determinant for the room assignment.

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A. Altered nutrition, less than body requirements for lactation B. Alteration in comfort related to nausea and abdominal distention C. Impaired bowel motility related to pain medication and immobility D. Fatigue related to cesarean delivery and physical care demands of infant

Impaired bowel motility related to pain medication and immobility Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. Options A and B are both caused by impaired bowel motility. Option D is not as important as impaired motility.

A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting? A. Hyperexcitability of reflexes B. Hyperextension of the head and back C. Inability to flex the chin to the chest D. Lateral facial paralysis

Inability to flex the chin to the chest Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck and place the chin to the chest. Although options A, B, and D may occur in meningitis, option A describes exaggerated spinal nerve reflex responses, option B describes opisthotonus, and option D may be related to cranial nerve pathology of the trigeminal nerve.

The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved? A. Increased oxygen saturation B. Increased urinary output C. Decreased apical pulse rate D. Decreased blood pressure

Increased oxygen saturation Bronchodilators increase the diameter of the bronchioles, resulting in improved oxygenation, reflected by an increase in oxygen saturation. Options B, C, and D do not indicate the desired effect of a bronchodilator.

A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make? A. Ask the client to describe the symptoms of the vaginal infection. B. Assess if the client has been sexually active recently. C. Tell the client to reschedule the examination in 1 week. D. Inform the client that the scheduled Pap test cannot be done today.

Inform the client that the scheduled Pap test cannot be done today. The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular sample, alters cytology analysis, and masks bacterial or sexually transmitted disease infections, so the Pap test should be postponed. Although options A, B, and C are indicated, the client needs further teaching for the return visit to perform the Pap smear test.

The nurse teaches a class on bioterrorism. Which methods of transmission are possible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.) A. Inhalation of powder form B. Handling of infected animals C. Spread from person to person through coughing D. Eating undercooked meat from infected animals E. Direct cutaneous contact with the powder

Inhalation of powder form Handling of infected animals Eating undercooked meat from infected animals Direct cutaneous contact with the powder Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E); however, the disease is not spread from person to person (C).

A client has a positive skin test for tuberculosis. Which prophylactic drug should the nurse expect to administer to this client? A. Isoniazid B. Carvedilol C. Acyclovir D. Griseofulvin

Isoniazid Isoniazid is the drug of choice for treatment of clients with positive skin tests for tuberculosis. Options B, C, and D are not the drugs used for treatment of TB.

The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A. January 14 to 15 B. January 22 to 23 C. January 29 to 30 D. February 6 to 7

January 29 to 30 This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30. Options A, B, and D are incorrect.

The nurse cares for an adolescent with a history of violence who now exhibits signs of sublimation. Which behavior by the adolescent best represents sublimation? A. Recently started wetting the bed. B. Joined a competitive boxing team. C. Kicks the dog after being scolded by his dad. D. Starts a student organization to ban violence.

Joined a competitive boxing team. Sublimation is a coping mechanism characterized by substituting an unacceptable feeling or action with a more socially acceptable one. Option A is an example of regression, Option C is characteristic of displacement, and Option D is consistent with undoing.

Which monitored pattern of fetal heart rate alerts the nurse to seek immediate intervention by the health care provider? A. Accelerations in response to fetal movement B. Early decelerations in the second stage of labor C. Fetal heart rate of 130 beats/min between contractions D. Late decelerations with absent variability and tachycardia

Late decelerations with absent variability and tachycardia Late decelerations indicate uteroplacental insufficiency and can be indicative of complications. When occurring with absent variability and tachycardia, the situation is ominous. 130 beats/min is an expected heart rate. Options A and B are not as critical.

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction.

Leave the catheter in place and reattempt with another catheter. It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization. The client should have at least 240 mL of urine after 8 hours. Option A does not resolve the problem. Option B will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted.

The nurse is caring for a client who is taking valproic acid. Which laboratory finding is most important to include in this client's record? A. Liver function test results B. Creatinine clearance C. Complete blood count D. Chemistry panel

Liver function test results Valproic acid is metabolized by the liver and can cause hepatotoxicity, so laboratory findings of liver function tests should be included in the client's record. Option B should be in the client record of those who are receiving lithium because it is excreted by the kidneys. Options C and D are routine laboratory tests and are not specifically related to administration of valporic acid.

During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared with the infant of a nonsmoking mother? A. Lower Apgar score recorded at delivery B. Lower initial weight documented at birth C. Higher oxygen use to stimulate breathing D. Higher prevalence of congenital anomalies

Lower initial weight documented at birth Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not to smoke during pregnancy. Options A, C, and D have not been clearly associated with smoking during pregnancy, but there is a strong correlation between smoking and lower birth weights.

A 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54 mm Hg. Based on these findings, which IV medication should the nurse administer? A. Amiodarone (Cordarone) B. Magnesium sulfate C. Lidocaine (Xylocaine) D. Procainamide (Pronestyl)

Magnesium sulfate Because the client has chronic alcoholism, she is likely to have hypomagnesemia. Option B is the recommended drug for torsades de pointes, which is a form of polymorphic ventricular tachycardia (VT) usually associated with a prolonged QT interval that occurs with hypomagnesemia. Options A and D increase the QT interval, which can cause the torsades to worsen. Option C is the antiarrhythmic of choice in most cases of drug-induced monomorphic VT, not torsades.

A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important? A. Maintain a balanced diet and adequate exercise. B. Be sure that the diet is adequate in salt intake. C. Monitor for any changes in sleep pattern. D. Report any unusual facial movements.

Maintain a balanced diet and adequate exercise. Several atypical antipsychotic medications can cause significant weight gain, so the client should be advised to maintain a balanced diet and adequate exercise. Option B is important with lithium, a mood stabilizer. Options C and D are less common than weight gain.

A pediatric client is discharged home with multiple prescriptions for medications. Which information should the nurse provide that is most helpful to the parents when managing the medication regimens? A. Maintain a drug administration record. B. Fill all prescriptions at one pharmacy. C. Allow one person to give the medications. D. Give all medications in small volumes.

Maintain a drug administration record. A written drug administration record provides a consistent plan to ensure safe adherence to multiple medication dosages and times. Although option B is an important safeguard to monitor for drug interactions, the parents should be given a tool to enhance their confidence and provide a mechanism to ensure accurate and timely medication administration without duplicating or omitting a dose. Using a written record to record medication administration allows more than one person to share the responsibility of giving medications to the child. Although smaller volumes ensure that all the medication is taken, it is more important to maintain an accurate administration schedule.

A client who was admitted two days earlier to a drug rehabilitation unit tells the nurse, "I'm going to do what you people tell me to do so I can get out of here and get a job." What is the most accurate interpretation of this client's statement? A. The treatment program is effective and the client is highly motivated. B. Defense mechanisms are being used to decrease anxiety. C. Manipulation is being used to achieve the client's personal goals. D. The client has insight into his behaviors, so privileges should be given.

Manipulation is being used to achieve the client's personal goals. Drug abusers and patients with anti-social behaviors tend to be manipulative, so option C is the best interpretation of the client's statement at this time in the client's treatment. He has been in treatment only 2 days, which is not enough time to benefit from the program, so options A and D are highly unlikely. Although defense mechanisms are frequently used to decrease anxiety, this statement is more likely because of option C.

A client with a dislocated shoulder is being prepared for a closed manual reduction using conscious sedation. Which medication should the nurse explain as a sedative used during the procedure? A. Inhaled nitrous oxide B. Midazolam IV C. Ketamine IM D. Fentanyl and droperidol IM

Midazolam IV Conscious sedation uses sedative-hypnotics that do not compromise the airway, so IV midazolam, a short-duration benzodiazepine sedative, provides conscious sedation with local and regional anesthesia and has an amnestic effect. Option A is a weak anesthetic and is rarely used alone. Option C causes profound analgesia that causes a client to appear catatonic and amnestic. Fentanyl is an opioid more commonly used as an analgesic during anesthesia, whereas droperidol is a skeletal muscle anesthetic agent used to reduce spasticity to ensure a smooth induction under general anesthesia and requires intubation and ventilation during its onset and duration.

Based on the clinical manifestations of Cushing syndrome, which nursing intervention would be appropriate for a client who is newly diagnosed with Cushing syndrome? A. Monitor blood glucose levels daily. B. Increase intake of fluids high in potassium. C. Encourage adequate rest between activities. D. Offer the client a sodium-enriched menu.

Monitor blood glucose levels daily. Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for increased blood glucose levels so that treatment can begin early. A common finding in Cushing syndrome is generalized edema. Although potassium is needed, it is generally obtained from food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is not indicated A low-calorie, low-carbohydrate, low-sodium diet is not recommended.

The nurse is caring for a client with chronic renal failure (CRF) who is receiving dialysis therapy. Which nursing intervention has the greatest priority when planning this client's care? A. Palpate for pitting edema. B. Provide meticulous skin care. C. Administer phosphate binders. D. Monitor serum potassium levels.

Monitor serum potassium levels. Clients with CRF are at risk for electrolyte imbalances, and imbalances in potassium can be life threatening. One sign of fluid retention is pitting edema, but it is an expected symptom of renal failure and is not as high a priority as option D. Options B and C are common nursing interventions for CRF but not as high a priority as option D.

During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose levels. D. Evaluate the client's oxygen saturation and breath sounds.

Monitor the client's serum potassium and blood glucose levels. Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels. Options A, B, and D provide valuable assessment data but are of less priority than option C.

When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing intervention is most important to implement? A. Use a blanket as a mummy restraint. B. Monitor the infant's heart rate. C. Lubricate the catheter with saline. D. Explain the procedure to the parents.

Monitor the infant's heart rate. All interventions may be implemented during nasogastric tube insertion, but the most important nursing action is to monitor the infant's heart rate, which may decrease because of vagal nerve stimulation and can occur when the tube is inserted. Options A, C, and D are of lower priority than option B.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities? A. Wear support stockings. B. Reduce salt in the diet. C. Move about every hour. D. Avoid constrictive clothing.

Move about every hour. Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous return. Option A would increase venous return from varicose veins in the lower extremities but would be of little help with swelling. Option B might be helpful with generalized edema but is not specific for edematous lower extremities. Option D does not address venous return, and there is no indication in the question that constrictive clothing is a problem.

A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit implement first? A. Instruct the nursing staff to close all window blinds and curtains in clients' rooms. B. Move clients and visitors into the hallways and close all doors to clients' rooms. C. Visually confirm the location of the tornado by checking the windows on the unit. D. Assist all visitors with evacuation down the stairs in a calm and orderly manner.

Move clients and visitors into the hallways and close all doors to clients' rooms. In the event of a tornado, all persons should be moved into the hallways, away from windows, to prevent flying debris from causing injury. Although option A may help decrease the amount of flying debris, it is not safe to leave clients in rooms with closed blinds; option B is a higher priority at this time. Hospital staff should stay away from windows to avoid injury and should focus on client evacuation into hallways rather than option C. Option D is not the first action that should be taken.

A client with HIV who was recently diagnosed with tuberculosis (TB) asks the nurse, "Why do I need to take all of these medications for TB?" What information should the nurse provide? A. Antiretroviral medications decrease the efficacy of the TB drugs. B. Multiple drugs prevent the development of resistant organisms. C. Duration of the medication regimen is shortened. D. Potential adverse drug reactions are minimized.

Multiple drugs prevent the development of resistant organisms. A multidrug regimen is prescribed for a client with HIV and TB to prevent the development of resistance of the tubercle bacilli. Although antitubercular medications can inhibit some antiretrovirals, a multidrug regimen is needed to inhibit the proliferation of the virulent tubercle bacilli. The duration of antitubercular therapy is typically 6 to 9 months and is not shortened by the use of multiple medications. A client who is receiving HIV and TB therapy is at an increased risk of adverse reactions because of the complex medication regimens and complications secondary to immunosuppression.

The nurse is assessing a stuporous client in the emergency department who is suspected of overdosing with opioids. Which agent should the nurse prepare to administer if the client becomes comatose? A. Naloxone hydrochloride B. Atropine sulfate C. Vitamin K D Flumazenil

Naloxone is an opioid antidote used in opioid overdose to reverse CNS and respiratory depression. Atropine is used for bradycardia, intestinal hypertonicity and hypermotility, muscarinic agonist poisoning, peptic ulcer disease, and biliary colic. Vitamin K is used to manage warfarin overdose and vitamin K deficiency in newborns. Flumazenil reduces the sedative effects of benzodiazepines following general anesthesia or overdose.

A client is admitted with a diagnosis of depression. Which of the following characteristics is most indicative of depression? A. Grandiose ideation B. Self-destructive thoughts C. Suspiciousness of others D. Negative self-image

Negative self-image A negative self-image is a specific indicator for depression. Option A occurs with paranoia or paranoid ideation. Option B may be seen in depressed clients, but not always.

A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A. Vitamin K1, 5 mg IM daily B. High-calorie, low-sodium diet C. Fluid restriction to 1500 mL/day D. Nembutal sodium at bedtime for rest

Nembutal sodium at bedtime for rest Sedatives such as pentobarbital are contraindicated for clients with liver damage and can have dangerous consequences. Option A is often prescribed because the normal clotting mechanism is damaged. Option B is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease.

A 19-year-old male client who has sustained a severe head injury is intubated and placed on assisted mechanical ventilation. To facilitate optimal ventilation and prevent the client from "fighting" the ventilator, the health care provider administers pancuronium bromide IV, with adjunctive opioid analgesia. What medication should be immediately accessible for a potential complication with this drug? A. Dantrolene sodium B. Neostigmine bromide C. Succinylcholine bromide D.Epinephrine

Neostigmine bromide Neostigmine bromide and atropine sulfate, both anticholinergic drugs, reverse the respiratory muscle paralysis caused by pancuronium bromide. Options A, C, and D are not antagonists to pancuronium bromide and would not be helpful in reversing the effects of the drug compared with the use of anticholinergics.

A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? A. Azotemia B. Oliguria C. Hyperkalemia D. Nephron obstruction

Nephron obstruction CKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure, which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The obstruction of urine flow will resolve with the return of an adequate glomerular filtration rate, and when it does, dialysis will no longer be needed. Options A, B, and C are manifestations seen in the acute and chronic forms of kidney disease.

A male client asks the nurse why condoms should not be lubricated with the spermicide nonoxynol-9. Which response is best for the nurse to provide? A. The risk of female infertility and spontaneous abortion is linked with nonoxynol-9. B. Partners can develop intermittent interstitial cystitis if the spermicide is used after the expiration date. C. The spermicide decreases the amount of vaginal and penile sensitivity for up to 8 to 12 hours. D. Nonoxynol-9 provides no protection from STDs and has been linked to the transmission of HIV.

Nonoxynol-9 provides no protection from STDs and has been linked to the transmission of HIV. The use of condoms and a water-based spermicide is recommended because nonoxynol-9 can cause a rash that allows viruses a portal of entry if the condom breaks, which increases the risk of transmission of sexually transmitted diseases (STDs), such as human immunodeficiency virus (HIV), herpes, human papillomavirus (HPV), or hepatitis B virus (HBV). Options A and B are inaccurate. Nonoxynol-9 may cause vaginal irritation, not option C.

A male client is admitted for observation after being hit on the head with a baseball bat. Six hours after admission, the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on room air. Which intervention should the nurse perform first? A. Administer oxygen per nasal cannula at 2 L/min. B. Plan to check his vital signs again in 30 minutes. C. Notify the health care provider of the change in mental status. D. Ask the client why he thinks there are bugs in the bed.

Notify the health care provider of the change in mental status. One of the earliest signs of increased intracranial pressure (ICP) is a change in mental status. It is important to act early and quickly when symptoms of increased ICP occur. Because his oxygen saturation is normal, the administration of oxygen is not the top priority. Vital signs should be monitored frequently, but the client's confusion should be reported immediately. Option D is not a useful intervention.

The nurse notes that the hemoglobin level of a client receiving darbepoetin alfa has increased from 6 to 10 g/dL over the first 2 weeks of treatment. Which action should the nurse take? A. Encourage the client to continue the treatment, because it is effective. B. Advise the client that the dose will need to be increased. C. Assess the client's skin color for continued pallor or cyanosis. D. Notify the health care provider of the change in the client's laboratory values.

Notify the health care provider of the change in the client's laboratory values. Although an increase in the client's hemoglobin level is desired, a rapid increase (more than 1 g/dL in a 2-week period) may lead to hypertension, so the health care provider should be notified of this excessive increase. Options A and B may lead to a dangerous increase in blood pressure. Because the client's anemia has improved, option D is of greater priority than continuing to monitor for signs of anemia.

The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP? A. Remove the client's nail polish and dentures. B. Assist the client to the restroom to void. C. Obtain the client's height and weight. D. Offer the client emotional support.

Offer the client emotional support. By using therapeutic techniques to offer support, the nurse can determine any client concerns that need to be addressed. Options A, B, and C are all actions that can be performed by the UAP under the supervision of the nurse.

The nurse is observing an unlicensed assistive personnel (UAP) performing morning care for a bedridden client with Huntington disease. Which care measure is most important for the nurse to supervise? A. Oral care B. Bathing C. Foot care D. Catheter care

Oral care The client with Huntington disease experiences problems with motor skills such as swallowing and is at high risk for aspiration, so the highest priority for the nurse to observe is the UAP's ability to perform oral care safely. Options B, C, and D do not necessarily require registered nurse (RN) supervision because they do not ordinarily pose life-threatening consequences.

The nurse is reviewing prescribed medications with a female client who is preparing for discharge. The client asks the nurse why the oral dose of an opioid analgesic is higher than the IV dose that she received during hospitalization. Which response is best for the nurse to provide? A. A higher dose of analgesic medication may be needed after discharge. B. An error in the dose calculation may have occurred when the prescribed dose was converted. C. The doses should be the same unless the pain is not well controlled. D. Oral forms of drugs must pass through the liver first, where more of the dose is metabolized.

Oral forms of drugs must pass through the liver first, where more of the dose is metabolized. Oral doses of medication are usually larger than parenteral doses to compensate for the first-pass effect in the liver after oral administration, which metabolizes more of the drug's dose before affecting its therapeutic response. Although recommended dose ranges for adults should be individualized, a client's pain should be controlled at discharge, not option A or C. Option B is inaccurate information to convey to the client.

The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.) A. Pain in the lower back that radiates to abdomen B. Contractions decreased in frequency with ambulation C. Progressive cervical dilation and effacement D. Discomfort localized in the abdomen E. Regular and rhythmic painful contractions

Pain in the lower back that radiates to abdomen Progressive cervical dilation and effacement Progressive cervical dilation and effacement These are all signs of true labor. Options B and D are signs of false labor.

Which interventions should be performed by the nurse when caring for a woman in the fourth stage of labor? (Select all that apply.) A. Maintain bed rest for the first 6 hours after delivery. B. Palpate and massage the fundus to maintain firmness. C. Have client empty bladder if fundus is above umbilicus. D. Check perineal pad for color and consistency of lochia. E. Apply ice pack or witch hazel compresses to the perineum.

Palpate and massage the fundus to maintain firmness. Check perineal pad for color and consistency of lochia. Apply ice pack or witch hazel compresses to the perineum. The fundus should be palpated and massaged frequently to prevent hemorrhage (B). The lochia should be assessed to detect for hemorrhage (D) and ice packs and witch hazel can decrease edema and discomfort (E). Bed rest is only recommended for the first 2 hours (A). A full bladder is suspected if the fundus is deviated to the right or left of the umbilicus (C).

A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? A. Pedal pulses will be weak or absent in the left foot. B. The client will state that the left foot is usually warm. C. Flexion and extension of the left foot will be limited. D. Capillary refill of the client's left toes will be brisk.

Pedal pulses will be weak or absent in the left foot. Symptoms associated with decreased blood supply are weak or absent pedal and tibial pulses. The client with diabetes experiences vascular scarring as a result of atherosclerotic changes in the peripheral vessels. This results in compromised perfusion to the dependent extremities, which further delays wound healing in the affected foot. Although flexion and extension may be limited, depending on the degree of damage, this is not always the case. Options B and D are signs of adequate perfusion of the foot, which would not be expected in this client.

The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift.

Perform range-of-motion exercises to prevent contractures. Performing range-of-motion exercises is beneficial in reducing contractures around joints. Options B, C, and D are all potentially harmful practices that place the immobile client at risk of complications.

A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? A. Administer lidocaine, 75 mg intravenous push. B. Perform synchronized cardioversion. C. Defibrillate the client as soon as possible. D. Administer atropine, 0.4 mg intravenous push.

Perform synchronized cardioversion. With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion to convert the cardiac rhythm back to normal sinus rhythm. Option A is a medication used for ventricular dysrhythmias. Option C is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. Option D is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation.

A newborn female whose mother is HIV-positive is scheduled for the first follow-up assessment with the nurse. If the child is HIV-positive, which initial symptom is she most likely to exhibit? A. Shortness of breath B. Joint pain C. Persistent cold D. Organomegaly

Persistent cold Respiratory tract infections commonly occur in the pediatric population, but the child with AIDS has a decreased ability to defend the body against these common infections. Thus, the most typical presenting symptom of a child who contracted AIDS through vertical transmission (i.e., from the mother during delivery) is a persistent cold or respiratory infection. Options A, B, and D are symptoms of AIDS complications that may occur later as the disease progresses.

The nurse admits a child to the intensive care unit with a possible diagnosis of Wilms tumor - What is the most safety precaution for child? A. maintain NPO status B. Limit visitors to the immediate family C. Place a do not palpate abdomen sign on head of bed D. Encourage ambulation in the pre-operative period

Place a do not palpate abdomen sign on head of bed Protect child from injury; place a sign on bed stating "no abdominal palpation" (to prevent accidental fragmentation and dislodging into the abdominal cavity). The other option choices are not relevant at this time.

Which nursing intervention should be implemented postoperatively in an infant with spina bifida after repair of a meningocele? A. Limit fluids to prevent infection to the surgical site. B. Place the infant in the prone position. C. Provide a low-residue diet to limit bowel movements. D. Cover sac with a moist sterile dressing.

Place the infant in the prone position. The infant should be placed in the prone position to alleviate pressure on the surgical site, which is in the sacrum. Fluids should be increased postoperatively to prevent dehydration. A high-fiber diet should be implemented to prevent constipation. After the repair, the sac is no longer exposed, so option D does not apply.

In administering the antiinfective agent chloramphenicol IV to a client with bacterial meningitis, the nurse observes the client closely for signs of bone marrow depression. Which laboratory data would be most important for the nurse to monitor? A. Platelet count B. Blood urea nitrogen level C. Culture and sensitivity D. Serum calcium level

Platelet count Chloramphenicol can cause irreversible, fatal bone marrow depression, so the nurse should monitor the client's platelet count. Options B, C, and D do not provide data related to bone marrow depression when monitoring a client who has been prescribed this medication.

The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first? A. Draw arterial blood gases. B. Notify the primary health care provider. C. Position in a high Fowler position with the legs down. D. Obtain a chest x-ray.

Position in a high Fowler position with the legs down. Positioning the client in a high Fowler position with dangling feet will decrease further venous return to the left ventricle. Options A, B, and D should be performed after the change in position.

The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A. Suctions oral secretions from mouth B. Positions head of bed flat when changing sheets C. Takes temperature using the axillary method D. Keeps head of bed elevated at 30 degrees

Positions head of bed flat when changing sheets Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration. Options A, C, and D are all acceptable tasks performed by the UAP.

The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, "I don't know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing? A. Taking-in phase B. Postpartum blues C. Attachment difficulty D. Letting-go phase

Postpartum blues During the postpartum period, when serum hormone levels fall, women are emotionally labile, often crying easily for no apparent reason. This phase is commonly called postpartum blues, which peaks around the fifth postpartum day. The taking-in phase is the period following birth when the mother focuses on her own psychological needs; typically, this period lasts for 24 hours. Crying is not a maladaptive attachment response. It indicates a normal physical and emotional response. The letting-go phase is when the mother sees the child as a separate individual.

Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the health care provider prior to surgery? A. Crying that is unrelieved by comforting measures B. Presence of an inguinal bulge after gentle palpation C. Refusal to take oral feedings D. Straining during defecation

Presence of an inguinal bulge after gentle palpation The parents should notify the health care provider if the hernia remains irreducible after implementing simple measures, such as gentle palpation, warm bath, and comforting to reduce crying. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates, swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency surgical release. Options A and D may cause the hernia to protrude but do not necessitate notification of the health care provider. Option C may not be specific to the hernia.

The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care? A. Restore skin integrity. B. Prevent infection. C. Promote healing. D. Improve nutrition.

Prevent infection. The prevention of infection is a priority goal for this client. Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, options A and C are unattainable goals. Option D is important but of less priority than option B.

A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take? A. Notify the health care provider immediately and force fluids. B. Prior to giving the next dose, notify the health care provider of these symptoms. C. Record the symptoms and continue with medication as prescribed. D. Hold the medication and refuse to administer additional doses.

Prior to giving the next dose, notify the health care provider of these symptoms. Although these are expected symptoms, the health care provider should be notified prior to the next administration of the drug. Early side effects of lithium carbonate (occurring with serum lithium levels below 2 mEq/L) generally follow a progressive pattern, beginning with diarrhea, vomiting, drowsiness, and muscular weakness (option C). At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. Option A will lower the lithium level. Option D is not warranted.

The charge nurse observes a student nurse enter the room of a client who is prescribed airborne precautions. The application of which personal protective equipment by the student indicates a correct understanding of this precaution? A. Surgical mask, clean gloves, and gown B. Properly fitted N95 respirator or mask C. Sterile gloves and gown D. Goggles, clean gloves, and gown

Properly fitted N95 respirator or mask The use of personal protective equipment (PPE) for airborne precautions includes a properly prefitted N95 respirator or mask. Options A, C, and D do not provide the appropriate respiratory equipment for airborne precautions. A surgical mask is used for preventing transmission of droplet precautions.

Which response best supports the observations that the nurse identifies in a client who is experiencing a placebo effect? A. Beneficial response or cure for disease B. Behavioral or psychotropic responses C. Malingering or drug-seeking behaviors D. Psychological response to inert medication

Psychological response to inert medication The placebo effect is a response in the client that is caused by the psychological impact of taking an inert drug that has no biochemical properties. A placebo effect can be therapeutic, negative, or ineffective but provides no cure or benefit to the client's progress. The placebo effect may evoke behavioral changes but does not affect neurochemical psychotropic changes. Malingering and drug seeking are behaviors that a client exhibits to obtain treatment for nonexistent disorders or obtain prescription medications.

A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision? A. Notify the family that the resident will have to be discharged if his behavior does not improve. B. Notify administration of the PN's insubordination and need for counseling about her statements. C. Ask the PN what she has done to encourage the resident to believe that she is his daughter. D. Reassign the PN until the resident can be assessed more completely for reality orientation

Reassign the PN until the resident can be assessed more completely for reality orientation. Temporary reassignment is the best option until the resident can be examined and his medications reviewed. He may have worsening cerebral dysfunction from an infection or electrolyte imbalance. Option A is not the best option because the family cannot control the resident's actions. The administration may need to know about the situation, but not as a case of insubordination. Implying that the PN is somehow creating the situation is inappropriate until a further evaluation has been conducted.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father? A. Suggest that his wife seek professional counseling to deal with her symptoms. B. Explain that his wife is exhibiting ambivalence about the pregnancy. C. Ask him to report similar abnormal behaviors at the next prenatal visit. D. Reassure him that normal maternal-fetal bonding is occurring.

Reassure him that normal maternal-fetal bonding is occurring. These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during the second trimester. Options A and C are not necessary because the behaviors displayed are normal.

When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A. Record the amount on the client's fluid output record. B. Encourage the client to increase oral fluid intake. C. Notify the health care provider of the findings. D. Palpate the client's bladder for distention.

Record the amount on the client's fluid output record. The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output, but no additional action is needed.

Which physiologic finding in an older adult contributes to an adverse drug reaction? A. Reduced renal excretion B. Reduced gastrointestinal motility C. Increased hepatic metabolism D. Increased risk of autoimmune disorders

Reduced renal excretion During the aging process, reduced renal function is common and contributes to drug accumulation that contributes to adverse reactions. Reduced hepatic function, not option C, predisposes an older adult to an increase in adverse drug reactions. Option B may occur frequently in an older client but does not impact the bioavailability of drugs. Although an older adult may have a decreased immune response, the aging client's risk for autoimmune disorders is not increased, nor does it affect drug pharmacotherapeutics.

A client with type 2 diabetes takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? A. NPO except for metformin and regular snacks B. NPO except for oral antidiabetic agent C. Novolin N insulin subcutaneously twice daily D. Regular insulin subcutaneously per sliding scale

Regular insulin subcutaneously per sliding scale Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO and coping with the major stress of surgery. Option A increases the risk of vomiting and aspiration. Options B and C provide less precise control of the blood glucose level.

While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position? A. Confront the client who tipped over the chair about the inconsiderate behavior. B. Dismiss the other clients from the group therapy session for a 10-minute break. C. Reinforce reality to the client on the floor and remove him to a quiet space. D. Call a security code and medicate both clients with an antianxiety drug.

Reinforce reality to the client on the floor and remove him to a quiet space. The client who is diagnosed with PTSD is re-experiencing the traumatic experience and needs reality reassurance (confirmation that there is no danger at this time) and reduced stimuli. Options A, B, and D do not consider the needs of these two clients at this time.

The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement? A. Hang the solution at the current rate. B. Refrigerate the solution until needed. C. Prepare the solution with new tubing. D. Return the solution to the pharmacy.

Return the solution to the pharmacy. Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy. Options A, B, and C are not indicated because the solution should not be administered.

Which nursing intervention(s) should be implemented when caring for a client with bipolar disorder in the manic phase? (Select all that apply.) A. Report lithium level of 2.0 mEq/L to the primary health care provider. B. Encourage competitive physical activities as part of the client's therapy. C. Provide an environment with increased stimuli to engage the client. D. Maintain consistent salt levels in the diet when client is taking lithium. E. Assess the client's nutritional and hydration status.

Report lithium level of 2.0 mEq/L to the primary health care provider. Maintain consistent salt levels in the diet when client is taking lithium. Assess the client's nutritional and hydration status. A therapeutic level for serum lithium is 0.5 to 1.5 mEq/L, and the client with 2.0 mEq/L is experiencing toxicity (A). Consistent salt levels are important when taking lithium to maintain a therapeutic level (D). Because of the client's manic state, the client is at risk for impaired nutrition and dehydration; therefore, they should be assessed (E). Noncompetitive physical activities should be encouraged because of the risk for agitation (B), and decreased environmental stimuli is therapeutic for the manic phase (C).

A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse? A. Hypoactive bowel sounds with abdominal distention B. Client reports continued pain of 8 on a 10-point scale C. Respiratory rate of 12 breaths/min, with O2 saturation of 85% D. Client reports nausea after receiving the medication

Respiratory rate of 12 breaths/min, with O2 saturation of 85% Administration of a Schedule II opioid analgesic can result in respiratory depression, which requires immediate intervention by the nurse to prevent respiratory arrest. Options A, B, and D require action by the nurse but are of less priority than option C.

The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement? A. Perform range-of-motion exercises on the lower extremities every 4 hours. B. Place a small firm pillow under the upper back to flex the lumbar spine gently. C. Rest in bed with the head of the bed elevated 20 degrees and flex the knees. D. Position in reverse Trendelenburg with the feet firmly against the foot of the bed.

Rest in bed with the head of the bed elevated 20 degrees and flex the knees. Resting in bed with the head of the bed elevated 20 degrees and flexing the knees reduces stress on the lower back muscles. Range-of-motion exercises can result in paravertebral muscle spasms and increased pain. Bending the knees, rather than option B, reduces stress on the lower back. Option D places stress on the lower back and increases the client's pain.

During administration of theophylline, the nurse should monitor for signs of toxicity. Which symptom would cause the nurse to suspect theophylline toxicity? A. Dry mouth B. Urinary retention C. Restlessness D. Sedation

Restlessness Restlessness is a sign of theophylline intoxication. Other signs of toxicity are anorexia, nausea, vomiting, insomnia, tachycardia, arrhythmias, and seizures. Options A, B, and D are common side effects of antihistamines but do not indicate theophylline intoxication.

A client who is HIV-positive is receiving combination therapy with the antiviral medication zidovudine. Which instruction should the nurse include in this client's teaching plan? A. Take the drug as prescribed to cure HIV infections. B. Use the drug to reduce the risk of transmitting HIV to sexual contacts. C. Return to the clinic every 2 weeks for blood counts. D. Report to the health care provider immediately if dizziness is experienced.

Return to the clinic every 2 weeks for blood counts. Bone marrow depression with granulocytopenia is a severe but common adverse effect of zidovudine. Careful monitoring of CBCs is indicated. Options A and B are not correct instructions related to use of this medication. Option D is an expected side effect. The client should be instructed to avoid driving until this reaction improves.

A client who arrives in the postanesthesia care unit (PACU) after surgery is not awake from general anesthesia. Which action should the nurse implement first? A. Assess for deep tendon reflexes. B. Observe urinary output. C. Review the medication administration record (MAR). D. Administer naloxone.

Review the medication administration record (MAR). Most general anesthetics produce cardiovascular and respiratory depression, so a review of the client's MAR identifies all the medications received during surgery and helps the nurse anticipate the client's response and emergence from anesthesia. Options A and B are ongoing postoperative assessments. Based on the medications that the client has received, naloxone may need to be administered if indicated by the client's vital signs and delayed spontaneous reactivity.

The nurse is preparing a plan of care for a client receiving the glucocorticoid methylprednisolone. Which nursing diagnosis reflects a problem related to this medication that should be included in the care plan? A. Ineffective airway clearance B. Risk for infection C. Deficient fluid volume D. Impaired gas exchange

Risk for infection Corticosteroids depress the immune system, placing the client at risk for infection. Although options A, C, and D reflect diagnostic statements that may be applicable to this client, only option B is directly related to the administration of this medication.

A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take? A. Send the child home with the parents to see the health care provider before returning to school. B. Send the child home with the parents and report this to the health department. C. Cover the lesion with a dry gauze dressing and send the child back to class. D. Wash the lesion with antimicrobial soap, air-dry, and send the child back to class.

Send the child home with the parents to see the health care provider before returning to school. Impetigo is a staphylococcal infection and is transmitted by person-to-person contact. The child should be sent home with a note to the parents explaining the condition. Option B is not necessary because this is not a public health hazard. Option C slows the healing process and can contribute to spread of the infection. The lesions should be washed with soap and water, topical ointment applied, and left open to the air to dry. This will occur at the child's home.

A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit? A. Participating in telephone consultations with clients B. Identifying oneself by name and title to clients in telehealth communications C. Sending medical records to health care providers via the Internet D. Answering a client-initiated health question via electronic mail

Sending medical records to health care providers via the Internet Sending medical records over the Internet, even with the latest security protection, creates the greatest risk for liability because of the high potential of breaching client confidentiality and the amount of information being transferred. Client confidentiality is protected by federal wiretapping laws making telephone consultation a private and protected form of communication. By stating one's name and credentials in telehealth communication, one is taking responsibility for the encounter. E-mail initiated by the client poses less risk than sending records via the Internet.

The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented? A. Serum digoxin level is 1.5 ng/mL B. Blood pressure is 104/68 mm Hg C. Serum potassium level is 2.5 mEq/L D. Apical pulse is 68/min

Serum potassium level is 2.5 mEq/L Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin, which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL (toxic levels ≥ 2 ng/mL); Option A is within this range. Option B would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is < 60/min.

A nurse is assessing a client with heart failure who has been prescribed digoxin for therapy. Which finding indicates an issue with the medication management? A. Regular heart rate of 88 beats/min B. Serum potassium level, 2.9 mEq/L C. Weight decreases by 1 lb daily D. Serum sodium level, 138 mEq/L

Serum potassium level, 2.9 mEq/L A serum potassium level of 2.9 mEq/L is low, and side effects of digoxin toxicity are exacerbated when the potassium level is low. Options A, C, and D are all expected findings when caring for a client with congestive heart failure.

The nurse in the emergency department is caring for a client with type 1 diabetes mellitus in diabetic ketoacidosis (DKA). Which action should the nurse take first? A. Administer regular insulin IV. B. Start an IV infusion of normal saline. C. Check serum electrolyte levels. D. Give a potassium supplement.

Start an IV infusion of normal saline. The client in DKA experiences severe dehydration and must be rehydrated before insulin is administered. Options A, C, and D will follow rehydration.

A child is brought to the emergency department with a broken arm. Because of other injuries, the nurse suspects that the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? A. She is regressing to an earlier behavior pattern. B. She is sublimating her anger. C. She is projecting her feelings onto the nurse. D. She is suppressing her fear.

She is projecting her feelings onto the nurse. Projection is attributing one's own thoughts, impulses, or behaviors onto another; it is the mother who is probably harming the child, and she is attributing her actions to the nurse. The mother may be immature, but option A is not the best description of her behavior. Option B is substituting a socially acceptable feeling for an unacceptable one. These are not socially acceptable feelings. The mother may be suppressing her fear (option D) by displaying anger, but such an interpretation cannot be concluded from the data presented.

An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated femoral artery site. Which intervention should the nurse implement? A. Teach the parents how to ambulate the child in the room safely. B. Show the parents how to hold the child with the extremity extended. C. Restrain the child's lower extremities for a minimum of 4 hours. D. Place the child in a prone position to apply pressure to the site.

Show the parents how to hold the child with the extremity extended. The extremity should be extended to prevent trauma to the femoral catheterization site. Options A and D increase the risk for complications and are contraindicated. Option C is not necessary. Only the extremity that was catheterized requires immobilization.

Which nonverbal action should the nurse implement to demonstrate active listening?' A. Sit facing the client. B. Cross arms and legs. C. Avoid eye contact. D. Lean back in the chair.

Sit facing the client. Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client, which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not option B, and leaning toward the client, not option D. To communicate involvement and willingness to listen to the client, eye contact should be established and maintained.

The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further assessment reveals that he is concerned about his edematous facial features. Based on these assessment findings, the nurse should plan interventions related to which nursing diagnosis? A. Social isolation B. Altered health maintenance C. Knowledge deficit D. Ineffective coping

Social isolation Peer acceptance and body image are significant issues in the growth and development of adolescents. Option A addresses the problem of a lack of contact with peers stemming from his desire to protect his ego. Options B, C, and D are not supported by the assessment finding.

A 42-year-old client is admitted to the emergency department after taking an overdose of amitriptyline in a suicide attempt. Which drug should the nurse plan to administer to reverse the cardiac and central nervous system effects of amitriptyline? A. Sodium bicarbonate B. Naloxone C. Phentolamine mesylate D. Atropine sulfate

Sodium bicarbonate Sodium bicarbonate is an effective treatment for an overdose of tricyclic antidepressants such as amitriptyline to reverse QRS prolongation. Options B, C, and D are not the preferred agents for treating this drug overdose.

The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom, finds the client unconscious on the floor. Which intervention should the nurse implement first? A. Administer an antidysrhythmic medication. B. Start cardiopulmonary resuscitation. C. Prepare for mechanical ventilation. D. Assess the client's pulse oximetry.

Start cardiopulmonary resuscitation. Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started immediately until the crash cart arrives. Options A and C are appropriate, but CPR is the priority action until a defibrillator is available, which is the most effective treatment for ventricular fibrillation. The client is dying, and option D does not address the seriousness of this situation.

The nurse is caring for a client with deep vein thrombosis who is on a continuous IV heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the nurse take? A. Increase the rate of the heparin infusion using a nomogram. B. Decrease the heparin infusion rate and give vitamin K IM. C. Continue the heparin infusion at the current prescribed rate. D. Stop the heparin drip and prepare to administer protamine sulfate.

Stop the heparin drip and prepare to administer protamine sulfate. An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be stopped. The antidote for heparin is protamine sulfate. Increasing the rate would increase the risk for hemorrhage. The infusion should be stopped, and vitamin K is the antidote for warfarin (Coumadin). Keeping the infusion at the current rate would increase the risk for hemorrhage.

After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation? A. Switch to skim milk. B. Switch to orange juice. C. Add a source of protein. D. Add herbal tea.

Switch to skim milk. Dietary recommendations to reduce cancer risk include reduced consumption of fats, with increased consumption of fruits, vegetables, and fiber. Option A promotes reduced fat consumption. Orange slices provide more fiber than orange juice. Options B, C, and D are not standard recommendations for reducing cancer risk.

A seriously ill female client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about her feelings related to her own death. C. Collaborate with the health care provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local health care facility.

Talk with the client about her feelings related to her own death. The nurse should first assess the client's feelings about her death and determine the extent to which this statement expresses her true feelings. The client may need additional pain management, but further assessment is needed before implementing option A. Options C and D are both premature interventions and should not be implemented until further assessment is obtained.

The nurse expects a clinical finding of cyanosis in an infant with which conditions? (Select all that apply.) A. Ventricular septal defect (VSD) B. Patent ductus arteriosus (PDA) C. Coarctation of the aorta D. Tetralogy of Fallot E. Transposition of the great vessels

Tetralogy of Fallot Transposition of the great vessels Both tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease, in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and E). (A, B, and C) are all abnormal cardiac conditions, but are classified as acyanotic and involve left-to-right shunts, increased pulmonary blood flow, or obstructive defects.

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

The UAP auscultates the popliteal pulse with the cuff on the lower leg. When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures an accurate assessment, and option C provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan? A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week. B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week. C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month. D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.

The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month. In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel closes by the end of the second month. These growth and development milestones are frequently included in questions on the licensure examination. Options A, B, and C are incorrect.

A client who is receiving chlorpromazine HCl to control his psychotic behavior also has a prescription for benztropine. When teaching the client and/or significant others about these medications, what should the nurse explain about the use of benztropine in the treatment plan for this client? A. This medication will reduce the side effect of urinary retention. B. This drug potentiates the effect of chlorpromazine HCl. C. The benztropine is used to control extrapyramidal symptoms. D. The combined effect of these drugs will modify psychotic behavior.

The benztropine is used to control extrapyramidal symptoms. Benztropine, an anticholinergic drug, is used to control extrapyramidal symptoms associated with chlorpromazine HCl (Thorazine) use. Options A, B, and D are not accurate statements regarding the use of benztropine for clients who are treated with chlorpromazine HCl for the control of psychosis.

Methenamine mandelate is prescribed for a client with a urinary tract infection and renal calculi. Which finding indicates to the nurse that the medication is effective? A. The frequency of urinary tract infections decreases. B. The urine changes color and pain is diminished. C. The dipstick test changes from +1 to trace. D. The daily urinary output increases by 10%.

The frequency of urinary tract infections decreases. Mandelamine is prescribed to acidify the urine, decreasing the incidence of calcium phosphate calculi and urinary tract infections. Option B is related to the administration of pyridine. Mandelamine has no effect on option C or D.

Which finding should be reported to the primary health care provider when caring for a client who has a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP)? A. The client reports a continuous feeling of needing to void. B. Urinary drainage is pink 24 hours after surgery. C. The hemoglobin level is 8.4 g/dL 3 days postoperatively. D. Sterile saline is being used for bladder irrigation.

The hemoglobin level is 8.4 g/dL 3 days postoperatively. A hemoglobin level of 8.4 g/dL is abnormally low and may indicate hemorrhage. Options A, B, and D are all expected findings after a TURP.

Which assessment finding indicates that nystatin swish and swallow, prescribed for a client with oral candidiasis, has been effective? A. The client denies dysphagia. B. The client is afebrile with warm and dry skin. C. The oral mucosa is pink and intact. D. There is no reflux following food intake.

The oral mucosa is pink and intact. Nystatin swish and swallow is prescribed for its local effect on the oral mucosa, reducing the white curdlike lesions in the mouth and larynx. The ability to swallow does not indicate that the medication has been effective. Options B and D do not reflect effectiveness of the local medication.

A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit?' A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked. C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act. The Good Samaritan Act protects health care professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown.

The nurse plans to draw blood samples for the determination of peak and trough levels of gentamicin sulfate in a client receiving IV doses of this medication. When should the nurse plan to obtain the peak level? A. Thirty minutes after the dose is administered B. Immediately before giving the next dose C. When the next electrolyte levels are drawn D. Sixty minutes after the dose is administered

Thirty minutes after the dose is administered Peak drug serum levels are achieved 30 minutes after the IV administration of aminoglycosides, so option A is the optimum time to get a peak level. Options B, C, and D are not appropriate times associated with peak levels for gentamicin.

Which statement by the U.S. Food and Drug Administration (FDA) is an example of a black box or black label warning for the drug clopidogrel? A. This drug could cause heart attack or stroke when taken by clients with certain genetic conditions. B. Clopidogrel helps prevent platelets from sticking together and forming clots in the blood. C. This drug can be taken in combination with aspirin to reduce the risk of acute coronary syndrome. D. Clopidogrel can reduce the risk of a future heart attack when taken by clients with peripheral artery disease.

This drug could cause heart attack or stroke when taken by clients with certain genetic conditions. A black box warning is a notice required by the FDA on a prescription drug that warns of potentially dangerous side effects. Options B, C, and D are all desired effects of the drug.

The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed? A. Tidaling of water in water seal chamber B. Bilateral muffled breath sounds at bases C. Temperature of 101° F D. Absence of chest tube drainage for 2 days

Tidaling of water in water seal chamber Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the health care provider before the chest tube is removed to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure. Option B may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed. Option C usually indicates an infection, which may not be related to the chest tube. Option D is an expected finding.

A child with nephrotic syndrome is receiving prednisone. Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child? A. French toast sticks and orange juice B. Sausage egg muffin and grape juice C. Canadian bacon slices and hot chocolate D. Toasted oat cereal and low-fat milk

Toasted oat cereal and low-fat milk A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is option D. Option A is high in fat and sugar. Options B and C are high in fat and sodium.

A client with metastatic cancer reports severe continuous pain. Which route of administration should the nurse use to provide the most effective continuous analgesia? A. Oral B. Intravenous C. Transdermal D. Intramuscular

Transdermal Continuous pain is best managed by maintaining a constant serum drug level. Transdermal drug administration of an analgesic provides around-the-clock, controlled release of the medication that is absorbed through intact skin into the bloodstream to provide continuous pain relief. Option A is convenient, but gastrointestinal variables affect the absorption rate of the drug, its onset and intensity, and duration of response and requires repeated doses around the clock. Option B provides immediate action because the drug is infused directly into the bloodstream and is quickly metabolized, and repeated IV doses are required to maintain a continuous blood level. Option D requires repeated injections at regular intervals, which are uncomfortable, and absorption rates vary between muscle sites.

A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first? A. Auscultate the client's breath sounds. B. Turn off the continuous feeding pump. C. Check placement of the nasogastric tube. D. Measure the amount of residual feeding.

Turn off the continuous feeding pump. A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding to prevent further aspiration. Options A, C, and D should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.

A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A. Clamp the nasogastric tube. B. Confirm placement of the tube. C. Use a syringe to instill the medications. D. Turn off the intermittent suction device.

Turn off the intermittent suction device. The nurse should first turn off the suction and then confirm placement of the tube in the stomach before instilling the medications. To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time before reconnecting the suction.

When assessing a normal newborn, which findings should the nurse expect? (Select all that apply.) A. Umbilical cord contains one vein and two arteries B. Slightly edematous labia in the female newborn C. Absence of Babinski reflex D. Presence of white plaques on the cheeks and tongue E. Nasal flaring noted with respirations

Umbilical cord contains one vein and two arteries Slightly edematous labia in the female newborn These are normal findings (A and B). The others indicate abnormalities or complications and should be reported to the primary health care provider (C, D, and E).

Which action by the nurse is consistent with culturally competent care? A. Treating each client the same regardless of race or religion B. Ensuring that all Native American clients have access to a shaman C. Understanding one's own world view in addition to the client's D. Including the family in the plan of care for older clients

Understanding one's own world view in addition to the client's The nurse should understand his or her own values and views to prevent those values from being imparted to others, in addition to understanding the client's cultural views. Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity.

A nurse is assisting an 82-year-old client with ambulation and is concerned that the client may fall. Which area contains the older person's center of gravity? A. Head and neck B. Upper torso C. Bilateral arms D. Feet and legs

Upper torso Stooped posture results in the upper torso becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and elbows flex. The head and neck and feet and legs are not the center of gravity in the older adult. Although the arms comprise a part of the upper torso, they do not reflect the best and most complete answer.

The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP? A. Use designated isolation precautions. B. Keep the lighting in the room dim. C. Allow the parents to assist with care. D. Report any pain that the child experiences.

Use designated isolation precautions. All these are important measures to review with the UAP, but the most important is option A. Improper use of isolation precautions can place other staff and clients at risk for infection. Options B, C, and D promote client comfort and reduce anxiety but are of a lower priority than option A.

What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.) A. Use lanolin to moisturize the tops and bottoms of the feet. B. Soak the feet in warm water for at least 1 hour daily. C. Wash feet daily and dry well, particularly between the toes. D. Use over-the-counter products to remove corns and calluses. E. Wear leather shoes that fit properly.

Use lanolin to moisturize the tops and bottoms of the feet. Wash feet daily and dry well, particularly between the toes. Wear leather shoes that fit properly. Options A, C, and E are therapeutic interventions for foot care in the diabetic client. Options B and D are contraindicated and could cause foot infection or injury.

A psychiatric client is discharged from the hospital with a prescription for haloperidol. Which instruction should the nurse include in the discharge teaching plan for this client? A. Take with antacids to reduce gastrointestinal irritation. B. Use sunglasses and sunscreen when outdoors. C. Eat foods low in fiber and salt. D. Count the pulse before each dose.

Use sunglasses and sunscreen when outdoors. Photosensitivity is a common adverse effect of haloperidol (Haldol); therefore, the use of sunglasses and sunscreen should be included in the discharge teaching for this client. Options A, C, and D are not pertinent to client teaching regarding the use of haloperidol (Haldol).

A 2-month-old infant is scheduled to receive the first DPT immunization. What is the preferred injection site to administer this immunization? A. Dorsal gluteal B. Vastus lateralis C. Ventral gluteal D. Deltoid

Vastus lateralis The preferred intramuscular site for children younger than 2 years is the vastus lateralis. Options A, C, and D are not preferred injection sites for the infant at 2 months of age.

The nurse should encourage a laboring client to begin pushing at which point? A. When the cervix is completely effaced B. When the client describes the need to have a bowel movement C. When the cervix is completely dilated D. When the anterior or posterior lip of the cervix is palpable

When the cervix is completely dilated Pushing begins with the second stage of labor, when the cervix is completely dilated at 10 cm. If pushing begins before the cervix is completely dilated, the cervix can become edematous and may never dilate completely, necessitating an operative delivery. The most effective pushing occurs when the cervix is completely dilated and the woman feels the urge to push (Ferguson reflex).

A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time? A. Diabetes insipidus B. Hypotension C. Hyperkalemia D. Uremia

hypotension During the transition from oliguria to the diuretic phase of acute renal failure, the tubule's inability to concentrate the urine causes osmotic diuresis, which places the client at risk for hypovolemia and hypotension. Option A is related to the secretion of antidiuretic hormone (ADH) and not specifically to the kidney function. Because of the excessive fluid loss, the client is at risk for potassium loss, not option C. Option D is characteristic of chronic renal failure with multiple body system involvement.

A 25-year-old client has been particularly restless, and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? A. "No one is after you. You're safe here." B. "You'll feel better after you have rested." C. "I know you must feel lonely and frightened." D. "Come with me to your room, and I will sit with you."

"Come with me to your room, and I will sit with you." Option D is the best response because it offers support without judgment or demands. Option A is challenging the client's delusion. Option B is offering false reassurance. Option C is a violation of therapeutic communication because the nurse is telling the client how she or he feels (frightened and lonely), rather than allowing the client to describe his or her own feelings. Hallucinating and delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis.

The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then compress the inhaler." B. "Compress the inhaler while slowly breathing in through your mouth." C. "Compress the inhaler while inhaling quickly through your nose." D. "Exhale completely after compressing the inhaler and then inhale."

"Compress the inhaler while slowly breathing in through your mouth." The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration.

A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother? A. "Is your son's short stature a social embarrassment to him or the family?" B. "What types of foods do both your children eat now and what did they eat when they were infants?" C. "Did any significant trauma occur with the birth of your son?" D. "Did your daughter also start her menstrual period at 12 years of age?

"Did your daughter also start her menstrual period at 12 years of age?" Girls are expected to mature sexually and grow physically sooner than boys. Furthermore, girls only grow an average of 2 inches after menses begins. Option A is not appropriate at this time. The mother is worried that something is wrong with her son physically. Option B has less to do with stature than growth and development. Option C is not related to growth hormone deficiencies, which are idiopathic (without known causes).

A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to make? A. "How can I help you? Tell me more about your problems." B. "Things probably aren't as bad as they seem right now." C. "Let's talk about what is right with your life." D. "I hear your misery, but things will get better soon."

"How can I help you? Tell me more about your problems." Offering self shows empathy and caring and gives the client the opportunity to talk while the nurse listens. Option B dismisses the client's perception that things are really bad and potentially stops further communication with the client. Option C avoids the client's problems and promotes denial. "I hear your misery" is an example of reflective dialogue and would be the best choice if it were not for the rest of the sentence, "but things will get better soon," which offers false reassurance.

A middle-aged adult was discharged from a treatment center 6 weeks ago following treatment for suicide ideation and alcohol abuse. In a follow-up visit to the mental health clinic, the client complains of lethargy, apathy, irritability, and anxiety. Which question is most important for the nurse to ask? A. "Are you taking prescribed antidepressants?" B. "How much alcohol do you consume daily?" C. "What seems to precipitate the anxious feelings?" D. "How many hours do you sleep per day?"

"How much alcohol do you consume daily?" First, and most importantly, the client's use of alcohol should be determined because further treatment is dependent on the client's sobriety, and asking how much alcohol is being consumed is a better question than asking if the client is drinking, which is a "yes-no" answer that does not promote dialogue. Options A, C, and D provide worthwhile assessment data, but first the nurse should determine if the client is still drinking because all efforts to treat symptoms associated with depression are diminished if the client is still consuming alcohol.

A schizophrenic client who is taking fluphenazine decanoate is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse about a planned vacation and will return in 18 days. Which statement by the client indicates to the nurse a need for health teaching? A. "I am going to have lots of fun at the beach and plenty of time in the sun." B. "While I am on vacation, I will not eat or drink anything that contains alcohol." C. "I will notify the health care provider if I have a sore throat or flulike symptoms." D. "I will continue to take my benztropine mesylate every day."

"I am going to have lots of fun at the beach and plenty of time in the sun." Photosensitivity is a side effect of fluphenazine decanoate, so the client should be instructed to avoid the sun. Options B, C, and D indicate accurate knowledge. Alcohol acts synergistically with fluphenazine decanoate. A sore throat and flulike symptoms are signs of agranulocytosis, which is also a side effect of Prolixin. To avoid extrapyramidal symptoms (EPS), anticholinergic drugs, such as Cogentin, are often prescribed prophylactically with fluphenazine decanoate.

Which statement indicates that client teaching regarding the administration of the chemotherapeutic agent daunorubicin HCl has been effective? A. "I should use an astringent mouthwash after every meal." B. I will eat high-fiber foods and drink lots of water." C. "I expect my urine to be red for the next few days." D. "I should use sunscreen when I spend time outdoors."

"I expect my urine to be red for the next few days." Daunorubicin HCl causes the urine to turn red in color. Option A is not recommended. Options B and D are interventions that promote general good health but are not specific to treatment with daunorubicin HCl.

A client is taking famotidine. Which client statement should the nurse further assess because it may indicate that the client is experiencing a side effect of this drug? A. "I have heartburn whenever I lie down." B. "I am never hungry. I've lost weight in the past 2 weeks." C. "I have a funny metallic taste in my mouth." D. 11"I seem to be having difficulty thinking clearly."

"I seem to be having difficulty thinking clearly." A common side effect of of famotidine is confusion. Options A, B, and C are not side effects of this medication.

A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that teaching has been effective? A. "I will not take my digoxin if my heart rate is higher than 100 beats/min." B. "I should weigh myself once a week and report any increases." C. "It is important to increase my fluid intake whenever possible." D. "I should report an increase of swelling in my feet or ankles."

"I should report an increase of swelling in my feet or ankles." An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider. Digitalis should be held when the heart rate is lower than 60 beats/min. The client with heart failure should weigh himself or herself daily and report a gain of 2 to 3 lb. An increase in fluid can worsen heart failure.

The nurse is evaluating a client's understanding of the prescribed antilipemic drug lovastatin. Which client statement indicates that *further teaching is needed*? A. "My bowel habits should not be affected by this drug." B. "This medication should be taken once a day only." C. "I will still need to follow a low-cholesterol diet." D. "I will take the medication every day before breakfast."

"I will take the medication every day before breakfast." The enzyme that helps metabolize cholesterol is activated at night, so this medication should be taken with the evening meal. Options A, B, and C reflect correct information about lovastatin.

A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the most therapeutic? A. "I'll leave your tray here. I am available if you need anything else." B. "You're not being poisoned. Why do you think someone is trying to poison you?" C. "No one on this unit has ever died from poisoning. You're safe here." D. "I will talk to your health care provider about the possibility of changing your diet."

"I'll leave your tray here. I am available if you need anything else." Option A is the best choice because the nurse does not argue with the client or demand that the client eat but offers support by agreeing to be there if needed, which provides an open, rather than closed, response to the client's statement. Options B and C are challenging the client's delusions, and option B asks "why." Probing questions, which start with "why," are usually not therapeutic communication for a psychotic client. Option D has not addressed the actual problem—that is, the client's delusions.

A client is receiving oral griseofulvin for a persistent tinea corporis infection. Which response by the client indicates an accurate understanding of the drug teaching conducted by the nurse? A. "I'll wear sunscreen whenever I mow the lawn." B. "This is the worse bacterial infection I've ever had." C. "I will need to take the medication for 7 days." D. "My urine will probably turn brown due to this drug."

"I'll wear sunscreen whenever I mow the lawn." Photosensitivity is a side effect of griseofulvin, so clients should be cautioned to wear protective sunscreen during sun exposure. Options B, C, and D are not accurate statements about side effects of this medication.

The level of consciousness (LOC) should be established immediately when a head injury has occurred. Spontaneous eye opening is a simple measure of alertness that indicates that arousal mechanisms are intact. Option A is not the best indicator of LOC. Although option B is important, vital signs are not the best indicators of LOC and can be evaluated after the client's LOC has been determined. Option C can be assessed after LOC has been established by assessing eye opening. A. "I will read all the teaching booklets you gave me before surgery." B. "I have had surgery before, so I know what to expect afterward." C. "All the things people have told me will help me take care of my back." D. "Let me show you the method of turning I will use after surgery."

"Let me show you the method of turning I will use after surgery." The outcome of learning is best demonstrated when the client not only verbalizes an understanding but can also provide a return demonstration. A 14-year-old client may or may not follow through with option A, and there is no measurement of learning. Option B may help the client understand the surgical process, but the type of surgery may have been very different, with differing postoperative care. In option C, the client may be saying what the nurse wants to hear without expressing any real understanding of what to do after surgery.

The nurse is taking the family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the mother is most important in formulating a plan of care for this child? A. "Our first child was born with a cleft lip." B. "We are very careful not to get sunburns in our family." C. "My first child sometimes got a diaper rash." D. "My husband and our daughter are both lactose-intolerant."

"My husband and our daughter are both lactose-intolerant." Environmental exposure to allergens (milk) and a positive family history for milk allergies are important data in planning care of the child with atopic dermatitis because milk allergies can contribute to the child's outbreaks. Option A is not a contributing factor. Option B is an environmental factor in other skin diseases but does not have a strong correlation with eczema in children. Option C is not unusual and occurs in the diaper area, whereas atopic dermatitis occurs most often on the face and extensor aspects of the arms and legs.

A client is receiving antiinfective drug therapy for a postoperative infection. Which complaint should alert the nurse to the possibility that the client has contracted a superinfection? A. "My mouth feels sore." B. "I have a headache." C. "My ears feel plugged up." D. "I feel constipated.

"My mouth feels sore." Stomatitis caused by a thrush infection, which can cause mouth pain, is a sign of superinfection. Options B, C, and D are more typical side effects, rather than symptoms, of a superinfection.

A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic. Which statement by the parent warrants immediate intervention by the nurse? A. "My son often chokes while I am feeding him." B. "Is it normal for my child's legs to cross each other?" C. "He gets stiff when I pull him up to a sitting position." D. "My 4-year-old son is jealous of his little brother."

"My son often chokes while I am feeding him." Airway obstruction is always a priority when caring for any client. Options B and C are characteristics of spastic cerebral palsy and may involve one or both sides. These children have difficulty with fine motor skills, and attempts at motion increase abnormal postures. Option D is an expected behavior and may need to be addressed, but it is not a priority over choking.

During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization? A. "Sometimes I take an extra one of my pills when I hear the voices." B. "The voices are louder when I forget to take my medication." C. "No matter what I do, I cannot make the voices go away." D. "I just try to tell the voices to stop when they bother me."

"No matter what I do, I cannot make the voices go away." Hospitalization is needed if the client continues to hear voices telling the client to do things that can cause self-harm. Option A or B does not require hospitalization unless symptoms become severe. The client should continue symptom management strategies to prevent hospitalization.

A client comes to the obstetric clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the nurse, "I'm having second thoughts about wanting to have this baby." Which response is best for the nurse to make? A. "It's normal to feel ambivalent about a pregnancy when you are not feeling well." B. "I think you should discuss these feelings with your health care provider." C. "How does the father of your child feel about your having this baby?" D. "Tell me about these second thoughts you are having about this pregnancy."

"Tell me about these second thoughts you are having about this pregnancy." Although ambivalence is normal during the first trimester, option D is the best nursing response at this time. It is reflective and keeps the lines of communication open. Option A is not the best response because it offers false reassurance. Option B dismisses the client's feelings. The nurse should use communication skills that encourage this type of discussion, not shift responsibility to the care provider. Option C may eventually be discussed, but it is not the most important information to obtain at this time.

A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? A. "It sounds like you're feeling very sad." B. "Tell me more about how you're feeling." C. "How often do you have crying spells?" D. "Do you want to talk about these feelings?"

"Tell me more about how you're feeling." It is most therapeutic to ask an open-ended question and encourage the client to explore his or her feelings. Option A is a leading response, and the client may not be feeling sad. Options C and D are closed-ended questions that do not facilitate communication.

Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate? A. "I need to tell the health care provider about your child's tendency to be accident-prone." B. "Tell me more about these accidents that your child has been having." C. "I need to report these injuries to the authorities because they do not seem accidental." D. "Boys this age always seem to require more supervision and can be quite accident-prone."

"Tell me more about these accidents that your child has been having." Option B seeks more information using an open-ended, nonthreatening statement. Option A might be appropriate but is not the best answer because the nurse is being somewhat sarcastic and is also avoiding the situation by referring it to the health care provider for resolution. Although it is true that suspected cases of child abuse must be reported, option C is almost an attack and is jumping ahead before conclusive data are obtained. Option D is a cliché and dismisses the seriousness of the situation.

The nurse is assessing a male adolescent client's knowledge of contraception. The teen states, "I have all the info I need." What is the best response by the nurse? A. "Tell me what you know about birth control." B. "Do you know how to apply a condom?" C. "Teen pregnancy should not be taken lightly." D. "You need to visit with your guidance counselor."

"Tell me what you know about birth control." Teens often obtain information from peers, which may not be accurate. Knowing the source of the information may assist the nurse in evaluating the information that the teenager has regarding contraception. It would be best for the nurse to ask a more general question, such as option A. Option B is narrow in focus. Options C and D are blocks to any further communication.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best? A. "This is not an unusually shaped head, especially for a first baby." B. "It may look odd, but newborn babies are often born with heads like that." C. "That is normal. The head will return to a round shape within 7 to 10 days." D. "Your pelvis was too small, so the head had to adjust to the birth canal."

"That is normal. The head will return to a round shape within 7 to 10 days." Option C reassures the mother that this is normal in the newborn and provides correct information regarding the return to a normal shape. Although option A is correct, it implies that the client should not worry. Any implied or spoken "don't worry" is usually the wrong answer. Option B is condescending and dismissing; the mother is seeking reassurance and information. Option D is a negative statement and implies that molding is the mother's fault.

A woman whose first child died at 6 weeks of age because of sudden infant death syndrome (SIDS) is being discharged following the birth of her second child. The mother tells the nurse that she is fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this woman? A. "You can prevent SIDS if your baby sleeps on the side or back. You will have to monitor the baby carefully." B. "The fear of losing another child to SIDS is very realistic. Have you thought about what support you may need?" C. "An apnea monitor will alert you if the baby stops breathing. This will give you the peace of mind that you need." D. "My neighbor's baby died of SIDS last year, and she went to a SIDS support group. That really helped her."

"The fear of losing another child to SIDS is very realistic. Have you thought about what support you may need?" The most effective way to provide emotional support is to acknowledge what clients may be feeling, be a sounding board for them so they can listen to themselves, and allow them to discover their own solutions. Option A implies to the mother that she can prevent SIDS from occurring, which is an unrealistic expectation. Offering a personal opinion about what will help this client or about what has helped a neighbor is not as effective as helping the client discover what would be best for her.

The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A. "At home I take my pills at 8:00 am." B. "It costs a lot of money to buy all of these pills." C. "I get so tired of taking pills every day." D. "This is a new pill I have never taken before."

"This is a new pill I have never taken before." The client's recognition of a "new" pill requires further assessment to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained. Although comments about cost should be considered when developing a discharge plan, option D is a higher priority. The client's feelings C should be acknowledged, but observation of the five rights of medication administration is most essential.

The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? A. "What makes you think we did anything to your baby?" B. "Are you or any of your blood relatives of Asian descent?" C. "Those are stork bites and will go away in about 2 years." D. "Those are Mongolian spots and will gradually fade in 1 or 2 years."

"Those are Mongolian spots and will gradually fade in 1 or 2 years." Mongolian spots are areas of bluish-black or gray-blue pigmentation seen primarily on the dorsal area and buttocks of infants of Asian or African descent or dark-skinned babies. Option A is a defensive answer. Although Mongolian spots occur more frequently in those of Asian and African descent, option B does not respond to the father's concern. Telangiectatic nevi, frequently referred to as stork bites, appear reddish-purple or red and are usually on the face or head and neck area.

The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of regular and NPH insulin. Which statement indicates that the client needs further instruction? A. "I should balance my daily exercise with my dietary intake and insulin dosages." B. "When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." C. "I should inject my insulin into a different site to reduce the development of scar tissue." D. "I should remove the dose of clear insulin first and then the dose of cloudy insulin from the vials."

"When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." Aspiration is not necessary when giving insulin because it could increase tissue trauma and affect the absorption rate. Option C helps minimize tissue atrophy, which can affect the absorption of the insulin. Options A and D are correct procedures. The client should balance an active physical lifestyle with diet, insulin, and blood glucose monitoring to ensure tight serum glucose level control. When mixing insulins in the same syringe, the clear (Regular) insulin is withdrawn first to avoid contamination of the clear vial with cloudy NPH insulin, which will alter the absorption rate of the remaining Regular insulin.

An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections? A. "I know you are capable of giving yourself the insulin." B. "Giving yourself the injection seems to make you nervous." C. "When I watched you give yourself the injection, you did it correctly." D. "Tell me what you want me to do to help you give yourself the injection at home."

"When I watched you give yourself the injection, you did it correctly." The nurse needs to focus on the client's positive behaviors, so focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. Option A does not focus on the specific behaviors related to giving the injection and could be interpreted as punitive. Option B uses reflective dialogue to assess the client's feelings, but telling the client that he is nervous may serve as a negative reinforcement of this behavior. Option D reinforces the client's dependence on the nurse.

At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make? A. "Yes, I am the leader today. Would you like to be the leader tomorrow?" B. "Yes, I will be leading this group. What would you like to accomplish?" C. "Yes, I have been assigned to lead this group. I will be here for the next 6 weeks." D. "Yes, I am the leader. You seem angry about not being the leader yourself."

"Yes, I will be leading this group. What would you like to accomplish?" Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. Option B provides information and refocuses the group to defining its function. Option A is manipulative bargaining. Option C does not focus the group on its purpose or task. Option D is interpreting the client's feelings and is almost challenging.

The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the practical nurse (PN)? A. A client with nausea who needs a nasogastric tube inserted B. A client in hypertensive crisis who needs titration of IV nitroglycerin C. A newly admitted client who needs to have a plan of care established D. A client who is ready for discharge who needs discharge teaching

A client with nausea who needs a nasogastric tube inserted The client mentioned in option A has a need for a skill that is within the scope of practice for the PN. Titration of an IV drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not delegated.

A 33-year-old client is admitted to a psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client? A. A 35-year-old client who recently attempted suicide B. A manic client who has started lithium carbonate treatment C. A client who is bipolar and is pacing the floor while telling jokes to everyone D. A paranoid client who believes that the staff is trying to poison the food

A manic client who has started lithium carbonate treatment Option B appears to be the most stable client described since treatment was begun with lithium carbonate (treatment of choice for manic depression). Being around another depressed individual might enhance this client's own depression and possibly support suicidal ideation. Clients in the manic stage of bipolar disease enhance the level of anxiety of those around them, which would not be therapeutic for the client at this time. Paranoid ideation, which is characterized by suspiciousness, would also increase anxiety in this client.

In addition to nitrate therapy, a client is receiving nifedipine, 10 mg PO every 6 hours. The nurse should plan to observe for which common side effect of this treatment regimen? A. Hypotension B. Hyperkalemia C. Hypocalcemia D. Seizures

A. Hypotension Nifedipine reduces peripheral vascular resistance and nitrates produce vasodilation, so concurrent use of nitrates with nifedipine can cause hypotension with the initial administration of these agents. Options B, C, and D are not side effects of this treatment regimen.

Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP? A. An adolescent who was readmitted to the hospital because of a postoperative infection B. A woman with a new colostomy who requires discharge teaching C. A woman who had a hip replacement and may be transferred to the home care unit D. A man who had a cholecystectomy and currently has a nasogastric tube set to intermittent suction

A woman who had a hip replacement and may be transferred to the home care unit A hip replacement is considered a clean case, and transferring the client to another unit is likely to involve physically moving the client and her belongings. The charge nurse will be responsible for providing a report to the home care unit if the transfer occurs. The adolescent client is infected, and an employee who works on an OB unit should be assigned to clean cases in case the employee is required to return to the OB unit. This requires the skills of a registered nurse (RN) to do discharge teaching and provide emotional support. This may require skills beyond the level of this UAP.

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) A. Shave the area where the TENS will be placed. B. Obtain small needles for insertion. C. Place the TENS unit directly over or near the site of pain. D. Explain to the client that drowsiness may occur immediately after using TENS. E. Describe the use of TENS for postoperative procedures such as dressing changes.

A. Shave the area where the TENS will be placed. C. Place the TENS unit directly over or near the site of pain. E. Describe the use of TENS for postoperative procedures such as dressing changes. The TENS unit consists of a battery-operated transmitter, lead wires, and electrodes. The electrodes are placed directly over or near the site of pain (C), and hair or skin preparations should be removed before attaching the electrodes (A). The TENS unit is useful for managing postoperative pain or pain associated with postoperative procedures, such as removing drains or changing dressings (E). Electrodes are used, not needles (B) and, unlike with opioids, pain relief is achieved without drowsiness (D).

Which instructions should the nurse provide to an adolescent female client who is initiating treatment with isotretinoin for acne vulgaris? (Select all that apply.) A. "Notify the health care provider immediately if you think you are pregnant." B. "If your acne gets worse, stop the medication and call the health care provider." C. "Take a daily multiple vitamin to prevent deficiencies and promote dermal healing." D. "Dermabrasion for deep acne scars should be postponed for 1 month after therapy is stopped." E. "If you begin crying more than usual and feel sad, stop the drug and call the health care provider." F. "Before, during, and after therapy, two effective forms of birth control must be used at the same time."

A."Notify the health care provider immediately if you think you are pregnant." E. "If you begin crying more than usual and feel sad, stop the drug and call the health care provider." F. "Before, during, and after therapy, two effective forms of birth control must be used at the same time." Isotretinoin has been found to cause pregnancy category D drug-related birth defects, premature births, and fetal death (A), which necessitates the use of effective birth control methods before, during, and after therapy (F). Isotretinoin is associated with sadness (E), depression, suicidal ideations, and other serious mental health problems. An initial exacerbation of acne (B) is common when starting drug therapy. Isotretinoin is a retinoid related to vitamin A, and taking additional multivitamin supplements (C) can predispose the client to vitamin A toxicity. The client should stop taking isotretinoin at least 6 months before cosmetic procedures, such as dermabrasion (D), because the drug can increase the chances of scarring.

A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, he is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which intervention should the nurse implement first? A. Increase the ventilator VT to 850 mL. B. Decrease the ventilator IMV to a rate of 8 breaths/min. C. Reduce the FiO2 to 0.70 and redraw ABGs. D. Add 5 cm positive end-expiratory pressure (PEEP).

Add 5 cm positive end-expiratory pressure (PEEP). Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level. Options A, B, and C will not result in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure.

The nurse is preparing to administer a secondary infusion of a dobutamine solution to a client. The nurse notes that the solution is brown in color. Which action should the nurse implement? A. Verify the prescribed dose with the health care provider. B. Discard the solution and reorder from the pharmacy. C. Dilute the solution with more normal saline until it becomes lighter in color. D. Administer the drug if the solution's reconstitution time is <24 hours.

Administer the drug if the solution's reconstitution time is <24 hours. The color of the dobutamine solution is normal, and the solution should be administered within 24 hours after reconstitution, so the time of reconstitution should be verified before administering the solution of medication. Option A is not indicated. Option B is not necessary. Additional dilution of a drug in solution is stated in the manufacturer's reconstitution instructions, but option C is not needed.

Methylphenidate is prescribed for daily administration to a 10-year-old child with attention-deficit/hyperactivity disorder (ADHD). In preparing a teaching plan for the parents of this child newly diagnosed with ADHD, which instruction is most important for the nurse to provide to the parents? A. Administer the medication in the morning before the child goes to school. B. Plan to implement periodic interruptions in the administration of the drug. C. Attempt to be consistent when setting limits on inappropriate behavior. D. Seek professional counseling if the child's behavior continues to be disruptive.

Administer the medication in the morning before the child goes to school. Methylphenidate is a central nervous system (CNS) stimulant. To be most effective in affecting the child's behavior, the dose of the drug should be administered in the morning before the child goes to school. Drug holidays are often prescribed to assess the child's degree of recovery; however, such interruptions are not conducted in the early phase of treatment and are usually implemented when side effects occur over a period of time. Options C and D are worthwhile instructions but do not have the priority of option A.

A female client who has started long-term corticosteroid therapy tells the nurse that she is careful to take her daily dose at bedtime with a snack of crackers and milk. Which is the best response by the nurse? A. Advise the client to take the medication in the morning, rather than at bedtime. B. Teach the client that dairy products should not be taken with her medication. C. Tell the client that absorption is improved when taken on an empty stomach. D. Affirm that the client has a safe and effective routine for taking the medication.

Advise the client to take the medication in the morning, rather than at bedtime. Daily doses of long-term corticosteroid therapy should be administered in the morning to coincide with the body's normal secretion of cortisol. Clients receiving long-term corticosteroids need to increase their intake of calcium, which generally means an increase in dairy products. Corticosteroids can often cause gastrointestinal distress and should be administered with meals. The client has established a safe routine by taking the medication with a snack, but the routine will be more effective if done in the morning.

Over a period of several weeks, one participant of a socialization group at a community daycare center for older adults monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? A. Talk to the client outside the group about his behavior. B. Ask the client to give others a chance to talk. C. Allow the group to handle the problem. D. Ask the client to join another group.

Allow the group to handle the problem. After several weeks, the group is in the working phase, and the group members should be allowed to determine the direction of the group. The nurse should ignore the comments and allow the group to handle the situation. A good leader should not have separate meetings with group members, because such behavior is manipulative on the part of the leader. Option B is dictatorial and is not in keeping with good leadership skills. Option D is avoiding the problem. Remember, identify which phase the group is in (initial, working, or termination) as an aid to determining expected communication style.

Which nursing diagnosis has the highest priority when planning care for an infant with eczema? A. High risk for altered parenting related to feelings of inadequacy B. Altered comfort (pruritus) related to vesicular skin eruptions C. Altered health maintenance related to knowledge deficit of treatment D. Risk for impaired skin integrity related to eczema

Altered comfort (pruritus) related to vesicular skin eruptions Altered comfort (pruritus) has the highest priority because itching will cause the infant to scratch, creating complications such as scarring or infection. Options A, C, and D are all important nursing diagnoses and should be considered when developing the infant's plan of care, but they do not have the priority of option B.

A client believes that his health care provider is an FBI agent and that his apartment is a site for slave trading. The client believes that the FBI has cameras in the apartment, so it is not safe to return there. Based on these symptoms, which class of medication is most likely to be prescribed for this client? A. Antianxiety medication B. Mood stabilizer C. Antipsychotic D. Sedative-hypnotic

Antipsychotic An antipsychotic will most likely be prescribed because the client's thoughts are delusional. The client needs an antipsychotic medication to promote rational thoughts. Option A may lessen anxiety associated with the delusions, but is not the treatment of choice for altered thoughts. Option B will manage mood swings, and Option D will be prescribed for sleep.

When providing nursing care for a client receiving pyridostigmine bromide for myasthenia gravis, which nursing intervention has the highest priority? A. Monitor the client frequently for urinary retention. B. Assess respiratory status and breath sounds often. C. Monitor blood pressure each shift to screen for hypertension. D. Administer most medications after meals to decrease gastrointestinal irritation.

Assess respiratory status and breath sounds often. The client should be assessed often for signs of respiratory complications. The client with myasthenia gravis is at greatest risk for life-threatening respiratory complications because of the weakness of the diaphragm and ancillary respiratory muscles caused by the disease process. Cholinergic agents used to reduce muscle weakness can also cause hypersalivation, increased respiratory secretions, and possible bronchoconstriction. Although options A, C, and D reflect helpful interventions, they do not have the priority of option B in caring for the client with myasthenia gravis.

A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement? A. Teach the client testicular self-examination (TSE). B. Assess for the presence of blood in the urine. C. Ask about scrotal pain or blood in the semen. D. Inquire about a history of kidney stones.

Ask about scrotal pain or blood in the semen. Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms. Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer. Although hematuria is associated with renal disease or calculi, the client's pain is associated with ejaculate, not urine.

A mother brings her 18-month-old child to the community health center because the child has had "bad diarrhea" for the last 3 days. She states, "I bought some of this liquid at the pharmacy and gave my daughter a half-ounce." The nurse sees that the bottle contains loperamide. Which intervention is most important for the nurse to implement initially? A. Tell the mother never to give this drug to her toddler. B. Ask if any other siblings have experienced diarrhea. C. Take the child's oral and tympanic temperatures. D. Ask the mother when the child last voided.

Ask the mother when the child last voided. Determining when the child last voided is most important because urine output is decreased with dehydration and an 18-month-old with a 3-day history of diarrhea could be severely dehydrated. Although the manufacturer states that loperamide should not be given to a child younger than 2 years except under the direction of a health care provider, option A is not the best answer for this question. In addition, loperamide causes an anticholinergic effect of urinary retention. Data obtained in options B and C are not as high a priority as option D in this situation.

The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C. Milk the tube to remove any excessive blood clot buildup. D. Assess for kinks or dependent loops in the tubing.

Assess for kinks or dependent loops in the tubing. The least invasive nursing action should be performed first to determine why the drainage has diminished. Option A is completed after assessing for any problems causing the decrease in drainage. Option B is no longer considered standard protocol because the increase in pressure may be harmful to the client. Option C is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.

A client with Tourette syndrome takes haloperidol to control tics and vocalizations. The client has become increasingly drowsy over the past 2 days and reports becoming dizzy when changing from a supine to sitting position. Which action should the nurse take? A. Assess for poor skin turgor, sunken eyeballs, and concentrated urine output. B. Recognize that a sedative effect is expected and continue monitoring the client. C. Have the caregiver hold the next two doses of the medication to reduce the drug toxicity. D. Determine whether the client's urine is pink or reddish brown, and report findings to the health care provider.

Assess for poor skin turgor, sunken eyeballs, and concentrated urine output. Because haloperidol causes CNS effects of sedation and decreased thirst, the nurse should assess for signs of dehydration. Although sedation may occur with haloperidol administration, this side effect may signal an adverse CNS reaction; therefore, option B is not a sufficient intervention when client safety is threatened. Option C could precipitate withdrawal-emergent dyskinesia, which is potentially life threatening. Option D is expected.

The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement? A. Assess the child's mucous membranes and skin turgor. B. Contact food services about needed menu restrictions. C. Determine the child's food likes and dislikes. D. Ask the parents about the child's recent dietary intake.

Assess the child's mucous membranes and skin turgor. An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit. The nurse should first assess for indications of fluid volume deficit and then implement options B, C, and D.

Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention should the nurse implement based on these results? A. Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B. Assess the client for pain and administer pain medication as prescribed. C. Encourage the client to take short shallow breaths for 5 minutes. D. Prepare to administer sodium bicarbonate IV over 30 minutes.

Assess the client for pain and administer pain medication as prescribed. These ABGs reveal respiratory alkalosis, and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A PaO2 of 96 mm Hg does not indicate the need for an increase in oxygen administration. The PaCO2 indicates mild hyperventilation, so option C is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate is indicated for the treatment of metabolic acidosis, not respiratory alkalosis.

Prior to administering an oral suspension, which intervention is most important for the nurse to implement? A. Assess the client's ability to swallow liquids. B. Obtain applesauce in which to mix the medication. C. Determine the client's food likes and dislikes. D. Auscultate the client's breath sounds.

Assess the client's ability to swallow liquids. An oral suspension is a liquid, so the nurse needs to assess the client's ability to swallow liquids to ensure that the client will not choke. If the client has difficulty swallowing liquids, a thickening substance may be used. If a food product is used to thicken the liquid, option C would be beneficial. Option D may also be warranted, but only if the client is at risk for aspiration, determined by option A.

A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the health care provider and request a prescription for a large-volume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

Assess the client's medical record to determine the client's normal bowel pattern. This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention. Option A, B, or D may then be implemented, if warranted.

Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit.

Assess the client's neurologic status. This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status to be sure that the client understands and can legally provide consent for surgery. Option A does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified and permission obtained from the next of kin.

A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action should the nurse take first? A. Administer an antianxiety medication PRN. B. Assess the client's vital signs. C. Notify the primary health care provider. D. Determine coping mechanisms used in the past.

Assess the client's vital signs. Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is important that the nurse assess the client and rule out physiologic causes. Nonpharmacologic measures should be taken first. Options C and D may be considered but are not as high priority as the initial physiologic assessment.

A client who is first day postoperative after a mastectomy becomes increasingly restless and agitated. Vital signs are temperature, 100° F; pulse, 98 beats/min; respirations, 24 breaths/min; and blood pressure, 120/80 mm Hg. Which intervention should the nurse implement first? A. Administer a PRN dose of a prescribed analgesic. B. Assess the incision for any drainage or redness. C. Instruct the UAP to take vital signs hourly. D. Assist the client to a more comfortable position.

Assess the incision for any drainage or redness. The nurse's priority is to observe for possible hemorrhage. The client is at high risk for hypovolemic shock and is exhibiting early symptoms of shock. Remember, in early shock the blood pressure may be stable or increase slightly as a compensatory mechanism. If there is no obvious indication of bleeding, the client should then be assessed for the need of an analgesic and options A, C, and D should be implemented.

The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members? A. Assign the PNs to perform am care and assist with feeding the clients. B. Assign the UAPs to take vital signs and obtain daily weights. C. Assign the RNs to answer the call lights and administer all medications. D. Assign the PNs to assist health care providers on rounds and perform glucometer checks.

Assign the UAPs to take vital signs and obtain daily weights. A UAP can take vital signs and daily weights on stable clients. UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the PN. All team members can answer call lights, and PNs can administer some of the medications, so assigning the RN these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds, and the UAP can perform glucometer checks, so assigning the PN these tasks is not an effective use of available personnel.

A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or stroke. Options B and C are within defined parameters, and Option D is not a recognized chronic complication of diabetes. A. Orient the client to activities on the unit. B. Document suicide precautions on the shift report. C. Assign the client to a semiprivate room. D. Obtain a verbal no-suicide contract with the client.

Assign the client to a semiprivate It is most important to prevent the risk of self-harm from social isolation, so the client should be assigned to a semiprivate room. Option A does not have the priority of option C. Options B and D can be implemented if the client admits suicidal ideation. However, based on the fact that this client is mildly depressed and that he attempted suicide 5 years ago using a method that is usually nonlethal (aspirin overdose), it is most important to prevent social isolation..

A 22-year-old client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam. When developing the nursing care plan for this client, which intervention would be most important for the nurse to include? A. Assist client to focus on personal strengths. B. Set limits on self-defacing comments. C. Remind the client of daily activities in the milieu. D. Assist the client to identify why he or she was self-destructive.

Assist client to focus on personal strengths. Encouraging the client to focus on his or her strengths helps the client become aware of positive qualities, assists in improving self-image, and aids in coping with past and present situations. Although nursing actions should assist the client in decreasing self-defacing comments and informing the client of daily activities in the milieu, these interventions are not priorities at this time. Option D is not as important as assisting the client to overcome the depression, which resulted in the overdose, and asking "why" is not therapeutic.

An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement? A. Assist the client to walk to the bathroom and do not leave the client alone. B. Request that the UAP assist the client onto a bedpan. C. Ask if the client needs to have a bowel movement or void. D. Assess the client's bladder to determine if the client needs to urinate.

Assist the client to walk to the bathroom and do not leave the client alone. Barbiturates cause central nervous system (CNS) depression, and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom. A bedpan is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, option C is irrelevant in terms of meeting this client's safety needs. There is no indication that this client cannot voice her or his needs, so assessment of the bladder is not needed.

The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan? A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks. B. Exhibit regular, soft-formed stool within 1 month. C. Demonstrate the irrigation procedure correctly within 1 week. D. Attend an ostomy support group within 2 weeks.

Attend an ostomy support group within 2 weeks. Attending a support group will be beneficial to the client and should be encouraged because adaptation to the ostomy can be difficult. This goal is attainable and is measurable. Option A is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish option B. Option C is not necessary.

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? A. Avoid alcohol because it is excreted in breast milk. B. Eat a high-roughage diet to help prevent constipation. C. Increase caloric intake by approximately 500 cal/day. D. Increase fluid intake to at least 3 quarts each day.

Avoid alcohol because it is excreted in breast milk. Alcohol should be avoided while breastfeeding because it is excreted in breast milk and may cause a variety of problems, including slower growth and cognitive impairment for the infant. Options B, C, and D should also be included in diet teaching for a breastfeeding mother; however, because these do not involve safety of the infant, they do not have the same degree of importance as option A.

An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform? A. Measure the client's calf circumference. B. Auscultate the client's breath sounds. C. Observe for ecchymosis and petechiae. D. Obtain the client's blood pressure.

Auscultate the client's breath sounds. All these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds because the client may have a pulmonary embolus secondary to the thrombophlebitis. Option A may provide data that support the nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment because bruising is not a typical finding associated with thrombophlebitis. Option D is always useful in evaluating the client's response to a problem but is of less immediate priority than breath sound auscultation.

The nurse is providing discharge instructions to a client who has received a prescription for an antibiotic that is hepatotoxic. Which information should the nurse include in the instructions? A. Avoid ingesting any alcohol or acetaminophen. B. Schedule a follow-up visit for a liver biopsy in 1 month. C. Activities that are strenuous should be avoided. D. Notify the health care provider of any increase in appetite.

Avoid ingesting any alcohol or acetaminophen. Combining hepatotoxic drugs, such as acetaminophen and alcohol, increases the risk of liver damage, so option A is an important discharge instruction. Although clients who receive hepatotoxic drugs should be screened for any changes in serum liver function test (LFT) results, option B is not indicated. Rest is advantageous during an infectious process, but activity restriction is unnecessary. A client who is receiving a hepatotoxic drug should report any hepatotoxic symptoms, such as jaundice, dark urine, or light-colored stools, but an increased appetite does not need medical attention.

What instructions should the nurse include in the discharge teaching plan of a client who has recently been prescribed oxazepam? (Select all that apply.) A. Take the medication in the morning for best results. B. Do not combine this medication with alcohol. C. This medication is typically used for short-term treatment. D. Stop the drug immediately if sleepiness occurs. E. Avoid driving or operating equipment while taking this drug.

B. Do not combine this medication with alcohol. C. This medication is typically used for short-term treatment. E. Avoid driving or operating equipment while taking this drug. Harm can occur if oxazepam is taken with alcohol or other central nervous system (CNS) depressants (B). Oxazepam is a benzodiazepine used for the short-term treatment of anxiety (C). Sleepiness is an expected side effect; therefore, driving or operating equipment should be avoided (E). The drug should be taken in the evening because of sedation effects (A) and should be tapered, not immediately stopped, because of withdrawal effects (D).

An 8-year-old child is receiving digoxin for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take? A. Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. B. Hold the next dose of digoxin until the health care provider can be notified because the serum digoxin level is elevated. C. Administer the next dose of digoxin and notify the health care provider that the child is showing signs of toxicity. D. Notify the health care provider that the child's pulse rate is below normal for her age group.

Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. Nausea and vomiting are early signs of digoxin toxicity. However, the normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min, and the therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, option A is the best of the choices provided because the serum digoxin level is within normal levels. Option B is not warranted by the data presented. The digoxin level is within the therapeutic range, and the child is not showing signs of toxicity. The child's pulse rate is within normal range for her age group.

A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? A. 3+ protein in the urine B. Blood urea nitrogen > 25 mg/dL C. Blood pH > 7.45 D. Urine output, 2500 mL/day

Blood urea nitrogen > 25 mg/dL Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria, an expected finding. Metabolic acidosis is the potential complication, not alkalosis. During the diuretic phase of acute renal failure, there can be a normal output volume (≈2000 mL/day), which can result from IV fluid hydration.

The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse expect this child to exhibit? A. Throws a temper tantrum when told he must share the toys. B. Plays by himself for most of the day. C. Boasts aggressively when telling a story. D. Cries and is fearful when separated from his parents.

Boasts aggressively when telling a story. Four-year-old children are aggressive in their behavior and enjoy telling tales. Options A and D are typical toddler behaviors. A preschooler's play is usually cooperative, so playing alone is not typical.

A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. During the initial nursing assessment, which symptoms will this child most likely exhibit? A. Bone pain, pallor B. Weakness, tremors C. Nystagmus, anorexia D. Fever, abdominal distention

Bone pain, pallor Option A lists the most common presenting symptoms of leukemia. Leukemic cells invade the bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain and anemia results from decreased erythrocytes, causing pallor. Options B and C could be associated with central nervous system disorders. Option D commonly occurs in children but is not specific for leukemia.1

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A. Breastfeed the infant, ensuring that both breasts are completely emptied. B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C. Breastfeed on the unaffected breast only until the mastitis subsides. D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.

Breastfeed the infant, ensuring that both breasts are completely emptied. Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease antibiotic effects on the infant.

A 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when flexing the child's right hip during a routine physical examination. The orthopedic physician suspects that the child might have developmental dysplasia of the hip (DDH). The parents ask the nurse to identify risk factors commonly associated with DDH. Which response is accurate? A. Vertex delivery B. Male gender C. Breech presentation D. Second-born child

Breech presentation Developmental dysplasia of the hip (DDH) occurs more often in infants who present in the breech position, not the vertex (head-first) position. Twice as many females as males present in the breech position; thus, 80% of children with DDH are females, not males. Of breech presentations, 60% occur with first-born children, not subsequent siblings, possibly because of the unstretched uterus and compaction of the surrounding abdominal contents, which tend to increase compression on the uterus in the nulliparous woman.

A mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is nonproductive. What advice should the nurse provide to this mother? A. Watch the boy a few more days and see if the cough begins to produce sputum. B. The full 10-day course of antibiotics must be completed before effectiveness can be evaluated. C. Give the child plenty of fluids and an over-the-counter cough suppressant. D. Bring the child to the clinic today for an examination related to the cough.

Bring the child to the clinic today for an examination related to the cough. The child should be evaluated as soon as possible for pneumonia. Antibiotics usually improve symptoms during the first few days of treatment but should be continued for the full prescribed course. A continued cough after 7 days of antibiotic treatment may indicate an infectious process in the lower lungs, which could cause a nonproductive cough. Children with pneumonia can deteriorate unexpectedly and rapidly and can become seriously ill, with no sputum production. Option B delays evaluation too long. Although giving fluids is advisable, cough suppressants might mask symptoms of a serious condition.

Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma? A. Inspection of the skin B. Breath sound auscultation C. Pain scale measurement D. Mobility limitations

C. Pain scale measurement Multiple myeloma is a tumor that causes bone marrow changes, which most commonly manifest as pain, so measurement of the client's pain is the highest priority. Options A, B, and D are part of the complete assessment but do not have the priority of option C for this client.

Which age-related change in the older adult has the highest safety implication for the client? A. Change in height B. Hair loss C. Stooped posture D. Age spots

C. Stooped posture Stooped posture results in the upper torso becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and elbows flex. This age-related change can put the older adult at risk for falls. Options A, B, and D are age-related changes but are not high safety concerns.

Which instructions should the nurse include in the discharge teaching plan of a male client who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.) A. Keep the medication in your pocket so that it can be accessed quickly. B. Call 911 if chest pain is not relieved after one nitroglycerin. C. Store the medication in its original container and protect it from light. D. Activate the emergency medical system after three doses of medication. E. Do not use within 1 hour of taking sildenafil citrate (Viagra).

Call 911 if chest pain is not relieved after one nitroglycerin. Store the medication in its original container and protect it from light. Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B). The medication should be kept in the original container to protect from light (C). Keeping the medication in the shirt pocket provides an environment that is too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never be taken with sildenafil (E).

The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? A. Ask the UAP to check for the advanced directive while the nurse completes the assessment. B. Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C. Check the medical record for the advanced directive and then complete the client assessment. D. Call for the charge nurse to check the advanced directive while continuing to assess the client.

Call for the charge nurse to check the advanced directive while continuing to assess the client. Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status. Options A and B are tasks that must be completed by a nurse and cannot be delegated to the UAP. Option C is contraindicated.

A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5." Which intervention should the nurse implement? A. Give the medication as prescribed to decrease the client's pain. B. Call the anesthesia provider for a different medication for pain. C. Use nonpharmacologic techniques before giving the medication. D. Reassess the pain level in 30 minutes and medicate if it remains elevated.

Call the anesthesia provider for a different medication for pain. The nurse should call the provider for a different medication because morphine is a histamine-releasing opioid and should be avoided when the client has asthma. Option A is unsafe because it puts the client at risk for an asthma exacerbation. Even if the drug were safe for the client, options C and D both disregard the prescription and the client's need for pain relief in the immediate postoperative period.

In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels.

Check the bath water temperature. To prevent burns or excessive chilling, the nurse must check the bath water temperature. Options B, C, and D promote comfort and privacy and are important interventions but are of less priority than promoting safety.

A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first? A. Check the client's blood pressure. B. Teach her to elevate her feet when sitting. C. Obtain a 24-hour diet history to evaluate for the intake of salty foods. D. Assess the fetal heart rate

Check the client's blood pressure. The blood pressure should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and who have chronic hypertension are at increased risk. Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. Options B, C, and D can be done if the blood pressure is normal.

A nurse is preparing to end the shift and receives a laboratory report stating that a child with asthma has a theophylline level of 15 mcg/dL. Which action should the nurse take? A. Communicate the result to the oncoming nurse and document. B. Tell the oncoming nurse that the level is dangerously high. C. Ask the laboratory to redo the test because the result is faulty. D. Hold the next dose of theophylline based on this finding.

Communicate the result to the oncoming nurse and document. The therapeutic level of theophylline is 10 to 20 mcg/dL, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report. Based on the laboratory finding, options B, C, and D are not indicated.

To evaluate whether the administration of an antihypertensive medication has caused a therapeutic effect, which action should the nurse implement? A. Ask the client about the onset of any dizziness since taking the medication. B. Measure the client's blood pressure while the client is lying, sitting, and then standing. C. Compare the client's blood pressure before and after the client takes the medication. D. Interview the client about any past or recent history of high blood pressure.

Compare the client's blood pressure before and after the client takes the medication. Therapeutic effects are the expected or predictable physiologic responses to a medication. An antihypertensive medication is administered to lower blood pressure, so to determine if the therapeutic effect has been achieved, the nurse should compare the client's blood pressure before and after the client takes the medication. Options A and B provide data related to the side effect of hypotension, which may occur following the administration of an antihypertensive medication. Option D provides useful data but does not evaluate the medication's effectiveness.

A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings

Compare the current reading with the client's previously documented blood pressure readings. Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading.

A client who has trouble swallowing pills intermittently has been prescribed venlafaxine (XR) for depression. The medication comes in capsule form. What should the nurse include in the discharge teaching plan for this client? A. Capsule contents can be sprinkled on pudding or applesauce. B. Chew the medication thoroughly to enhance absorption. C. Take the medication with a large glass of water or juice. D. Contact the health care provider for another form of medication.

Contact the health care provider for another form of medication. Venlafaxine is administered PO in capsule form. Capsules that are extended-release (XR) or continuous-release (CR) contain delayed-release, enteric-coated granules to prevent decomposition of the drug in the acidic pH of the stomach. The client should notify the health care provider about the inability to swallow the capsule. This medication should not be chewed or opened so that the delayed-release, enteric-coated granules can remain intact. Water or juice will not affect the medication.

The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take? A. Consult with the pharmacist about the need to continue the medication. B. Administer the antihypertensive medication as prescribed preoperatively. C. Withhold the medication until the client is fully alert and vital signs are stable. D. Contact the health care provider to renew the prescription for the medication.

Contact the health care provider to renew the prescription for the medication. Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the health care provider if the antihypertensive medication is not included in the postoperative prescriptions. The pharmacist does not prescribe medications or renew prescriptions. The nurse must have a current prescription before administering any medications.

The charge nurse of a medical-surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A. Prepare to evacuate the unit, starting with the bedridden clients. B. UAPs should report to the emergency center to handle transports. C. The licensed staff should begin counting wheelchairs and IV poles on the unit. D. Continue with current assignments until more instructions are received.

Continue with current assignments until more instructions are received. When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received. Evacuation is typically a response of last resort that begins with clients who are most able to ambulate. Option B is premature and is likely to increase the chaos if incoming casualties are anticipated. Option C is poor utilization of personnel.

During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take?Select an option, then click Submit. A. Continue with the shift report and talk to the nurse about the incident at a later time. B. Ask the nurse to call the house supervisor to see if she must be reassigned. C. Stop the shift report and remind the nurse that all staff are floated equally. D. Inform the nurse that her behavior is disruptive to the rest of the staff.

Continue with the shift report and talk to the nurse about the incident at a later time. Continuing with the shift report is the best immediate action because it allows the nurse who was floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private. Option B encourages the nurse to shirk the float assignment. Option C is disruptive. Reprimanding the nurse in front of the staff would increase the nurse's hostility, so the nurse should be counseled in private.

During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first? A. Continuous IV infusion of magnesium B. One-time infusion of albumin C. Continuous epidural infusion of morphine D. Intermittent infusion of IV vancomycin

Continuous epidural infusion of morphine All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion is at highest risk for respiratory depression and should be assessed first. Option A can cause hypotension. The client receiving option B is at lowest risk for serious complications. Although option D can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as option C.

A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test results indicate that the medication is producing the desired effect? A. Increased hemoglobin and hematocrit levels B. Increased serum calcium level C. Decreased white blood cell (WBC) count D. Decreased triiodothyronine (T3) and thyroxine (T4) levels

Decreased triiodothyronine (T3) and thyroxine (T4) levels Propylthiouracil (PTU) is an adjunct therapy used to control hyperthyroidism by inhibiting the production of thyroid hormones. It is often prescribed in preparation for thyroidectomy or radioactive iodine therapy. It does not affect option A. Option B must be monitored after surgery in case the parathyroid glands were removed, but preoperative PTU does not increase the serum calcium level. If the client has an infection preoperatively, antibiotics will be given and option C monitored.

When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take? A. Deflate the cuff completely and immediately reattempt the reading. B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading. C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time. Option A could result in a falsely high reading. Option B reduces circulation, causes pain, and could alter the reading. Option D is not an accurate method of assessing blood pressure.

During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report? A. The occurrence of any episodes of sleep apnea B. The child's blood pressure, pulse, and respirations C. Length of rapid eye movement (REM) sleep that the child is experiencing D. Description of the family's home environment

Description of the family's home environment School-age children often resist bedtime. The nurse should begin by assessing the environment of the home to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. Option A often causes daytime fatigue rather than resistance to going to sleep. Option B is unlikely to provide useful data. The nurse cannot determine option C.

Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. Which action should the nurse take first? A. Remind the client to wear the nicotine patch. B. Determine if the client still needs constant observation. C. Encourage the client to attend the smoking cessation group. D. Explain that clients on constant observation cannot smoke.

Determine if the client still needs constant observation. The nurse should continually reassess the need for constant observation so that the client can have unit privileges such as outdoor breaks. Options A and C do not meet the client's need and desire to smoke. Option D will cause more agitation.

A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best? A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. B. Instruct the UAP not to wake the client under any circumstances during the night. C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8 hours. D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.

Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. Including habitual rituals that do not interfere with the client's care or safety may allow the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the client's standard of care and compromise safety.

Which intervention is most important for a nurse to implement prior to administering atropine PO? A. Determine the presence of 5 to 35 bowel sounds/min. B. Provide oral care prior to administration. C. Verify that the client's tendon reflexes are 2+. D. Have the client rate his or her pain on a 0 to10 scale.

Determine the presence of 5 to 35 bowel sounds/min. Anticholinergic drugs, such as atropine, have antispasmodic and antisecretory properties, which relax the gastrointestinal tract, and are therefore contraindicated in a client with intestinal atony. Oral care may be required after administration since atropine can dry secretions. Option B (used to determine dehydration) or (C). Atropine itself has no analgesic effect; it is used with opioids to potentiate their effect.

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to draw up the labeled saline solution. C. Use the saline solution and then relabel the bottle with the current date. D. Discard the saline solution and obtain a new unopened bottle.

Discard the saline solution and obtain a new unopened bottle. Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options A, B, and C describe incorrect procedures.

The home health nurse is assessing a male client being treated for Parkinson disease with carbidopa-levodopa. The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which intervention should the nurse implement? A. Perform a complete cranial nerve assessment. B. Instruct the client that he may be experiencing medication toxicity. C. Document the presence of these assessment findings. D. Advise the client to seek immediate medical evaluation.

Document the presence of these assessment findings. A masklike expression and infrequent blinking are common clinical features of parkinsonism. The nurse should document these expected findings. Options A and D are not necessary. Signs of toxicity of levodopa-carbidopa, include dyskinesia, hallucinations, and psychosis.

A client with mild parkinsonism is started on oral amantadine. Which statement accurately describes the action of this medication? A. Viral organisms that provide the underlyling pathophysiology for parkinsonism are eliminated. B. Acetylcholine in the myoneural junction is enhanced. C. Dopamine in the central nervous system is increased. D. Norepinephrine release is reduced within the peripheral system as the final step in dopamine uptake.

Dopamine in the central nervous system is increased. Amantadine is a dopamine-releasing agent; therefore, this medication increases the amount of dopamine present in the central nervous system. Although this medication is also an antiviral agent, the antiviral effect is not significant in the treatment of parkinsonism. Options B and D are not affected by amantadine.

The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.) A. Encourage alcohol and smoking cessation. B. Suggest supplementing diet with vitamin E. C. Promote regular weight-bearing exercises. D. Implement a home safety plan to prevent falls. E. Propose a regular sleep pattern of 8 hours nightly.

Encourage alcohol and smoking cessation. Promote regular weight-bearing exercises. Implement a home safety plan to prevent falls. Options A, C, and D are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are important supplements to aid in the decrease of bone loss. Regular sleep patterns are important to overall health but are not identified with a decreasing risk for osteoporosis.

Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.) A. Encourage annual physical and Pap smear. B. Take antiviral medication as prescribed. C. Use condoms to avoid transmission to others. D. Warm sitz baths may relieve itching. E. Use Nystatin suppositories to control itching. F. Use a douche with weak vinegar solution to decrease itching.

Encourage annual physical and Pap smear. Take antiviral medication as prescribed. Use condoms to avoid transmission to others. Warm sitz baths may relieve itching. The nurse should include (A, B, C, and D) in the teaching plan of a female client with genital herpes. (E) is specific for Candida infections, and option (F) is used to treat Trichomonas.

A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client's stress associated with repeated hospitalization? A. Allow the client to discuss the seriousness of the illness. B. Ensure that the client is provided with information about medications. C. Encourage as much independence in decision making as possible. D. Include the client in planning the course of treatment.

Encourage as much independence in decision making as possible. Hospitalization compromises an individual's sense of control and independence, which contributes to stress, so allowing the client as much independence in decisions as possible helps reduce stress experienced with repeated hospitalization. Options A, B, and D are important components in stress reduction, but the isolation and dependence associated with hospitalization alter the client's sense of control and affect the client's cognitive ability to understand and participate in the hospitalized plan of care.

Which nursing action is necessary for the client with a flail chest? A. Withhold prescribed analgesic medications. B. Percuss the fractured rib area with light taps. C. Avoid implementing pulmonary suctioning. D. Encourage coughing and deep breathing.

Encourage coughing and deep breathing. Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing. This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. Option C should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. Option A should not be withheld. Option B should not be applied because the fractures are clearly visible on the chest radiograph.

Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?' A. Instruct in the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D. Encourage frequent ambulation in the hallway.

Encourage frequent ambulation in the hallway. Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse should plan to encourage activities to increase mobility, such as frequent ambulation in the hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option B reduces the risk for aspiration. Option C reduces the risk for postoperative infection.

A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. Which action should the nurse implement? A. Advise the client to come to the clinic immediately for further assessment. B. Instruct the client to discontinue use of the drug and to make an appointment at the clinic. C. Suggest that the client learn to accept the cough as a side effect to a necessary prescription. D. Encourage the client to keep taking the drug until seen by the health care provider.

Encourage the client to keep taking the drug until seen by the health care provider. Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the medication. Immediate evaluation is not needed. Antihypertensive medications should not be stopped abruptly because rebound hypertension may occur. Option C is demeaning because the cough may be very disruptive to the client, and other antihypertensive medications may produce the desired effect without the adverse effect.

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A. Encourage the client to see the clinic's grief counselor. B. Determine if the client has a family history of suicide attempts. C. Inquire about whether the life partner was suffering from AIDS. D. Consult with the health care provider about the client's need for antidepressant medications.

Encourage the client to see the clinic's grief counselor. The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is indicated but is not a high-priority intervention. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated, depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness? A. Wear a cotton bra with nonbinding support. B. Increase nursing time gradually over several days. C. Ensure that the baby is positioned correctly for latching on. D. Manually express a small amount of milk before nursing.

Ensure that the baby is positioned correctly for latching on. The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latching on. The baby's body is in alignment with the ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast. Option A helps prevent chafing, and nonbinding support aids in prevention of discomfort from the stretching of the Cooper ligament. Option B is important but is not necessary for all women. Option D helps soften an engorged breast and encourages correct infant latching on but is not the best answer.

Two days after swallowing 30 tablets of alprazolam, a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.) A. Direct the client to sign a liability release form. B. Restrict the client's ability to leave the unit. C. Explain the benefits of remaining in the hospital. D. Instruct the client to take medications as prescribed. E. Provide the client with names of local support groups. F. Notify the health care provider of the client's intention.

Explain the benefits of remaining in the hospital. Instruct the client to take medications as prescribed. Notify the health care provider of the client's intention. To maintain safety and to provide information, the nurse should explain the potential benefits of continuing treatment in the hospital (C) and the need to take prescribed medications (D). This client, who is very likely self-destructive, should remain on the unit and the health care provider should be notified (F). Signing a release form (A) before leaving the hospital does not contribute to safety. The nurse may ask the client not to leave the hospital (B), but pressuring clients is unethical behavior. (E) may be helpful at a later time in this client's treatment program.

A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment? A. Notify the friend that all medical information will be kept confidential. B. Explain the relationship to the charge nurse and ask for reassignment. C. Approach the client and ask if the assignment is uncomfortable. D. Accept the assignment but protect the client's confidentiality.

Explain the relationship to the charge nurse and ask for reassignment. : Caring for a close friend can violate boundaries for nurses and should be avoided when possible (B). If the assignment is unavoidable (there are no other nurses to care for the client) then C, A, and D should be addressed.

A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take? A. Instruct the client to go to the emergency room. B. Recommend vaginal douching. C. Explain this is a normal finding. D. Determine if ovulation has occurred.

Explain this is a normal finding. The client is describing lochia serosa, a normal change in the lochial flow ©. Options A, B, and D are not recommended for this normal finding.

The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A. Maternal blood pressure B. Maternal temperature C. Fetal heart rate (FHR) D. White blood cell count (WBC)

Fetal heart rate (FHR) The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for color, odor, and consistency. Option A should be assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is monitored hourly after the membranes are ruptured to detect the development of amnionitis. Option D should be determined for all clients in labor.

A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse? A. Fever of 102° F B. Blood pressure of 150/90 mm Hg C. Abdominal cramping D. Dry mucous membranes

Fever of 102° F A sudden increase in temperature is an indicator of peritonitis. The nurse should notify the health care provider immediately. Options B, C, and D are also findings that require intervention by the nurse but are of less priority than option A. Option B may indicate a hypertensive condition but is not as acute a condition as peritonitis. Option C is an expected finding in clients with small bowel obstruction and may require medication. Option D indicates probable fluid volume deficit, which requires fluid volume replacement.

Prior to administering a scheduled dose of digoxin, the nurse reviews the client's current serum digoxin level, which is 1.3 ng/dL. Which action should the nurse implement? A. Administer Digibind to counteract the toxicity. B. Withhold the drug and notify the health care provider immediately. C. Withhold the dose and notify the health care provider during rounds that the dose was held. D. Give the dose of digoxin if the client's heart rate is within a safe range.

Give the dose of digoxin if the client's heart rate is within a safe range. The client's digoxin level of 1.3 ng/dL is not above the upper range of its therapeutic index (toxic level is >2.0 ng/dL), so the dose should be administered after the client's heart rate is evaluated. Digibind is administered for toxic levels of digoxin, so option A is not indicated. Options B and C are not necessary.

When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly? A. Albumin B. Calcium C. Glucose D. Alkaline phosphatase

Glucose TPN solutions contain high concentrations of glucose, so the blood glucose level is often monitored as often as q6h because of the risk for hyperglycemia. Option A is monitored periodically because an increase in the albumin level, a serum protein, is generally a desired effect of TPN. Option B may be added to TPN solutions, but calcium imbalances are not generally a risk during TPN administration. Option D may be decreased in the client with malnutrition who receives TPN, but abnormal values, reflecting liver or bone disorders, are not a common complication of TPN administration.

A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record? A. Gravida 1, para 0 B. Gravida 1, para 1 C. Gravida 2, para 0 D. Gravida 2, para 1

Gravida 2, para 0 This is the client's second pregnancy or second gravid event, so option C is correct. The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond. Option A does not take into account the current pregnancy, nor does option B, which also counts the miscarriage as a "para," an incorrect recording. Although option D is correct concerning gravidity, para 1 is incorrect.

The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement? A. Greet the client by first name during each social interaction. B. Determine if the client is experiencing auditory hallucinations. C. Introduce the client to peers on the unit as soon as possible. D. Assign the client to a group about developing social skills.

Greet the client by first name during each social interaction. The most important nursing intervention is to greet the client by name and provide short frequent contact to establish trust. The presence of auditory hallucinations can affect social interactions, but option B is not a priority intervention. Options C and D are effective interventions after individual rapport has been established with the client.

The nurse is preparing to administer dalteparin subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose? A. Tachypnea B. Guaiac-positive stool C. Multiple small abdominal bruises D. Dependent pitting edema

Guaiac-positive stool Dalteparin is an anticoagulant used to prevent deep vein thrombosis (DVT) in the at-risk client. If the client develops overt signs of bleeding such as guaiac-positive stool while receiving an anticoagulant, the medication should be held and coagulation studies completed. Option A is not an indication to hold the medication unless accompanied by signs of bleeding. Option C is an expected result. Option D is related to fluid volume, rather than anticoagulant therapy.

A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide? A. Most infants of HIV-positive women will continue to test positive for HIV antibodies. B. Infants who have HIV-positive mothers carry the virus and will eventually develop the disease. C. Medication taken during pregnancy to reduce the mother's viral load ensures that the infant is HIV-negative. D. HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.

HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present. All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so the evaluation of an infant for the HIV virus is determined at 18 months of age, when all the maternal antibodies are no longer in the infant's blood. Passive HIV antibodies disappear in the infant within 18 months of age. Option B is inaccurate. Although administration of HIV medication during pregnancy can significantly reduce the risk of vertical transmission, treatment does not ensure that the virus will not become manifest in the infant.

The nurse is preparing to administer the disease-modifying antirheumatic drug (DMARD) methotrexate to a client diagnosed with rheumatoid arthritis. Which intervention is most important to implement prior to administering this medication? A. Assess the client's liver function test results. B. Monitor the client's intake and output. C. Have another nurse check the prescription. D. Assess the client's oral mucosa.

Have another nurse check the prescription. Double-checking the prescription is an important intervention because death can occur from an overdose. This medication is administered weekly and in low doses for rheumatoid arthritis and should not be confused with administration of the drug as a chemotherapeutic agent. Options A and B are appropriate interventions for those who are receiving this drug, but they are not the most important interventions. Stomatitis is an expected side effect of this medication.

During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take? A. Encourage her to pant between contractions and blow with contractions. B. Coach her to take a deep cleansing breath and then refocus. C. Instruct her to pant three times and then exhale through pursed lips. D. Have her cup both hands over her nose and mouth while breathing.

Have her cup both hands over her nose and mouth while breathing. Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes transient respiratory alkalosis, so the client should cup both her hands over her mouth and nose so that she can rebreathe carbon dioxide. Options A, B, and C do not help restore carbon dioxide levels as effectively as rebreathing air in the cupped hands or from a paper bag.

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take? A. Administer oxygen by facemask. B. Notify the health care provider of the client's symptoms. C. Have the client breathe into her cupped hands. D. Check the client's blood pressure and fetal heart rate.

Have the client breathe into her cupped hands. Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands. Option A is inappropriate because the carbon dioxide level is low, not the oxygen level. Options B and D are not specific for this situation.

A burned child is brought to the emergency department, and the nurse uses a modified rule of nines to estimate the percentage of the body burned. When calculating the percentage of burn, which parts of the child's body are proportionally larger than an adult's? A Head and neck B. Arms and chest C. Legs and abdomen D. Back and abdomen

Head and neck The standard rule of nines is inaccurate for determining burned body surface areas with children because a child's head and neck are proportionately larger than an adult's. Specially designed charts are commonly used to measure the percentage of burn in children. Options B, C, and D are not proportionately different.

An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of C. difficile. While planning care, which nursing goal should the nurse establish as the priority? A. Fluid and electrolyte balance is maintained. B. Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. C. Abdominal pain is relieved and perianal skin integrity is maintained. D. Normal bowel patterns are reestablished.

Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. A priority goal for the client with infectious diarrhea caused by C. difficile is infection control precautions and the prevention of health care-associated infection (HAI) transmission. Options A and C are goals dependent on the return of the client's normal bowel pattern.

A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation is most significant? A. Heart palpitations B. Leg cramps C. Nausea D. Tetany

Heart palpitations Hypokalemia can cause heart palpitations, which are indicative of a dysrhythmia that could progress to a medical emergency. Options B and C are also of concern but are not as life threatening. Option D is a symptom of hypocalcemia.

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A. Help the client dangle his legs. B. Apply compression stockings. C. Assist with passive leg exercises. D. Ambulate three times a day.

Help the client dangle his legs. The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling, which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. Option B is indicated for venous insufficiency and indicated for bed rest. Ambulation is indicated to facilitate collateral circulation and may improve long-term complaints of pain.

An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated? A. Help the client determine ways to increase his fluid intake. B. Obtain an appointment for the client to have an eye examination. C. Instruct the client to use oxygen at night and increase the humidification. D. Schedule the client for tests to determine his sensitivity to cat hair.

Help the client determine ways to increase his fluid intake. Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness of breath. The nurse should suggest creative methods to increase the intake of fluids, such as having fruit juices in disposable containers readily available. Option B is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night. These symptoms are not indicative of option D and may unnecessarily upset the client, who depends on his pet for socialization.

A client who is HIV-positive is receiving epoetin alfa for the management of anemia secondary to zidovudine (AZT) therapy. Which laboratory finding is most important for the nurse to report to the health care provider? A. Hematocrit (HCT) of 58% B. Hemoglobin of 10.8 g/dL C. White blood cell count of 5000 mm3 D. Serum potassium level of 5 mEq/L

Hematocrit (HCT) of 58% Option A should be reported to the health care provider immediately because of the likelihood of a hypertensive crisis and because seizure activity increases with an increase in HCT of more than 4 points, or an HCT above 36%. Epoetin alfa stimulates erythropoiesis (production of red blood cells), thereby decreasing the need for blood transfusions. Uncontrolled hypertension can occur if erythropoietin levels are too high. Option B is the reason why the client is receiving epoetin alpha. Options C and D are within normal limits.

Which findings would suggest to the nurse that diagnosis of glomerulonephritis is correct? A. History of pneumonia. B. Hypotension C. Polyuria D. Hematuria

Hematuria Patients with glomerulonephritis experience dark colored urine due to hematuria. They experience hypertension, not hypotension so option B is incorrect. They experi-ence oliguria, thus option is C incorrect and they have a history of strep throat not pneumonia.

Which vaccination should the nurse administer to a newborn? A. Hepatitis B B. Human papilloma virus (HPV) C. Varicella D. Meningococcal vaccine

Hepatitis B The hepatitis B vaccination should be given to all newborns before hospital discharge. HPV is not recommended until adolescence. Varicella immunization begins at 12 months. Meningococcal vaccine is administered beginning at 2 years.

A client is prescribed a cholinesterase inhibitor, and a family member asks the nurse how this medication works. Which pharmacophysiologic explanation should the nurse use to describe this class of drug?' A. Promotes excretion of neurotoxins. B. Slows nerve cell degeneration. C. Improves nerve impulse transmission. D. Stimulates nerve cell regeneration.

Improves nerve impulse transmission. Cholinesterase inhibitors work to increase the availability of acetylcholine at cholinergic synapses, which aids in neuronal transmission and assists in memory formation. Basing an explanation on this concept, option C should provide an accurate explanation that the family can understand. Options A, B, and D are incorrect.

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely. B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. C. Her arms and hands receive the infant and she then cuddles the infant to her own body. D. She eagerly reaches for the infant and then holds the infant close to her own body.

Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. Attachment and bonding theory indicates that most mothers will demonstrate behaviors described in option B during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may exhibit different touching behaviors such as eagerly reaching for the infant and cuddling the infant close to her.

Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter? A. Self-care deficit B. Functional incontinence C. Fluid volume deficit D. High risk for infection

High risk for infection Indwelling urinary catheters are a major source of infection. Options A and B are both problems that may require an indwelling catheter. Option C is not affected by an indwelling catheter.

The nurse is assessing suicide risk for a client recently admitted to the acute psychiatric unit. Which finding is the most significant risk factor? A. High level of anxiety present B. History of previous suicide attempt C. Family history of depression D. Self-care deficit is noted

History of previous suicide attempt A previous history of a suicide attempt is the most significant risk factor for future suicide attempts because the client has previously implemented a plan. Options A, C, and D may also be risk factors but are not as significant as a history of previous attempts.

A client receives a prescription for theophylline PO to be initiated in the morning after the dose of theophylline IV is complete. The nurse determines that a theophylline level drawn yesterday was 22 mcg/mL. Based on this information, which action should the nurse implement? A. Hold the theophylline dose and notify the health care provider. B. Start the client on a half-dose of theophylline PO. C. The theophylline dose can be initiated as planned. D. The client is not ready to be weaned from the IV to the PO route.

Hold the theophylline dose and notify the health care provider. The therapeutic range for theophylline is 10 to 20 mcg/mL, so the theophylline dose should be held for fear of causing toxicity. Options B, C, and D are not indicated actions based on the reported theophylline level.

The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indica-tion(s) best supports the client's need for insertion of an indwelling urinary catheter? (Select all that apply.) A. Hourly urine output B. Bladder distention C. Urinary incontinence D. Intraoperative bladder decompression E. Urine sample for culture

Hourly urine output Bladder distention Intraoperative bladder decompression Continuous bladder drainage using an indwelling catheter is indicated for monitoring hourly urinary output (A), bladder distention (B), and bladder decompression (D) related to urinary retention under anesthesia. Less invasive measures, such as a condom catheter or bladder training for urinary incontinence (C) or midstream collection of urine for culture (E) are not indicated based on the client's description.

The health care provider prescribes the H2 antagonist famotidine, 20 mg PO in the morning and at bedtime. Which statement regarding the action of H2 antagonists offers the correct rationale for administering the medication at bedtime? A. Gastric acid secreted at night is buffered, preventing pepsin formation. B. Hydrochloric acid secreted during the night is blocked. C. The drug relaxes stomach muscles at night to reduce acid. D. Ingestion of the medication at night offers a sedative effect, promoting sleep.

Hydrochloric acid secreted during the night is blocked. H2 antagonists act on the parietal cells to inhibit gastric secretion. Some gastric secretion occurs all the time, even when the stomach is empty, unless medications are taken to inhibit this action. Options C and D are not actions of famotidine. Option A is the action of antacids. Antacids do not affect healing or prevent the recurrence of ulcers; they merely provide symptomatic relief. Knowing the difference between H2 antagonists and antacids is important when teaching clients.

A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted? A. If MSAFP (maternal serum alpha-fetoprotein) and estriol levels are high and the human chorionic gonadotropin (hCG) level is low, results are positive for a possible chromosomal defect. B. If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. C. If MSAFP and estriol levels are within normal limits, there is a guarantee that the baby is free of all structural anomalies. D. If MSAFP, estriol, and hCG are absent in the blood, the results are interpreted as normal findings.

If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. Low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood sample are indications of possible chromosomal defects. High levels of MSAFP and estriol in the blood sample after 15 weeks of gestation can indicate a neural tube defect, such as spina bifida and anencephaly, not chromosomal defects. One of the limitations of the multiple marker screening is that any defects covered by skin will not be evident in the blood sampling. After 15 weeks of gestation, there will be traces of MSAFP, estriol, and hCG in the blood sample.

When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she "can't handle" the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the son has the right to waive informed consent for her. C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.

If informed consent is withheld from a client, health care providers could be found guilty of negligence. Health care providers may be found guilty of negligence, specifically assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so option A is not a valid rationale. Advanced age does not automatically authorize the son to make all decisions for his mother, and there is no evidence that the client is mentally incompetent. Although option C may have been upheld in the past, when paternalistic medical practice was common, today's courts are unlikely to accept it.

A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide, 0.04 mg/kg every 12 hours IV, is prescribed. What is the priority nursing diagnosis for this client? A. Impaired communication related to paralysis of skeletal muscles B. High risk for infection related to increased intracranial pressure C. Potential for injury related to impaired lung expansion D. Social isolation related to inability to communicate

Impaired communication related to paralysis of skeletal muscles To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletal muscle relaxant such as vecuronium is usually prescribed. Option A is a serious outcome because the client cannot communicate his or her needs. Although this client might also experience option D, it is not a priority when compared with option A. Infection is not related to increased intracranial pressure. The respirator will ensure that the lungs are expanded, so option C is incorrect.

The nurse is caring for a client who is one day post-acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which intervention should the nurse implement first? A. Obtain an IV pump for antiarrhythmic infusion. B. Increase the client's oxygen flow rate. C. Prepare for immediate countershock. D. Gather equipment for endotracheal intubation.

Increase the client's oxygen flow rate. 'Increasing the oxygen flow rate provides more oxygen to the client's myocardium and may decrease myocardial irritability as manifested by the frequent PVCs. Option A can be delegated and is a lower priority action than option B. Defibrillation may eventually be necessary, but option C is not the immediate treatment for frequent PVCs. Option D may become necessary if the client stops breathing but is not indicated at this time.

Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.) A. Increased heartburn that is not relieved with doses of antacids B. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit C. Shoes and rings that are too tight because of peripheral edema in extremities D. Decrease in ability for the client to sleep for more than 2 hours at a time E. Chronic headache that has been lingering for a week behind the client's eyes

Increased heartburn that is not relieved with doses of antacids Chronic headache that has been lingering for a week behind the client's eyes Options A and E are possible signs of preeclampsia or eclampsia but can also be normal signs of pregnancy. These signs should be reported to the health care provider for further evaluation for the safety of the client and the fetus. Options B, C, and D are all normal signs during the last trimester of pregnancy.

The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? A. Polyuria B. Polydipsia C. Weight loss D. Infection

Infection Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be absent in older adults.

Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? A. Stress incontinence B. Infection C. Painless gross hematuria D Peritonitis

Infection Infection is the major complication resulting from stasis of urine and subsequent catheterization. Option A is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intraabdominal pressure. Option C is the most common symptom of bladder cancer. Option D is the most common and serious complication of peritoneal dialysis.

In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A. Witness the client's signature to the permit. B. Answer the client's questions about the surgery. C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. The surgeon should be informed immediately that the permit is not signed. It is the surgeon's responsibility to explain the procedure to the client and obtain the client's signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained by the health care provider or surgeon, including answering the client's questions. The client's questions should be addressed before the permit is signed.

An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to implement for this client? A. Initiate airborne infection precautions. B. Place a surgical mask on the client. C. Don an isolation gown and latex gloves. D. Start protective (reverse) isolation precautions.

Initiate airborne infection precautions. This client is exhibiting classic symptoms of tuberculosis (TB), and the client is from a high-risk population for TB. Therefore, airborne infection precautions, which are indicated for TB, should be used with this client. Option B is used with droplet precautions. There is no evidence that option C or D would be warranted at this time.

When administering an intramuscular injection, which factor is most important to ensure the best medication absorption? A. Compress the syringe plunger quickly. B. Select a small-gauge needle. C. Inject the needle at a 90-degree angle. D. Select a small-diameter syringe.

Inject the needle at a 90-degree angle. Injecting the needle at a 90-degree angle allows the medication to be injected into the muscle so that appropriate absorption can occur. Too rapid injection of the medication may be painful and may cause medication leakage and reduced absorption. Option B will reduce injection discomfort but will not affect absorption. A syringe barrel that is too small increases the pressure during the injection and may traumatize tissue without improving medication absorption.

A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which intervention should the nurse implement first? A. Obtain a scale to weigh the infant's diapers. B. Instruct the mother to offer Pedialyte regularly. C. Insert an intravenous (IV) line and begin IV fluids. D. Obtain a stool specimen for analysis.

Insert an intravenous (IV) line and begin IV fluids. An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is to initiate IV fluids to rehydrate the infant. Options A, B, and D can then be implemented as needed.

A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique? A. Turns on the continuous wall suction to 190 mm Hg. B. Inserts the catheter until resistance or coughing occurs. C. Withdraws the catheter while maintaining suctioning. D. Reclears the tracheostomy after suctioning the mouth.

Inserts the catheter until resistance or coughing occurs. Option B indicates correct technique for performing suctioning. Suction pressure should be between 80 and 120 mm Hg, not 190 mm Hg. The catheter should be withdrawn 1 to 2 cm at a time with intermittent, not continuous, suction. Option D introduces pathogens unnecessarily into the tracheobronchial tree.

A female client is receiving tamoxifen following surgery for breast cancer. She reports the onset of hot flashes to the nurse. Which intervention should the nurse implement? A. Instruct the client that hot flashes are a side effect that often occurs with the use of this medication. B. Encourage the client to verbalize her feelings and fears about the recurrence of her breast cancer. C. Help the client schedule an appointment for evaluation of the need to increase the dose of medication. D. Notify the health care provider that the client needs immediate evaluation for medication toxicity.

Instruct the client that hot flashes are a side effect that often occurs with the use of this medication. Tamoxifen is an estrogen receptor blocker used to treat breast carcinoma. Hot flashes are a common side effect. If the hot flashes become bothersome, the client can be instructed in measures to reduce the discomfort. Hot flashes are not an indication of option B, C, or D.

When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include? A. Keep the residual limb elevated during positioning. B. Instruct the client to grasp the overhead trapeze bar. C. Maintain alignment with an abduction pillow. D. Use pillow support to prevent turning to a prone position.

Instruct the client to grasp the overhead trapeze bar. The client will gain upper body strength and independence by using the overhead trapeze bar for positioning. Elevation of the residual limb is controversial because a flexion contracture of the hip may result, so it is not necessary to maintain elevation during positioning. Option C is used for alignment following some hip surgeries. A prone position should be encouraged to stretch the flexor muscles and prevent flexion contracture of the hip.

A client taking linezolid at home for an infected foot ulcer calls the home care nurse to report the onset of watery diarrhea. Which intervention should the nurse implement? A. Schedule appointments to obtain blood samples for drug peak and trough levels. B. Reassure the client that this is an expected side effect that will resolve in a few days. C. Instruct the client to obtain a stool specimen to be taken to the laboratory for analysis. D. Advise the client to begin taking an over-the-counter antidiarrheal agent.

Instruct the client to obtain a stool specimen to be taken to the laboratory for analysis. Antibiotics, such as linezolid, can cause pseudomembranous colitis, resulting in severe watery diarrhea. The prescriber should be notified, and a stool specimen should be obtained and analyzed for this complication. Severe diarrhea is not an indication of drug toxicity, so option A is not warranted. Although gastrointestinal disturbance can be an adverse effect of linezolid, a stool specimen should be obtained because the client reports the diarrhea is severe. Antidiarrheal medications are contraindicated in the presence of this colitis and should not be started until this potential complication is ruled out.

The nurse is scheduling a client's antibiotic peak and trough levels with the laboratory personnel. What is the best schedule for drawing the trough level? A. Give the dose of medication, and call the laboratory to draw the trough STAT. B. Arrange for the laboratory to draw the trough 1 hour after the dose is given. C. Instruct the laboratory to draw the trough immediately before the next scheduled dose. D. Give the first dose of medication after the laboratory reports that the trough has been drawn.

Instruct the laboratory to draw the trough immediately before the next scheduled dose. The best time to draw a trough is the closest time to the next administration. Option A will provide a peak level. Option B will not provide the most accurate trough level. The medication is given before peak and trough levels are obtained.

The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that his mobility is greatly reduced. What is the most likely cause of the child's impaired mobility? A. Pathologic fractures B. Poor alignment of joints C. Dyspnea on exertion D. Joint inflammation

Joint inflammation Joint inflammation and pain are the typical manifestations of an exacerbation of JRA. Options A, B, and C are not specifically related to JRA.

What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client? A. Just above the xiphoid process, on the upper third of the sternum B. Below the xiphoid process, midway between the sternum and the umbilicus C. Just above the xiphoid process, on the lower third of the sternum D. Below the xiphoid process, midway between the sternum and the first rib

Just above the xiphoid process, on the lower third of the sternum The correct placement of the hands for chest compressions in CPR is just above the notch where the ribs meet the sternum on the lower part of the sternum. Option A is too high. Option B would not compress the heart. Option D would likely cause damage to both structures, possibly causing a puncture of the heart, and would not render effective compressions.

A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A. Immediately after feeding B. Just prior to tube feeding C. Continuous inflation is required D. Inflation is not required

Just prior to tube feeding The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. Options A and D place the client at risk for aspiration. Option C places the client at risk for tracheal wall necrosis.

A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor? A. Authority issues in childhood B. Anger about being hospitalized C. Low self-esteem D. Phobia of food

Low self-esteem Delusional clients have difficulty with trust and have low self-esteem. Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encouraged to build self-esteem. Options A, B, and D are not specifically related to the development of delusions.

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level

Low serum albumin level Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.

When caring for a client on digoxin therapy, the nurse knows to be alert for digoxin toxicity. Which finding would predispose this client to developing digoxin toxicity? A. Low serum sodium level B. High serum sodium level C. Low serum potassium level D. High serum potassium level

Low serum potassium level Hypokalemia predisposes the client on digoxin to digoxin toxicity, which usually presents as abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and atrioventricular (AV) dissociation. Assessment of serum potassium levels with prompt correction of hypokalemia is an important intervention for the client taking digoxin. Options A, B, and D are not relevant.

When caring for a child with congenital heart disease and polycythemia, which nursing intervention has the highest priority? A. Administering oxygen therapy continuously B Restricting fluids as ordered C. Maintaining adequate hydration D. Maintaining digoxin levels

Maintaining adequate hydration The key word in this question is polycythemia. Hydration decreases blood viscosity and the risk for thrombus formation, the most common complication of polycythemia. Options A and D are nursing interventions for the cardiac client but do not treat polycythemia. Fluid intake should be increased, not restricted.

A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign should the nurse monitor with greater frequency than the typical unit protocol? A. Maternal temperature B. Fetal blood pressure C. Maternal respiratory rate D. Fetal heart rate

Maternal temperature Maternal temperature should be monitored frequently as a primary indicator of infection. This client's rupture of membranes (ROM) occurred at least 20 hours ago (12 hours before coming to the hospital, in addition to 8 hours since hospital admission). Delivery is not imminent, and there is an increased risk of the development of infection 24 hours after ROM. Option B cannot be established with standard bedside monitoring. Option C is not specifically related to ROM. Option D is always monitored during labor; this situation would not prompt the nurse to increase FHR monitoring.

A child is having a generalized tonic-clonic seizure. Which action should the nurse take? A. Move objects out of the child's immediate area. B. Quickly slip soft restraints on the child's wrists. C. Insert a padded tongue blade between the teeth. D. Place in the recovery position before going for help.

Move objects out of the child's immediate area. The first priority during a seizure is to provide a safe environment, so the nurse should clear the area to reduce the risk of trauma. The child should not be restrained because this may cause more trauma. Objects should not be placed in the child's mouth because it may pose a choking hazard. Although option D should be implemented after the seizure, the nurse should not leave the child during a seizure to get help.

In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take? A. Advise the client that the shunt is intact and ready for dialysis as scheduled. B. Encourage the client to keep the shunt site elevated above the level of the heart. C. Notify the health care provider of the findings immediately. D. Flush the site at least once with a heparinized saline solution.

Notify the health care provider of the findings immediately. Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the health care provider so that intervention can be initiated to restore function of the shunt. Option A is incorrect. Option B will not resolve the obstruction. An AV shunt is internal and cannot be flushed without access using special needles.

A client with metastatic cancer who has been receiving fentanyl for several weeks reports to the nurse that the medication is not effectively controlling the pain. Which intervention should the nurse initiate? A. Instruct the client about the indications of opioid dependence. B. Monitor the client for symptoms of opioid withdrawal. C. Notify the health care provider of the need to increase the dose. D. Administer naloxone per PRN protocol for reversal.

Notify the health care provider of the need to increase the dose. Clients can develop a tolerance to the analgesic effect of opioids and may require an increased dose for effective long-term pain relief. The client is not exhibiting indications of dependence, withdrawal, or toxicity.

The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse? A. Remove all ice from the client's room. B. Ask the client what foods she might consider eating. C. Remind the client that what she eats affects her baby. D. Notify the health care provider.

Notify the health care provider. The health care provider should be notified when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia. Option A is overreacting and may be perceived as punishment by the client. Option B allows the dietary department to customize the client's tray but fails to address physiologic problems associated with not consuming nutritious foods in pregnancy. Option C is judgmental and blocks further communication.

On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client's expected date of birth (EDB)? A. November 22 B. November 8 C. December 22 D. October 22

November 22 Option A correctly applies the Nägele rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15 + 7 = 22). Options B, C, and D are not calculated correctly.

The nurse is caring for a hospitalized client with myasthenia gravis. Which finding requires the most immediate action by the nurse? A. O2 saturation, 89% B. Reports diplopia C. Ptosis to left eye D. Difficulty speaking

O2 saturation, 89% Respiratory failure is a life-threatening complication that can occur with myasthenia gravis. Options B, C, and D are signs of the disease but are not as life threatening as decreased oxygen saturation.

The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A. Determine how the client feels about changing the dressing. B. Ask the client to describe the procedure in writing. C. Seek a family member's evaluation of the client's ability to change the dressing. D. Observe the client change the dressing unassisted.

Observe the client change the dressing unassisted. Observing the client directly will allow the nurse to determine if mastery of the skill has been obtained and provide an opportunity to affirm the skill. Option A may be therapeutic but will not provide an opportunity to evaluate the client's ability to perform the procedure. Option B may be threatening to an older client and will not determine his ability. Option C is not as effective as direct observation by the nurse.

A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing intervention should be included in this infant's discharge teaching plan? A. Observe the parents applying a Pavlik harness. B. Provide a referral for an orthopedic surgeon. C. Schedule a physical therapy follow-up home visit. D. Teach the parents to check for hip joint mobility.

Observe the parents applying a Pavlik harness. It is important that the hips of infants with hip dysplasia are maintained in an abducted position, which can be accomplished by using the Pavlik harness; this keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. Early treatment often negates the need for surgery, and option B is not indicated until approximately 6 months of age. Option C is not indicated for hip dysplasia. It is best for the pediatrician to monitor hip joint mobility, and teaching the parents to perform this technique is likely to increase their anxiety.

The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first? A. Measure the urine specific gravity. B. Obtain IV fluids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's breath sounds.

Obtain IV fluids for infusion per protocol. The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.

The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? A. Assess the need to change a central line dressing. B. Obtain a fingerstick blood glucose level. C. Answer a family member's questions about the client's plan of care. D. Teach the client side effects to report related to the current medication regimen.

Obtain a fingerstick blood glucose level. Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform. Options A, C, and D are skills that cannot be delegated to UAP.

The apical heart rate of an infant receiving digoxin for congestive heart failure is 80 beats/min. Which intervention should the nurse implement first? A. Administer the next dose of digoxin as scheduled. B. Obtain a serum digoxin level. C. Administer a PRN dose of atropine sulfate. D. Assess for S3 and S4 heart sounds.

Obtain a serum digoxin level. Sinus bradycardia (rate <90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level is the highest priority. Further doses of digoxin should be withheld until the serum level is obtained. Option C is not indicated unless the client exhibits symptoms of diminished cardiac output. Option D provides information about cardiac function but is of less priority than option B.

One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first? A. Stimulate the infant to cry. B. Wrap the infant in warm blankets. C. Feed the infant formula. D. Obtain a serum glucose level.

Obtain a serum glucose level. This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level. Option A is an intervention for a lethargic infant. Option B should be done based on the temperature, but first the glucose level should be obtained. Option C helps raise the blood sugar, but first the nurse should determine the glucose level.

A client has been receiving levofloxacin, 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement? A. Perform a digital evaluation for fecal impaction. B. Administer a PRN dose of psyllium. C. Obtain a stool specimen for culture and sensitivity. D. Instruct the UAP to obtain incontinent pads for the client.

Obtain a stool specimen for culture and sensitivity. Long-term use of levofloxacin can cause foul-smelling diarrhea because of Clostridium difficile infection or associated colitis, so it is most important to obtain a stool specimen. Impaction is unlikely, so option A is of less priority and may not be necessary. Option B is a bulk-forming agent that may be used for constipation or diarrhea. Treatment of the diarrhea and client comfort are important interventions but of less priority than determining the cause of the client's diarrhea.

An infant is receiving digoxin for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What intervention should the nurse implement? A. Call for a portable chest radiograph. B. Obtain a therapeutic drug level. C. Reassess the heart rate in 30 minutes. D. Administer digoxin immune Fab stat.

Obtain a therapeutic drug level. Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level has the highest priority. Option A is not indicated at this time. Option C provides helpful assessment data but does not address the cause of the problem and delays needed intervention. Option D is indicated for a serious, life-threatening overdose with digoxin.

When blood or blood products are administered, which task can be assigned to the licensed practical nurse (PN)? A. Initiation of the blood product B. Obtaining vital signs after infusion has begun C. Assessment of client's condition prior to blood administration D. Evaluation of client's response after receiving blood product

Obtaining vital signs after infusion has begun Blood and blood products must be initiated by the registered nurse (RN); however, obtaining vital signs may be delegated as long as the results are evaluated by the RN. Options A, C, and D are all part of the nursing process and the scope of the RN.

When providing client teaching about the administration of methylphenidate (Ritalin) to a parent of a child diagnosed with ADHD, which instruction should the nurse include in the teaching plan? A. The doses should be given exactly 12 hours apart to sustain a therapeutic serum level. B. Doses should be scheduled at midmorning and midafternoon to achieve optimal benefit. C. Give the medication only on school days and when the child appears to be anxious. D. Offer the child the medication with breakfast and after the child eats lunch.

Offer the child the medication with breakfast and after the child eats lunch. Administering the medication at breakfast and after lunch provides the correct spacing of the doses to maximize the child's attention span and helps prevent the appetite suppression associated with the drug. Doses should be spaced at 6-hour intervals, not option A. Option B is likely to increase insomnia. Option C disrupts the normal dosing schedule, resulting in ineffective treatment. Doses should be discontinued only for brief intervals (with the health care provider's approval) when the client's condition is being evaluated or if the client is being weaned from the medication entirely.

A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation? A. Advocate for the rights of the staff to watch television once their assignments are complete. B. Confront the administrator about making a decision that will negatively affect the residents. C. Offer to develop an alternate solution so that the residents can continue to watch television. D. Remind the administrator that watching television helps the night shift staff remain awake.

Offer to develop an alternate solution so that the residents can continue to watch television. The role of the nurse-manager in the mediation process is to assess the problem, analyze the information, and reframe it in a manner that might provide compromise. The staff do not have the right to watch television while being paid to work. Option B challenges the administrator and is likely to alienate the administrator, causing anger and shutting off further communication. Option D is not a sound rationale for the use of the television.

Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)? A. Clients' names are not used while they are in a public waiting room. B. Nurses should not recommend any community self-help groups by specific name, such as Alcoholics Anonymous. C. Clients must pick up their filled prescriptions from a pharmacy in person with a photo identification card. D. Old medical records are kept in a locked file cabinet in the department.

Old medical records are kept in a locked file cabinet in the department. Past medical records must be "secured" and "reasonably protected" from inadvertent viewing. A locked room or file cabinet can serve this purpose, and when any protected health information (PHI) is discarded, it must be shredded. A person's name only (without his or her diagnosis or treatment) is not considered confidential or PHI. Nurses may suggest categories of community resources, with examples, such as Alcoholics Anonymous, but cannot market a specific program in which they have a financial interest. Others can pick up a client's filled prescriptions.

Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? A. Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B. Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C. Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D. Opioids suppress respirations, which increases PCO2 and contributes to an elevated ICP.

Opioids suppress respirations, which increases PCO2 and contributes to an elevated ICP. The greatest risk associated with opioids such as morphine is respiratory depression that causes an increase in PCO2, which increases ICP and masks the early signs of intracranial bleeding in head injury. Options A, B, and C do not support the risks associated with opioid use in a client with increased ICP.

A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture? A. Bilateral jugular venous distention B. Oral temperature of 102° F C. Intermittent focal motor seizures D. Intractable pain in the cervical region

Oral temperature of 102° F Clients with basilar skull fractures are at high risk for infection of the brain, as indicated by an increased oral temperature, because the fracture leaves the meninges open to bacterial invasion. Clients may experience options C and D, but these findings do not pose as great a life-threatening risk as infection. Jugular distention is not a typical complication of basal skull fractures.

A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur? A. Failing eyesight resulting in an unsafe environment B. Renal osteodystrophy resulting from chronic kidney disease (CKD) C. Osteoporosis resulting from declining hormone levels D. Cerebral vessel changes causing transient ischemic attacks

Osteoporosis resulting from declining hormone levels The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years. Option A may or may not have contributed to the accident, but eye changes were not involved in promoting the hip fracture. Option B is not a common condition of older people but is associated with CKD. Although option D may result in transient ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis.

A child with cystic fibrosis is receiving ticarcillin disodium for Pseudomonas pneumonia. For which adverse effect should the nurse assess and report promptly to the health care provider? A. Petechiae B. Tinnitus C. Oliguria D. Hypertension

Petechiae Adverse effects of ticarcillin disodium include hypothrombinemia and decreased platelet adhesion, which can result in the presence of petechiae. Options B, C, and D are not adverse effects primarily associated with the administration of ticarcillin disodium.

A client who has chronic back pain is on long-term pain medication management and asks the nurse why his pain relief therapy is not as effective as it was 2 months ago. How should the nurse respond? A. The phenomenon occurs when opiates are used for more than 6 months to relieve pain. B. Withdrawal occurs if the drug is not tapered slowly while being discontinued. C. Pharmacodynamic tolerance requires increased drug levels to achieve the same effect. D. A consistent dosage with around-the-clock administration is the most effective.

Pharmacodynamic tolerance requires increased drug levels to achieve the same effect. Pharmacodynamic tolerance explains the client's need for an increased drug level to produce effects that formerly occurred at lower drug levels. Tolerance can occur with opioids during shorter periods of use. Although a withdrawal syndrome can occur if the client develops a dependency, this does not address the client's immediate concern of drug effectiveness. Although a stable serum drug level provides effective pain management, the client's complaint is consistent with a tolerance to his current pain management regimen.

Which physiologic mechanism explains a drug's increased metabolism that is triggered by a disease process? A. Selectivity response B. Pharmacokinetics C. Pharmacodynamics D. Pharmacotherapeutics

Pharmacokinetics describes the physiologic process of a drug's movement throughout the body and how the drug's interaction is affected by an underlying disease. Selectivity, or a selective drug, is defined as a drug that elicits only the response for which it is given. Pharmacodynamics is the impact of drugs on the body. Pharmacotherapeutics is defined as the use of drugs to diagnose, prevent, or treat disease or prevent pregnancy.

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan? A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B. Wash off the yellow exudate on the glans once every day to prevent infection. C. Place petroleum ointment around the glans with each diaper change and cleansing. D. Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.

Place petroleum ointment around the glans with each diaper change and cleansing. With each diaper change, the glans penis should be washed with warm water to remove any urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface. Prepackaged wipes often contain other products that may irritate the site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process and should not be removed. If bleeding occurs at home, the client should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call the health care provider.

A child with a permanent tracheostomy is confined to a wheelchair and is going to school for the first time tomorrow. During the school day, which intervention should be implemented for this child? A. Cover the tracheostomy site with clothing so that other children will not notice. B. Apply suction for 30 seconds when inserting a catheter into the stoma. C. Discourage the child from coughing deeply to remove mucous secretions. D. Place suctioning supplies on the back of the wheelchair when transporting.

Place suctioning supplies on the back of the wheelchair when transporting. Suctioning supplies should always be readily available for use with any client who has a tracheostomy. Options A, B, and C do not describe safe practices for this child with a tracheostomy.

A child breaks out with varicella infection (chickenpox) while hospitalized for a minor surgical procedure. Which intervention should the nurse implement first? A. Place a mask on the child before transporting the child outside the room. B. Immunize exposed family members with the varicella vaccine. C. Place the child in strict isolation to prevent an outbreak on the unit. D. Determine which staff have had varicella before making assignments.

Place the child in strict isolation to prevent an outbreak on the unit. The period of communicability of varicella is 2 days before the rash appears until all lesions are crusted; varicella is spread by direct or indirect contact of saliva or vesicles. Strict isolation is indicated to prevent further exposure to staff and others. Staff who have had varicella or the vaccine are not susceptible to contracting or spreading the virus and should be the only personnel assigned to care for this client. Option A is not sufficient to prevent exposure to others. Option B must be done prior to exposure.

The nurse is caring for a child with intussusception who is scheduled for a barium enema prior to a surgical procedure. Which action should the nurse take first? A. Evacuate the bowel of impacted feces B Administer magnesium sulfate C. Place the child on a clear liquid diet D. Assess the stool for white color

Place the child on a clear liquid diet Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception. In preparation for a barium enema, the client should first be placed on a clear liquid diet for the entire day; then magnesium sulfate is administered for bowel evacuation. A barium enema is likely to cause option A. After the enema, white stool may be seen as the body naturally removes any remaining barium.

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A. Place the client in a high Fowler position. B. Help the client assume a left side-lying position. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx.

Place the client in a high Fowler position. Instruct the client to swallow after the tube has passed the pharynx. (A and D) are the correct steps to follow during nasogastric intubation. Only the unconscious or obtunded client should be placed in a left side-lying position (B). The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E).

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take immediately? A. Notify the health care provider or anesthesiologist. B. Continue to assess the blood pressure every 5 minutes. C. Place the client in a lateral position. D. Turn off the continuous epidural.

Place the client in a lateral position. The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by facemask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately. To continue to monitor blood pressure without taking further action could constitute malpractice. Option D may also be warranted, but such action is based on hospital protocol.

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back.

Place the client in a side-lying position. Pull the auricle upward and outward. The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement? A. Turn the client to her side. B. Begin oxygen by nasal cannula at 2 L/min. C. Place the client in a slight Trendelenburg position. D. Assess for cervical dilation.

Place the client in a slight Trendelenburg position. The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions. Option A may be helpful but is not as likely to relieve the pressure as the Trendelenburg position. Option B is not helpful with cord compression. Option D is not the priority intervention at this time. After repositioning the client, a vaginal examination is indicated to rule out cord prolapse and assess for cervical change.

A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period? A. Place the infant upright in an infant seat position. B. Provide mittens with the use of elbow restraints. C. Use soft rubber catheters for nasal suctioning. D. Apply water-soluble lubricant to the suture line.

Place the infant upright in an infant seat position. The use of an infant seat simulates a supine position with the head elevated and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan bow and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry the suture line and cause crusting, which predisposes the suture line to poor healing and scarring.

A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's hips are externally rotated. Which intervention is most important for the nurse to implement? A. Request a prescription for a bed board to provide increased back support. B. Reposition the client so that both feet are supported by the bed board. C. Move the trapeze bar to allow the client to pull with the upper extremities. D. Place trochanter rolls on the lateral aspects of the client's thighs.

Place trochanter rolls on the lateral aspects of the client's thighs. Trochanter rolls should be placed on the lateral aspects of the thighs to prevent external rotation of the hips when the client is in a supine position. Although options A, B, and C are supportive equipment used to maintain proper positioning of the client who is immobile, it is most important to maintain the lower extremities in the aligned anatomical position. A bed board provides increased back support, especially with a soft mattress. The footboard maintains the feet in dorsiflexion and prevents foot drop. The trapeze bar allows the client to participate while turning in the bed, during transfers in and out of bed, or performing upper arm exercises.

The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP? A. Obtain the remainder of the preoperative admission information. B. Check the vomiting client for signs of tube feeding aspiration. C. Position the client who has vomited on his side and obtain vital signs. D. Teach the preoperative client coughing and deep breathing exercises.

Position the client who has vomited on his side and obtain vital signs. The UAP can be assigned to perform tasks that do not require the judgment of the nurse, such as positioning the client and obtaining vital signs. Options A and B involve assessment, which should be performed by a nurse. Option D involves initial client teaching, which should be performed by the nurse.

During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A. Prepare the client for a pericardial tap. B. Administer intravenous furosemide (Lasix). C. Assist the client to cough and breathe deeply. D. Instruct the client to restrict oral fluid intake.

Prepare the client for a pericardial tap. The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap. Lasix IV is not indicated for treatment of pericarditis. Because the client's breath sounds are clear, option C is not a priority. Fluids are frequently increased in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the same priority as option A.

A nurse working in the emergency department admits a client with full-thickness burns to 50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse take first? A. Insert a large-bore IV for fluid resuscitation. B. Prepare to assist with maintaining the airway. C. Cleanse the wounds using sterile technique. D. Administer an analgesic for pain.

Prepare to assist with maintaining the airway. High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with lung injury. Airway management is the first priority of care. Options A, C, and D are all appropriate interventions in managing the client with a burn but are not as critical as establishing an airway.

The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? A. Tall, spiked T waves B. A prolonged QT interval C. A widening QRS complex D. Presence of a U wave

Presence of a U wave A U wave is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). Options A, B, and C are all signs of hyperkalemia.

Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)? A. Provide a room that can be kept warm. B. Make sure that the room can be kept dark. C. Keep the client close to the nursing unit. D. Select a room that is visible from the nurses' desk.

Provide a room that can be kept warm. Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option B is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet environment is preferred to option C, which is often very noisy. Option D is not necessary.

A 27-year-old client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. The client is demanding and active. Which intervention should the nurse include in this client's plan of care A. Schedule the client to attend various group activities. B. Reinforce the client's ability to make decisions. C. Encourage the client to identify feelings of anger. D. Provide a structured environment with little stimuli.

Provide a structured environment with little stimuli. Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment. Noncompetitive activities that can be carried out alone should be planned for these clients. Option A is contraindicated because stimuli should be reduced as much as possible. Impulsive decision making is characteristic of clients with bipolar disorder. To prevent future complications, the nurse should monitor these clients' decisions and assist them in the decision-making process. Option C is more often associated with depression than with bipolar disorder.

On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement? A. Provide packaged foods for the client to eat. B. Begin the client on total parenteral nutritional (TPN) therapy. C. Provide a well-balanced liquid diet for the client. D. No action is necessary because the client will eat when hungry.

Provide a well-balanced liquid diet for the client. The nurse should strive to provide a safe environment (adequate nutrition is part of a safe environment) and should not argue with the client's delusions. Option C is the least invasive while providing nutrition that does not argue with the client's delusion. Option A is given to those with paranoid delusions. Option B is invasive and would be used as a last resort. Option C should be tried first. This client's delusion could be life threatening and should not be ignored.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention should the nurse implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby. B. Ask the woman to describe why she was unsuccessful with breastfeeding her last child. C. Encourage the woman to develop a positive attitude about breastfeeding to help ensure success. D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery. Options A and B might provide interesting data, but gathering this information is not as important as providing support and instructions to the new mother. Although option C is also true, this response by the nurse might seem judgmental to a new mother.

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury

Pulse characteristics Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway, so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. Use thread to tie off the umbilical cord. B. Provide privacy for the woman. C. Reassure the husband and keep him calm. D. Put the newborn to the breast immediately.

Put the newborn to the breast immediately. Putting the newborn to the breast will help contract the uterus and prevent a postpartum hemorrhage. This intervention has the highest priority. Option A is not necessary; the infant can be transported attached to the placenta. Option B is an important psychosocial need but does not have the priority of option D. Although the husband is an important part of family-centered care, he is not the most important concern at this time.

The nurse is planning the care for a client who is admitted with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which interventions should the nurse include in this client's plan of care? (Select all that apply.) A. Salt-free diet B. Quiet environment C. Deep tendon reflex assessments D. Neurologic checks E. Daily weights

Quiet environment Deep tendon reflex assessments Neurologic checks Daily weights Correct responses are (B, C, D, and E). SAIDH results in water retention and dilutional hyponatremia, which causes neurologic changes when serum sodium levels are less than 115 mEq/L. The nurse should maintain a quiet environment (B) to prevent overstimulation and assess deep tendon reflexes (C) and perform neurologic checks (D) to monitor for neurologic deteriora-tion. Daily weights (E) should be monitored to assess for fluid overload. (A) would contribute to dilutional hyponatremia.

An adult client who lives in a residential facility is mentally retarded and has a history of bipolar disorder. During the past week, the client has refused to wear clothes and frequently exposes his/her body to other residents. Which intervention should the nurse implement? A.Establish a one-to-one relationship to discuss the behavior. B. Redirect the client to physically demanding activities. C. Encourage the client to verbalize thoughts when acting out. D. Restrict social interactions with other residents in the facility

Redirect the client to physically demanding activities. The client is exhibiting manic behavior related to bipolar disorder, and the nurse should redirect the client to activities that are physically demanding so that energy can be expended in a socially acceptable manner. Psychotic clients are not capable of option A. When exhibiting acting-out behavior, the client is distracted and option C is difficult. Option D is likely to increase manic behaviors, such as mood swings and acting-out behaviors.

A client with acute lymphocytic leukemia is to begin chemotherapy today. The health care provider's prescription specifies that ondansetron is to be administered IV 30 minutes prior to the infusion of cisplatin. What is the rationale for administering Zofran prior to the chemotherapy induction? A. Promotion of diuresis to prevent nephrotoxicity B. Reduction or elimination of nausea and vomiting C. Prevention of a secondary hyperuricemia D. Reduction in the risk of an allergic reaction

Reduction or elimination of nausea and vomiting Ondansetron is a type 3 receptor (5-HT3) antagonist that is recognized for improved control of acute nausea and vomiting associated with chemotherapy. 5-HT3 antagonists are most effective when administered IV prior to the induction of the chemotherapeutic agent(s). Options A, C, and D are not therapeutic actions of ondansetron.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A. Assign an unlicensed assistive personnel to transport the client via a wheelchair. B. Remind the client to walk carefully down the stairs until reaching a lower floor. C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

Remind the client to walk carefully down the stairs until reaching a lower floor. During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully. Ambulatory clients do not require the assistance of a wheelchair to be evacuated. Elevators should not be used during a fire, and fire doors should be kept closed to help contain the fire.

A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from anesthesia. Which nursing intervention should be included in this child's plan of care? A. Keep restraints on at all times to prevent unplanned extubation. B. Remove restraints one at a time and provide range-of-motion exercises. C. Remove all restraints simultaneously and provide play activities. D. Document the reason for application of the restraints every 72 hours.

Remove restraints one at a time and provide range-of-motion exercises. Removing restraints one at a time is safer than option C. The infant should have the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and range-of-motion exercises should be performed with these assessments. Under no circumstances should restraints be applied to the client continuously. Documentation of assessment findings regarding the restrained extremities must occur much more frequently than every 72 hours; however, the reason for using restraints must be justified and should be stated in the medical record.

The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client? A. Remove the brace 1 hour each day for bathing only. B. Remove the brace only for back range-of-motion exercises. C. Wear the brace against the bare skin to ensure a good fit. D. Wearing the brace will cure the spinal curvature.

Remove the brace 1 hour each day for bathing only. The Milwaukee brace is designed to slow the progression in spinal curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed a total of 1 hour a day for hygiene. There are no specific exercises for increasing the range of motion in the back that should be performed. A T shirt should be worn next to the body and the brace put on over the T shirt to protect the skin. The brace will not cure the spinal curvature but should slow the progression of the scoliosis.

A client receives pancuronium, a long-acting, nondepolarizing neuromuscular blocker, during surgical anesthesia. Which client situation should alert the nurse to evaluate the client for a prolonged muscle relaxation response to this medication? A. Hepatitis B. Heart failure C. Renal insufficiency D. History of emphysema

Renal insufficiency Pancuronium is eliminated via the kidneys, so a client with renal failure is at risk for prolonged muscle relaxation. Although hepatitis can interfere with this drug's metabolism, it does not place a client at increased risk for prolonged muscle relaxation. Options B and D do not cause prolonged muscle relaxation in a client who receives pancuronium.

A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? A. Obtain objective data such as radiographs before reporting suspicions. B. Confirm suspicions of abuse with the health care provider. C. Report any case of suspected child abuse. D. Document injuries to confirm suspected abuse.

Report any case of suspected child abuse. It is the nurse's legal responsibility to report all suspected cases of child abuse, and notifying the nurse manager or charge nurse starts the legal reporting process. Options A, B, and D delay the first step in reporting the abuse.

A client who is experiencing an acute attack of gouty arthritis is prescribed colchicine USP, 1 mg PO daily. Which information is most important for the nurse to provide the client? A Take the medication with meals. B. Limit fluid intake until the attack subsides. C. Stop the medication when the pain resolves. D. Report any vomiting to the clinic.

Report any vomiting to the clinic. The client should be instructed to report signs of colchicine toxicity, such as nausea, diarrhea, vomiting, and/or abdominal pain, to the health care provider. Food inhibits the absorption of colchicine when ingested concurrently. Limited fluid intake decreases the excretion of the uric acid crystals, which contributes to painful attacks. Typically, a client should remain on a daily dose of colchicine to decrease the number and severity of acute attacks, so stopping the medication after the pain resolves is not indicated.

An 8-year-old child is seen in the clinic with a green vaginal discharge. Which action is most important for the nurse to implement? A. Assess the child's blood pressure. B. Counsel the child to wear cotton underwear. C. Report as suspected child abuse. D. Determine if the child takes bubble baths.

Report as suspected child abuse. A green vaginal discharge is indicative of gonorrhea, a sexually transmitted disease. Because the child is 8 years old, the nurse should suspect child abuse and report the incident to the proper authorities. Option A is usually not related to infection. Options B and D are helpful in preventing bladder infections, but a green vaginal discharge is not a symptom of a bladder infection.

Minocycline, 50 mg PO every 8 hours, is prescribed for an adolescent girl diagnosed with acne. The nurse discusses self-care with the client while she is taking the medication. Which teaching points should be included in the discussion? (Select all that apply.) A. Report vaginal itching or discharge. B. Take the medication at 0800, 1500, and 2200 hours. C. Protect skin from natural and artificial ultraviolet light. D. Avoid driving until response to medication is known. E. Take with an antacid tablet to prevent nausea. F. Use a nonhormonal method of contraception if sexually active.

Report vaginal itching or discharge. Protect skin from natural and artificial ultraviolet light. Avoid driving until response to medication is known. Use a nonhormonal method of contraception if sexually active Adverse effects of tetracyclines include superinfections, photosensitivity, and decreased efficacy of oral contraceptives. Therefore, the client should report vaginal itching or discharge (A), protect the skin from ultraviolet light (C), and use a nonhormonal method of contraception (F) while on the medication. Minocycline is known to cause dizziness and ataxia, so until the client's response to the medication is known, driving (D) should be avoided. Tetracyclines should be taken around the clock (B) but exhibit decreased absorption when taken with antacids, so (E) is contraindicated.

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube 5 cm. D. Administer an intravenous antiemetic as prescribed.

Reposition the client on her side. The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, repositioning the client, should be attempted first, followed by options A and C, unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require option D.

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client.

Review the schedule of outdoor breaks with the client. The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Option A is contraindicated if the client wants to continue smoking. Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for this client only and is inconsistent with unit rules.

An older client who had a colon resection yesterday is receiving a constant dose of hydromorphone via a patient-controlled analgesia (PCA) pump. Which assessment finding is most significant and requires that the nurse intervene? A. The client is drowsy and complains of pruritus. B. Pupils are 3 mm; PERRLA. C. The area around the sutures is reddened and swollen. D. Respirations decrease to 14 breaths/min.

Respirations decrease to 14 breaths/min. Hydromorphone is an opioid agonist-analgesic of opiate receptors that inhibits ascending pathways and can cause respiratory depression. Older adults are more sensitive to opioids so the "start low and go slow" approach should be taken. Option A lists common side effects of opioids, particularly the opiates, which are usually harmless and often transient. Option B is within the normal range (2 to 6 cm). The suture site may be red and swollen as an inflammatory response, but no action is required if the skin around the incision is a normal color and temperature.

The nurse is caring for a client with respiratory distress whose arterial blood gas (ABG) results are as follows: pH, 7.33; PCO2, 50 mm Hg; PO2, 70 mm Hg; HCO3, 26 mEq/L. How should the nurse interpret these results? A. Metabolic acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Respiratory acidosis

Respiratory acidosis A pH < 7.25 and PCO2 > 45 mm Hg with a normal HCO3 indicates respiratory acidosis. Options A, B, and C are incorrect analyses of the ABGs.

An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." Which early signs indicate that the client is beginning to have delirium tremens? A. Abdominal cramping and watery eyes B Depression and fatigue C. Restlessness and confusion D. Hostility and anger

Restlessness and confusion A client experiencing alcohol withdrawal often has delirium tremens (DTs), which are characterized by progressive disorientation. Initially, the client will appear restless and confused and develop tachycardia, tachypnea, and diaphoresis. Hallucinations, paranoia, and seizures can also occur later in the development of DTs. Option A is indicative of withdrawal from opiates such as heroin or morphine. Option B is often seen in cocaine withdrawal. Option D is most characteristic of the paranoid client.

A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A. Avoid high-carbohydrate foods. B. Decrease intake of fat-soluble vitamins. C. Decrease caloric intake. D. Restrict salt and fluid intake.

Restrict salt and fluid intake. Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites. Options A, B, and C will not affect fluid retention.

The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A. Left brachial vein B. Right cephalic vein C. Dorsal side of the right wrist D. Right upper extremity

Right cephalic vein The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. Option D is not specific enough for documenting the location of the IV access.

The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis? A. Fluid volume deficit B. Self-care deficit C. Risk for infection D. Impaired nutrition

Risk for infection The primary reason for performing frequent mouth care preoperatively is to reduce the risk of postoperative infection because these clients may be regurgitating retained food particles, blood, or pus from the tumor. Meticulous oral care should be provided several times a day before surgery. Although oral care will be of benefit to the client who may also be experiencing option A, B, or D, these problems are not the primary reason for the provision of frequent oral care.

The health care provider has prescribed a low-molecular-weight heparin, enoxaparin prefilled syringe, 30 mg/0.3 mL IV every 12 hours, for a client following hip replacement. Prior to administering the first dose, which intervention is most important for the nurse to implement? A. Assess the client's IV site for signs of inflammation. B. Evaluate the client's degree of mobility. C. Instruct the client regarding medication side effects. D. Contact the health care provider to clarify the prescription.

Risk for infection Corticosteroids depress the immune system, placing the client at risk for infection. Although options A, C, and D reflect diagnostic statements that may be applicable to this client, only option B is directly related to the administration of this medication.

Which statement reflects the highest priority nursing diagnosis for an older client recently admitted to the hospital for a new-onset cardiac dysrhythmia? A. Diarrhea related to medication side effects B. Anxiety related to fear of recurrent anginal episodes C. Altered nutrition related to high serum lipid levels D. Risk for injury related to syncope and confusion

Risk for injury related to syncope and confusion The loss of cardiac function in aging decreases cardiac output, so dysrhythmias, particularly tachycardias, are poorly tolerated. With onset of a tachycardic or bradycardic dysrhythmia, cardiac output is compromised further, placing the client at risk of syncope and falling, as well as confusion. Option A is of high priority but less so than maintaining client safety. Clients may experience option B as a result of a newly diagnosed cardiac condition, but this nursing diagnosis does not have the priority of option D. Option C also does not have the priority of option D.

Which client is most likely to be at risk for spiritual distress? A. Roman Catholic woman considering an abortion B. Jewish man considering hospice care for his wife C. Seventh-Day Adventist who needs a blood transfusion D. Muslim man who needs a total knee replacement

Roman Catholic woman considering an abortion In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith. Jehovah's Witnesses, not Seventh-Day Adventists, prohibit blood transfusions. There is no conflict in the Muslim faith with regard to joint replacement.

A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client? A. Reduced peripheral edema B. Urinary output of at least 70 mL/hr C. Decrease in urine osmolarity D. Serum sodium level of 137 mEq/L

Serum sodium level of 137 mEq/L Syndrome of inappropriate antidiuretic hormone (SIADH) results from an abnormal production or sustained secretion of antidiuretic hormone, causing fluid retention, hyponatremia, and central nervous system (CNS) fluid shifts. The client's normalization of the serum sodium level (normal is 135 to 145 mEq/L) is the most important outcome because sudden and severe hyponatremia caused by fluid overload can result in heart failure. Fluid retention of SIADH contributes to daily weight gain, which can predispose to peripheral edema, but the higher priority outcome is the effect on serum electrolyte levels. Although options B and C are findings associated with resolving SIADH, they do not have the priority of option D.

Two hours after taking the first dose of penicillin, a client arrives at the emergency department complaining of feeling ill, exhibiting hives, having difficulty breathing, and experiencing hypotension. These findings are consistent with which client response that requires immediate action? A. Severe acute anaphylactic response B. Side reaction that should resolve C. Idiosyncratic reaction D. Cumulative drug response

Severe acute anaphylactic response Anaphylaxis related to penicillin can cause a life-threatening allergic response characterized by bronchospasm, laryngeal edema, and a precipitous drop in blood pressure. This client's ingestion of penicillin and presenting clinical picture indicate the client is having an acute reaction with respiratory difficulty. Options B, C, and D are other physiologic responses to medications, but immediate action is required for a potential loss of airway, breathing, and circulation.

A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? A. High Fowler position without a pillow behind the head B. Semi-Fowler position with a single pillow behind the head C. Right side-lying position with the head of the bed elevated 45 degrees D. Sitting upright and forward with both arms supported on an over the bed table

Sitting upright and forward with both arms supported on an over the bed table Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to increase the longitudinal and anterior-posterior size of the thoracic cage. Sitting upright and leaning forward with the arms supported on an over the bed table allows the thoracic cage to expand in all four directions and reduces dyspnea. A high Fowler position does not allow maximum expansion of the posterior lobes of the lungs. A semi-Fowler position restricts the expansion of the anterior-posterior diameter of the thoracic cage. Positioning a client on the right side with the head of the bed elevated does not facilitate lung expansion.

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A. Cyanosis of the hands and feet B. Skin color that is slightly jaundiced C. Tiny white papules on the nose or chin D. Red patches on the cheeks and trunk

Skin color that is slightly jaundiced Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and feet) is a common finding in newborns; it occurs because the capillary system is immature. Milia are small white papules present on the nose and chin that are caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on the cheeks and trunk are called erythema toxicum neonatorum, a common finding in newborns.

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium

Sodium Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically associated with prolonged NG suctioning.

Which action should the nurse implement when providing wound care instructions to a client who does not speak English? A. Ask an interpreter to provide wound care instructions. B. Speak directly to the client, with an interpreter translating. C. Request the accompanying family member to translate. D. Instruct a bilingual employee to read the instructions.

Speak directly to the client, with an interpreter translating. Wound care instructions should be given directly to the client by the nurse with an interpreter who is trained to provide accurate and objective translation in the client's primary language, so that the client has the opportunity to ask questions during the teaching process. The interpreter usually does not have any health care experience, so the nurse must provide client teaching. Family members should not be used to translate instructions because the client or family member may alter the instructions during conversation or be uncomfortable with the topics discussed. The employee should be a trained interpreter to ensure that the nurse's instructions are understood accurately by the client.

The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about the prevention of accidental poisonings. It is most important for the nurse to include which instruction? A. Tell children that they should not taste anything but food. B. Store all toxic agents and medicines in locked cabinets. C. Provide special play areas in the house and restrict play in other areas. D. Punish children if they open cabinets that contain household chemicals.

Store all toxic agents and medicines in locked cabinets. The only reliable way to prevent poisonings in young children is to make the items inaccessible. Teaching children not to taste anything but food is important but ineffective for young children. Options C and D will not control a child's curiosity.

A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate? A. Drowsiness and paroxysmal bradycardia B. Depressed reflexes and increased respirations C. Tachycardia and a feeling of nervousness D. A flushed warm feeling and dry mouth

Tachycardia and a feeling of nervousness Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness. Option A is not a side effect. Options B and D are side effects of magnesium sulfate.

A 67-year-old client is discharged from the hospital with a prescription for digoxin, 0.25 mg daily. Which instruction should the nurse include in this client's discharge teaching plan? A.Take the medication in the morning before rising. B. Take and record radial pulse rate daily. C. Expect some vision changes caused by the medication. D. Increase intake of foods rich in vitamin K.

Take and record radial pulse rate daily. Monitoring pulse rate is very important when taking digoxin. The client should be further instructed to report pulse rates <60 or >110 beats/min and to withhold the dosage until consulting with the health care provider in such a case. Options A and D are not necessary. Option C is an indication of drug toxicity, and the client should be instructed to report this immediately.

The health care provider prescribes oral contraceptives for a client who wants to prevent pregnancy. Which information is the most important for the nurse to provide to this client? A. Take one pill at the same time every day until all the pills are gone. B. Use condoms and foam instead of the pill while on any antibiotics. C. Limit sexual intercourse for at least one cycle after starting the pill. D. Use another contraceptive if two or more pills are missed in one cycle.

Take one pill at the same time every day until all the pills are gone. To maintain adequate hormonal levels for contraception and enhance compliance, oral contraceptives should be taken at the same time each day. There is no strong pharmacokinetic evidence that shows a relationship between the category of broad-spectrum antibiotic use and altered hormone levels in oral contraceptive users, so option B is not indicated at this time. Abstinence is the best method to prevent pregnancy during the first cycle. If a client misses two pills during the first week, the client should take two pills a day for 2 days and finish the package while using a backup method of birth control until her next menstrual cycle.

A client with angina pectoris is instructed to take sublingual nitroglycerin tablets PRN for chest pain. Which instruction should the nurse include in the client's teaching plan? A. Take one tablet every 3 minutes, up to five tablets. B. Take one tablet at the onset of angina and stop activity. C. Replace nitroglycerin tablets yearly to maintain freshness. D. Allow 30 minutes for a tablet to provide relief from angina.

Take one tablet at the onset of angina and stop activity. Nitroglycerin tablets should be taken at the onset of angina, and the client should stop activity and rest. One tablet can be taken every 5 minutes, up to three doses. Nitroglycerin should be replaced every 3 to 6 months, not every 12 months. Nitroglycerin should provide relief in 5 minutes, not 30 minutes.

A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an increase in blood pressure and temperature and demonstrates muscular rigidity. Which action should the nurse initiate? A. Place the client on seizure precautions and monitor frequently. B. Take the client's vital signs and notify the health care provider immediately. C. Describe the symptoms to the charge nurse and document them in the client's record. D. No action is required at this time because these are known side effects of the medications.

Take the client's vital signs and notify the health care provider immediately. This is an emergency situation, and the client requires immediate management in a critical care setting. These symptoms are descriptive of neuroleptic malignant syndrome (NMS), an extremely serious and life-threatening reaction to neuroleptic drugs. The major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can result in death. Option A is not indicated in this situation. Option C does not consider the seriousness of the situation. Option D is an incorrect statement.

When caring for a client with a tracheostomy, which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Teach the family about signs and symptoms of hypoxia. B. Take the vital signs and obtain an O2 saturation level. C. Evaluate the need for tracheal suctioning. D. Revise the plan of care to include tracheostomy care.

Take the vital signs and obtain an O2 saturation level. The nurse may delegate obtaining vital signs and O2 saturation; however, the nurse is responsible for following up on any reported data. Options A, C, and D are all part of the nursing process and should not be delegated under the nurse's scope of practice.

The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first? A. Inspect the dressing over the puncture site and under the client for bleeding. B. Take the vital signs to determine the client's response for a potential blood loss. C. Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D. Assess the client's pain level to determine the need for analgesic medication.

Take the vital signs to determine the client's response for a potential blood loss. After bone marrow aspiration, pressure is applied at the aspiration site, which is critical for a client with pancytopenia because of a decrease in the platelet count. The client's baseline vital signs should be obtained first to determine changes indicating bleeding caused by the procedure. Although options A, C, and D should be implemented after the procedure, the first action is to obtain a baseline assessment.

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide? A. Lie on your left side and call 911 for emergency assistance. B. Take an antacid and call back if the pain has not subsided. C. Take your blood pressure now, and if it is seriously elevated, go to the hospital. D. See your health care provider to obtain a prescription for a histamine blocking agent.

Take your blood pressure now, and if it is seriously elevated, go to the hospital. Checking the blood pressure for an elevation is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension. Additional data are needed to confirm an emergency situation as described in option A. Options B and D ignore the threat to client safety posed by a significant increase in blood pressure.

The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months

Taking anticoagulants for the past year Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with option C or D is at less of a surgical risk than with option B.

The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B. Sit quietly in the client's room until the client leaves the bathroom. C. Allow the client to cry alone and leave the client in the bathroom. D. Talk to the client and attempt to find out why the client is crying.

Talk to the client and attempt to find out why the client is crying. The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option A is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully. Although option C may be correct, the nurse should determine if the client's safety is compromised and offer assistance, even if it is refused.

A male client with Parkinson disease is prescribed the antiparkinsonian agent amantadine HCl. Which action should the nurse take? A. Encourage foods high in vitamin B6 such as meat or liver. B. Teach client to change positions slowly. C. Instruct client to take at the same time as prescribed beta blocker. D. Notify client that development of a rash is a common side effect.

Teach client to change positions slowly. Amantadine can cause postural hypotension, so sudden position changes should be avoided. Options A and C are contraindicated with this drug, and option D is a sign of a possible allergic reaction, not a common side effect.

A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D. Teach the importance of personal hygiene during menstruation with the client.

Teach the importance of personal hygiene during menstruation with the client. Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first, respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.

Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff? A. Team 1: RN team leader, PN; team 2: PN team leader, UAP B. Team 1: RN team leader, UAP; team 2: PN team leader, PN C. Team 1: PN team leader, PN; team 2: RN team leader, UAP D. Team 1: PN team leader, UAP; team 2: RN team leader, PN

Team 1: RN team leader, PN; team 2: PN team leader, UAP Team 1 includes high-risk clients who require a higher level of assessment and decision making, which should be provided by an RN and PN. Team 2 has stable clients at lower risk than those on team 1. Although two clients on team 2 require frequent care, the care is routine and predictable in nature and can be managed by the PN and UAP. Options B, C, and D do not use the expertise of the nursing staff for the high-risk clients.

A father of a 5-year-old boy calls the nurse to report that his son, who has had an upper respiratory infection, is complaining of a headache, and his temperature has increased to 103° F, taken rectally. Which intervention has the highest priority? A. Determine if the child has any allergies to antibiotics. B. Instruct the parent to give the child tepid baths. C. Instruct the parent to increase the child's fluid intake. D. Tell the parent to take the child to the emergency department.

Tell the parent to take the child to the emergency department. The child is exhibiting symptoms that may indicate possible meningitis, and the parents should be encouraged to get immediate evaluation. Options A, B, and C are all valuable interventions after the client is assessed and diagnosed.

The nurse prepares to administer digoxin, 0.125 mg IV, to an adult client with atrial fibrillation. Which client datum requires the nurse to withhold the medication? A. The apical heart rate is 64 beats/min. B. The serum digoxin level is 1.5 ng/mL. C. The client reports seeing yellow-green halos. D. The potassium level is 4.0 mEq/L.

The client reports seeing yellow-green halos. Reports of yellow-green halos and blurred vision are signs of digoxin toxicity. Options A, B, and C are normal findings.

A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD? A. The client's father was diagnosed with COPD in his 50s. B. A close family member contracted tuberculosis last year. C. The client smokes one to two packs of cigarettes per day. D. The client has been 40 pounds overweight for 15 years.

The client smokes one to two packs of cigarettes per day. Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD. The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation, although exposure to similar predisposing factors (e.g., smoking or inhaling secondhand smoke) may increase the likelihood of COPD incidence among family members. Options B and D do not exceed the risks associated with cigarette smoking in the development of COPD.

When developing a discharge teaching plan for a client after the insertion of a permanent pacemaker, the nurse writes a goal of "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met? A. The client demonstrates the procedures to change the rate of the pacemaker using a magnet. B. The client carries a card in his wallet stating the type and serial number of the pacemaker. C. The client tells the nurse that it is important to report redness and tenderness at the insertion site. D. The client states that changes in the pulse and feelings of dizziness are significant changes.

The client states that changes in the pulse and feelings of dizziness are significant changes. Changes in pulse rate and/or rhythm may indicate pacer failure. Feelings of dizziness may be caused by a decreased heart rate, leading to decreased cardiac output. The rate of a pacemaker is not changed by a client, although the client may be familiar with this procedure as explained by his health care provider. Option B is an important step in preparing the client for discharge but does not demonstrate knowledge of the symptoms of pacer failure. Option C indicates symptoms of possible incisional infection or irritation but does not indicate pacer failure.

Client teaching is an important part of the perinatal nurse's role. Which factor has the greatest influence on successful teaching of the pregnant client? A. The client's investment in what is being taught B. The couple's highest levels of education C. The order in which the information is presented D. The extent to which the pregnancy was planned

The client's investment in what is being taught When teaching any client, readiness to learn is related to how much the client has invested in what is being taught or how important the materials are to the client's particular life. For example, the client with severe morning sickness in the first trimester may not be ready to learn about labor and delivery but is probably very ready to learn about ways to relieve morning sickness. Options B and C are factors that may influence learning but are not as influential as option A. Even if a pregnancy is planned and very desirable, the client must be ready to learn the content presented.

A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide PO and 40 mg of furosemide PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? A. The client is noncompliant with his medications. B. The client recently consumed large quantities of pears or nuts. C. The client's renal function has affected his potassium level. D. The client needs to be started on a potassium supplement.

The client's renal function has affected his potassium level. The client has a normalized potassium level despite diuretic use. The kidney automatically secretes 90% of potassium consumed, but in chronic renal insufficiency (CRI), less potassium is excreted than normal. Therefore, the two potassium-wasting drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is no reason to believe that the client is noncompliant with his treatment. Pears and nuts do not affect the serum potassium level. There is no need for a potassium supplement because the client's potassium level is within the normal range.

Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse? A. The color of the dialysate outflow is opaque yellow. B. The dialysate outflow is greater than the inflow. C. The inflow dialysate feels warm to the touch. D. The inflow dialysate contains potassium chloride

The color of the dialysate outflow is opaque yellow. Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider. Options B and C are desired. Option D is commonly done to prevent hypokalemia.

A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine. Which statement given by the nurse would offer the client accurate information about this vaccine? A. The vaccine is given annually before the flu season to those older than 50 years. B. The immunization is administered once to older adults or those at risk for illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.

The immunization is administered once to older adults or those at risk for illness. It is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in their lifetime. Some recommend receiving the vaccine at 50 years of age. The influenza vaccine is given once a year. Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine. The vaccine is usually given once in a lifetime, but with immunosuppressed clients or clients with a history of pneumonia, revaccination is sometimes required.

The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A. The client will experience increased tolerance to the drug's effects and may need a higher dose. B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C. The medication will be more highly protein-bound, increasing the duration of action. D. The therapeutic index will be increased, placing the client at greater risk for toxicity.

The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. Because the absorptive process is eliminated when medications are administered via the IV route, the onset of action is more rapid, resulting in a more immediate effect. Drug tolerance, protein binding, and the drug's therapeutic index are not affected by the change in route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.

The nurse is obtaining a client's sexual history. Which finding requires additional follow-up regarding the client's self-image? A. Sexual intercourse with the spouse occurs four times a week. B. The spouse has never seen the client naked. C. The client has had surgery for permanent birth control. D. A history of a 20-lb weight loss occurred in the past year.

The spouse has never seen the client naked. It is usual for spouses to see each other without clothing, so a follow-up question about option B should provide additional information about the client's self-concept and body image. Options A and C are choices within the continuum of normal and acceptable sexual needs based on each couple's preferences. Body image is a perception of one's physical self, and weight gain or loss normally affects one's self-image.

The nurse assesses a pressure ulcer on a client's heel and notes full-thickness tissue loss, with some visible subcutaneous fat. How should the nurse stage this pressure ulcer?

The statement above describes a *stage III* ulcer, which is defined as full-thickness tissue loss in which subcutaneous fat may be exposed but without exposure of bone, tendon, or muscle. A stage I ulcer includes intact skin with nonblanchable redness of a localized area. A stage II ulcer is described by partial-thickness loss of dermis, including a shallow open ulcer with a pinkish red wound bed. Full-thickness tissue loss with exposed bone, tendon, or muscle and slough or eschar is indicative of a stage IV ulcer.

A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? A. The respiratory settings on the ventilator B. Only the client's spontaneous respirations C. The ventilator-assisted respirations minus the client's independent breaths D. The ventilator setting for respiratory rate and the client-initiated respirations

The ventilator setting for respiratory rate and the client-initiated respirations The nurse should count the client's respirations and document both the respiratory rate set by the ventilator and the client's independent respiratory rate. Never rely strictly on option A. Although the client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture of the client.

An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl to IM fluphenazine decanoate because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen? A. Long-acting medication is more effective than daily medication. B. A client with substance abuse must not take any oral medications. C. There will continue to be a risk of alcohol and drug interaction. D. Support groups are only helpful for substance abuse treatment.

There will continue to be a risk of alcohol and drug interaction. Alcohol enhances the side effects of fluphenazine HCl. The half-life of fluphenazine HCl PO is 8 hours, whereas the half-life of the fluphenzaine decanoate IM is 2 to 4 weeks. Therefore, the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting fluphenzaine decanoate IM. Options A, B, and D provide incorrect information.

The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A. Two weeks before menstruation B. Immediately after menstruation C. Immediately before menstruation D. Three weeks before menstruation

Two weeks before menstruation Ovulation occurs 14 days before the first day of the menstrual period. Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies. Options B, C, and D are incorrect.

Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall? A. Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC) counts. B. Chemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels. C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. D. Serum electrolytes reveal a decreased sodium level and increased potassium level.

Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying. Laboratory findings in options A, B, and D are not considered to be normal findings in an older adult.

The identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful handwashing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns

Use of careful handwashing technique Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection.

The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct? A. Using one syringe, first insert air into the regular vial and then insert air into the NPH vial. B. Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. C. Avoid combining the two insulins because incompatibility could cause an adverse reaction. D. Administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate stick.

Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH. Air should first be injected into the NPH vial and then air should be inserted into the regular vial. NPH and regular insulin are compatible, and combining will reduce the number of injections. The insulin is ordered subcutaneously and NPH cannot be given IV.

The nurse is assessing a client at 20 weeks' gestation. Which measurement should be compared with the client's current weight to obtain the most accurate data about her weight gain during pregnancy? A. Usual prepregnant weight B. Weight at the first prenatal visit C. Weight during previous pregnancy D. Recommended pattern of weight gain

Usual prepregnant weight Comparing the client's current weight with her prepregnant weight allows for the calculation of weight gain. By the time of the first prenatal visit, she may have already gained weight. Option C may not be relevant to weight gain with the current pregnancy. Option D should be evaluated based on serial weights, not just a single current weight.

When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7 to 10 days. B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white cheesy substance, predominantly located in the skin folds. D. Pseudostrabismus found in newborns is treated by minor surgery.

Vernix is a white cheesy substance, predominantly located in the skin folds. Vernix, found in the folds of the skin, is a characteristic of term infants. Milia are not red marks made by forceps but are white pinpoint spots usually found over the nose and chin that represent blockage of the sebaceous glands. Meconium is the first stool, but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is normal at birth through the third or fourth month and does not require surgery.

The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A. Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B. Apply ice packs to edematous or tender joints to reduce pain and swelling. C. Warm the child with an electric blanket prior to getting the child out of bed. D. Immobilize swollen joints during acute exacerbations until function returns.

Warm the child with an electric blanket prior to getting the child out of bed. Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. Option A on an empty stomach is likely to cause gastric discomfort. Warm (not cold) packs or baths are used to minimize joint inflammation and stiffness. Option D is contraindicated, because joints should be exercised, not immobilized.

The nurse plans to teach blood glucose self-monitoring to a client who is newly diagnosed with diabetes mellitus type 1, and the health care provider has given the client a schedule for testing. In addition to the prescribed schedule, the nurse should also instruct the client to check the blood glucose level in which circumstance? A. Any time the client awakens during the night B. Whenever the client has feelings of dizziness C. Right after meals if insulin is not administered 30 minutes before the meal D. Only at scheduled times; additional testing is harmful to fingertips

Whenever the client has feelings of dizziness Clients should be instructed to always check their blood glucose level whenever they feel faint or dizzy. There is great variability in recommendations for the frequency of blood glucose testing. When first diagnosed, clients are often advised to test before and after meals and at bedtime, and then after meals and at bedtime for a short period. Once they are stable, clients may be advised to test four times a day or as little as once each week, depending on the consistency of their diet and exercise and stability of their blood sugar level. Options A, C, and D provide inaccurate information.

The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home.

While the nurse is taking the client's blood pressure, he has a carpal spasm. A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign.

A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client? A. As women age, they often become rounder in the middle because they do not exercise properly. B. Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur with aging. C. With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. D. Because there is no evidence of a diseased colon, there is no need to worry about abdominal size.

With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation. Option A is not the primary reason for the changes in body structure. Option B is not indicated because loss of muscle tone and constipation are age-related changes. Option D dismisses the client's concerns and does not help her understand the changes that she is experiencing.

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward, underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. Option B describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed. Clients should never be lifted under the axillae; this could damage nerves and strain the nurse's back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse's neck; this places undue stress on the nurse's neck and back and increases the risk for a fall.