Exam 4:Davis book

A child, diagnosed with acute nonlymphoid leukemia is admitted to a hospital with a fever and neutropenia. To avoid the complications associated with neutropenia, which nursing interventions should a nurse include in the child's plan of care? 1. Placing the child in a private room, restricting ill visitors, and using strict handwashing techniques 2. Encouraging a well-balanced diet, including ironrich foods, and helping the child avoid overexertion 3. Offering a moist, bland, soft diet, using toothettes rather than a toothbrush, and providing frequent saline mouthwashes 4. Avoiding rectal temperatures, avoiding injections, and applying direct pressure for 5 to 10 minutes after venipuncture

1

A nurse receives an order to administer a loop diuretic intravenous (IV) push to an adolescent client with hydronephrosis. For which adverse effects should the nurse monitor the client? SELECT ALL THAT APPLY. 1. Ototoxicity 2. Electrolyte abnormalities 3. Orthostatic hypotension 4. Hypertension 5. Hypoglycemia

1,2,3

When a nurse removes a syringe after giving an intravenous (IV) push medication through a heparin lock port on a central line, the lock port adheres to the syringe and is removed from the central line catheter hub. The nurse notes that the clamp on the central line catheter is still open and suspects that air may have entered the central line catheter. Which immediate actions should be taken by the nurse? SELECT ALL THAT APPLY. 1. Notify the health-care provider 2. Close the clamp on the central line catheter 3. Turn the client onto the right side with the feet higher than the head 4. Attach a 10-mL syringe to the catheter, open the clamp, and aspirate until blood returns 5. Flush the line with 0.9% NaCl and then heparin if ordered

1,2,4,5

A client, who has undergone several series of chemotherapy treatments for cancer, tells a nurse that he is thinking about foregoing further treatment. The client states he only underwent the last round of therapy to please his family and oncologist. Which is the most appropriate action for the nurse to take? 1. Use therapeutic communication techniques to speak to the client's family about his wishes 2. Listen carefully to the client and encourage him to express his concerns and feelings 3. Ask the client if he has searched the Internet or library for the newest treatment options 4. Notify the primary care provider and request a referral to hospice care

2

A mother is devastated and crying after telling a nurse that she was just told that the only chance for her child to live is to have a bone marrow transplant and the only compatible donor is her other child. Which is the most appropriate nursing action to meet the mother's needs at this time? 1. Calling a crisis counselor and making an appointment for the mother 2. Listening quietly while the mother talks and cries 3. Questioning the mother about her fears 4. Describing the process for obtaining the bone marrow for transplant

2

77-year-old client is diagnosed with an abdominal aortic aneurysm measuring 3.5 cm, which was discovered on a routine health physical. The client has a 30 pack-year history of cigarette smoking. Which learning need should a nurse identify as most important for the client? 1. Understand the importance and begin the process of smoking cessation 2. Understand and follow a reduced-sodium and low-saturated fat diet. 3. Follow through with medical supervision so the size of the aneurysm can be monitored at regular intervals 4. Verbalize understanding of preoperative and postoperative care following surgical repair of the aneurysm

3

A parish nurse is monitoring blood pressures at a blood pressure-screening clinic. A client, who just finished smoking a cigarette, asks the nurse for a blood pressure check. Which is the nurse's best action? 1. Ask the client to have the blood pressure taken on another day 2. Immediately take the client's blood pressure 3. Ask the client to return in 30 minutes and upon return take the client's blood pressure 4. Ask the client if the client knows that smoking leads to heart disease and cancer

3

A physician orders 10 mEq of potassium chloride (KCL) intravenously (IV) for an adult client whose serum potassium level prior to surgery is 3.3 mEq/L. Which action should be the nurse's first priority? 1. Administering the medication as soon as possible through IV bolus 2.Waiting to start the medication until the client is asleep in surgery 3. Diluting the medication in 100 mL of saline and administer over an hour 4. Applying warm towels to the client's arm to prevent vein irritation during administration

3

When a 4-year-old child arrives on a unit to be admitted for a lymph node biopsy, the child is crying and hugging a teddy bear. Which response by the nurse would be best? 1. "Hello, my name is Chris. Come with me; I am going to show you to your new room." 2. "I see that you are crying. Let's go to the playroom where you can meet other children." 3. "Hi. I know you are feeling scared. I see you brought your special teddy bear. What's your bear's name?" 4. "Can I hold you and your teddy bear, and then take you to the room where you can put teddy to bed?"

3

50. A clinic nurse is assessing a 9-year-old boy whose blood pressure is 112/72 mm Hg. Based on the findings, which nursing action is most appropriate? 1. Begin counseling including a low-sodium diet, weight control, and exercise 2. Refer the child for a workup for hypertension 3. Discuss with the physician the need for antihypertensive therapy 4. Document the child's blood pressure findings only

4

A client, who had a femoral popliteal bypass graft surgery 2 days earlier, requests nicotine patches because he does not want to begin smoking again. The nurse provides the client with positive encouragement for beginning smoking cessation with nicotine replacement therapy (NRT). Which statement should be the basis for the nurse's support? 1. NRT eliminates withdrawal symptoms. 2. NRT delivered intradermally is superior to other forms such as chewing gum. 3. NRT gradually allows the client to decrease the number of cigarettes smoked. 4. NRT increases the long-term success rate of the client remaining smoke free.

4

When a powdered chemotherapy medication spills on a hard surface in a clinical area, which required safety practices should a nurse use to clean the spill? 1.Wear protective gown, gloves, goggles, and head covering and use double-bag clean-up pads with open waste disposal bags 2.Wear protective gown, gloves, face shield, and foot coverings and use single-bag clean-up pads with an open waste disposal bag 3.Wear protective gown, gloves, face shield, and head covering and use single-bag clean-up pads with an open waste disposal bag 4.Wear protective gown, gloves, goggles and a respirator mask and use double-bag clean-up pads with open waste disposal bags

4

A 33-year-old client reports left leg pain, right-sided chest pain, and a sudden onset of shortness of breath. Which action should be taken immediately by the nurse? 1. Take the client's temperature 2. Auscultate the client's the lung sounds 3. Percuss the client's abdomen 4. Request a stat chest x-ray

ANSWER: 2 Auscultation of lung sounds should be one of the first assessments performed by the nurse to determine the cause of the client's shortness of breath. Chest x-ray would be helpful in assessing the cause of shortness of breath but would need a physician's order and would not be the first priority. Percussion of abdomen and measurement of the client's temperature are helpful tools when completing a full assessment but are not priority in this situation. ➧ Test-taking Tip: Think about the ABCs: airway, breathing, circulation. Airway is priority.

A nurse is caring for an older adult client who has experienced unintended weight loss. Which energydense protein foods should the nurse offer to the client when the client requests a snack? 1. Carrot sticks and apple wedges 2. Peanut butter crackers and hard-boiled eggs 3. Whole wheat toast with jelly 4. Yogurt and cottage cheese

ANSWER: 2 Peanut butter and eggs are good sources of complete proteins and are energy and nutrient dense. Fruit and vegetables are not good sources of protein and are generally low in calories per serving. Grain products, such as whole wheat toast, are not good sources of protein and are not energy dense. Yogurt and cottage cheese are not considered energy dense. They are considered good sources of protein. ➧ Test-taking Tip: Select the best sources of complete proteins providing the most calories per serving.

Four parents call a clinic to have their children seen for unusual lumps or swelling. A nurse is trying to work the children into a physician's overbooked schedule. Which child should the nurse schedule to be seen first? 1. A child with Down's syndrome 2. A child who lives close to power lines 3. A child who has had chronic ear infections 4. A child whose sibling was treated for an osteosarcoma 's data.

ANSWER: 1 A correlation exists between some genetic disorders, such as Down's syndrome (trisomy 21), and childhood cancer. In a child with Down's syndrome, the probability of developing leukemia is about 20 times greater than that of other children. Studies have found marginally significant relationships between electromagnetic exposure and developing childhood cancer. Chronic infections do not automatically increase the risk for cancer. Studies suggest that in general there is not a strong constitutional genetic component for childhood cancers other than retinoblastoma. ➧ Test-taking Tip: Consider an option that would show a genetic correlation between cancer and the child

A client is to receive a scheduled dose of digoxin (Lanoxin®). A nurse determines that the client's apical pulse is irregular at 92 beats per minute and that the client's serum potassium level is 3.9 mEq/L. Which documentation by the nurse reflects the most appropriate action based on this information? 1. Serum potassium level within normal limits. Digoxin administered for rapid apical pulse. 2. Digoxin withheld because the client's heart rate is irregular. 3. Digoxin withheld to prevent toxicity due to the low serum potassium level. 4. Physician notified to report the irregular heart rate and low serum potassium level.

ANSWER: 1 Digoxin, a cardiac glycoside, slows and strengthens the heart. It is used for rate control in clients with atrial fibrillation. Atrial fibrillation produces an irregular rhythm. A normal serum potassium level is 3.8 to 5.5 mEq/L. Dysrhythmias can occur if digoxin is administered when the serum potassium level is low; the serum potassium level is within a normal range. Withholding the digoxin and notifying the physician are unnecessary. ➧ Test-taking Tip: Recall that the normal serum potassium level is 3.8 to 5.5 mEq/L. Review the nursing considerations/actions of digoxin if this question seems difficult.

An office nurse is evaluating a 32-weeks-pregnant client. The client presents for her routine visit with an elevated blood pressure of 142/89 mm Hg. Her urine is negative for protein and her weight gain is 2 pounds since her last routine visit at 30 weeks. She has trace pedal edema. Based on this information, the nurse should conclude that the client is most likely experiencing: 1. gestational hypertension. 2. chronic hypertension. 3. preeclampsia. 4. eclampsia.

ANSWER: 1 Gestational hypertension is defined as an elevation of maternal blood pressure with normal urine findings. Chronic hypertension occurs before 20 weeks and is a preexisting condition. Preeclampsia is marked by an elevated blood pressure with proteinuria. Eclampsia is characterized by the addition of nonepileptic seizures that coexist with preeclampsia. ➧ Test-taking Tip: Focus on the woman's symptoms. Review the definition of each of the options

A nurse is teaching a client experiencing hypoparathyroidism resulting from a lack of parathyroid hormone (PTH) about foods to consume. Which should be included on a list of appropriate foods for a client experiencing hypoparathyroidism? 1. Dark green vegetables, soybeans, and tofu 2. Spinach, strawberries, and yogurt 3. Whole grain bread, milk, and liver 4. Rhubarb, yellow vegetables, and fish

ANSWER: 1 Hypoparathyroidism from lack of PTH produces chronic hypocalcemia. Foods consumed should be high in calcium. Foods containing oxalic acid (spinach, rhubarb), and phytic acid (whole grains) reduce calcium absorption. ➧ Test-taking Tip: Recall that hypoparathyroidism produces hypocalcemia.

A 72-year-old client with a deep vein thrombosis in the left leg and a history of a brain tumor is hospitalized for 3 days. The client's care plan indicates a nursing diagnosis of Imbalanced nutrition: less than body requirements related to poor appetite and decreased oral intake. Which assessment finding would best indicate a need to revise the care plan related to the nursing diagnosis? 1. Oral mucous membranes are dry due to dehydration. 2. Daily intake and output reveals that daily caloric intake is inadequate. 3. Client is not receptive to education regarding nutrition. 4. Client states that he/she is not hungry.

ANSWER: 1 If the client has an impaired oral mucous membrane, it may be uncomfortable to chew and swallow food, therefore exacerbating the underlying condition. To help the client achieve the goal of balanced nutrition, addressing the problem on the care plan will alert caregivers to the issue and facilitate appropriate interventions. Although the other three answers may also support the client's nutrition needs, revising the care plan to address the impaired oral mucous membrane is the best action to take related to the diagnosis. ➧ Test-taking Tip:The key words are "best indicate." Select an option that would exacerbate the nursing diagnosis

Which instruction should a nurse include when teaching parents who have a child diagnosed with hypoparathyroidism? 1. Monitor for muscle spasms, tingling around the mouth, and muscle cramps. 2. Monitor for side effects of excess medication therapy, including dry, scaly, coarse skin. 3. Decrease intake of foods high in calcium and phosphorus. 4. Increase environmental stimuli and encourage participation in high-energy activities.

ANSWER: 1 In hypoparathyroidism, insufficient amounts of parathyroid hormone is produced and this affects serum calcium regulation. Muscle spasms, tingling around the mouth, and muscle cramps are signs of hypocalcemia which could indicate that treatment with vitamin D and calcium is ineffective. Dry, scaly, and coarse skin are signs of hypoparathyroidism, not medication overdose. Calcium-rich foods, such as dark green vegetables, soybeans, and tofu, should be encouraged (not decreased in amounts). Foods high in oxalic acid (e.g., spinach and rhubarb) and phytic acid (e.g., bran and whole grains) should be avoided because these reduce calcium absorption. Phosphorus-rich foods (dairy products) are also high in calcium and are usually not restricted unless serum phosphorus levels are exceptionally high. During crisis episodes the environmental stimuli needs to be decreased (not increased) and the child kept quiet. ➧ Test-taking Tip: Focus on looking for key words in the options that are opposite of the expected findings and treatment for hypoparathyroidism and eliminate the options.

A client, diagnosed with chronic, stable angina, telephones a clinic nurse. The client reports a headache lasting for several days after taking one dose of isosorbide mononitrate (Imdur®). The client also reports symptoms of orthostatic hypotension and palpitations. Which is the nurse's best action? 1. Recommend that the client make an appointment with the health-care provider 2. Have the client retime the dose to take it later in the day when the client is more active 3. Instruct the client to take two acetaminophen 325-mg tablets when taking the Imdur® dose 4. Teach the client that the headaches will subside over time with continued medication use

ANSWER: 1 Isosorbide mononitrate is a long-acting coronary vasodilator. Severe headaches, orthostatic hypotension, and palpitations may be a sign of isosorbide mononitrate toxicity, thus the client should be evaluated by a health-care provider. Other signs include syncope, dizziness, blurred vision, and light-headedness. Isosorbide mononitrate should be taken in the morning to improve blood flow to the heart and prevent angina attacks that can occur due to the increased oxygen demand from activity. A headache (but not a severe headache) can be treated with or prevented by analgesics taken either before or at the same time as the isosorbide mononitrate. Although the headaches will subside over time, the client is experiencing symptoms of isosorbide mononitrate toxicity. ➧ Test-taking Tip:The key words are the client's symptoms of "severe headache, orthostatic hypotension, and palpitations" and "best action." Think about the toxic effects of isosorbide mononitrate. Select option 1 because this is the only option that evaluates the cause of the client's symptoms. Options 3 and 4 are similar. When two options are similar in a multiple choice question, either one or both of the options are incorrect.

nurse cares for a client receiving combination chemotherapy of oxaliplatin (Eloxatin®), fluorouracil (5-FU), and leucovorin (Wellcovorin®). For which common side effects of this chemotherapy should the nurse assess the client? 1. Neurotoxicities and diarrhea 2. Cardiomyopathy and dysphagia 3. Renal insufficiency and gastritis 4. Photophobia and stomatitis

ANSWER: 1 Neurotoxicity and diarrhea occur frequently in clients receiving this medication regimen. Cardiomyopathy, dysphagia, renal insufficiency, gastritis, photophobia, and stomatitis are not common side effects of these chemotherapy agents. ➧ Test-taking Tip: Focus on the key words "common side effects" and use the process of elimination to rule out incorrect options. Concentrate on the medication's effect on the body.

A nurse obtains the following assessment data for a client diagnosed with acute myeloid leukemia. For which finding should a nurse plan interventions first? 1. Pain from mucositis 2.Weakness and fatigue 3. T 99°, P100, R 20, and BP 132/64 mm Hg 4. Ecchymosis and petechiae noted on arms ty.

ANSWER: 1 Pain control is priority. The altered vital signs (other than temperature) could be related to pain. Weakness and fatigue are due to anemia and also the disease process. The temperature warrants further monitoring because it could indicate a developing infection. Ecchymosis and petechiae are associated with low platelets counts. The nurse should check the laboratory report for the platelet level. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) to determine priority. In the absence of life-threatening findings, pain control should be priori

Which intervention should a nurse plan to incorporate in the care of a surgical client to decrease the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE)? 1. Use of intermittent compression devices on the lower extremities 2. Administration of heparin intravenously 3. Coughing and deep breathing exercises 4. Isometric leg exercises

ANSWER: 1 Recommendations to prevent DVT and PE address the need to improve circulation and counter any states of hypercoagulopathy. Intermittent compression devices improve circulation. While administration of heparin will achieve anticoagulation, a low dose of unfractionated or low-molecular-weight heparin is usually ordered subcutaneous, and not intravenous, administration. Coughing and deep breathing exercises and isometric leg exercises are positive actions but do not decrease the risk for DVT and PE. ➧ Test-taking Tip: Focus on actions to decrease the risk for deep venous thrombosis and pulmonary embolism. Evaluate each option to determine its effect on improving circulation and reducing hypercoagulation.

nurse is educating the parents of a school-aged child newly diagnosed with hyperthyroidism. Until the disease is under control, which instruction should be included in the education provided by the nurse? 1. Discontinue physical education classes at school. 2. Increase stimulation in the school environment. 3. Restrict the number of calories from carbohydrate foods. 4. Dress your child in cold weather clothing even in warm weather.

ANSWER: 1 The child should avoid any vigorous activity and unnecessary external stimulation and should wear clothing that is comfortable. The child may experience heat intolerance and should be provided with warm weather clothing, even in winter. The child's appetite may increase, but the child will continue to lose weight until the problem is controlled. ➧ Test-taking Tip: Knowledge of hyperthyroidism is needed to respond to this question. Note that options 1 and 2 are somewhat opposite; option 1 decreases stimulation and option 2 increases stimulation. Either one or both are incorrect

A female client is to receive chemotherapy and radiation for Hodgkin's lymphoma with cervical and axillary node involvement. A nurse evaluates that the client is coping positively when the client states: 1. "I selected a wig that matches my hair color, but I will miss my own hair." 2. "I am so glad that the chemotherapy and radiation treatments won't cause me to lose my hair." 3. "The chemotherapy-drug combination will prevent mucositis and immunosuppression." 4. "I have faith that my doctor will be able to cure me and I won't have any long-term effects."

ANSWER: 1 The client is expressing her feelings about her hair loss, but she has acted positively related to her feelings and selected a wig. Responses in options 2, 3, and 4 reflect either that the client is in denial or is uninformed regarding the effects of the chemotherapy and radiation treatments. Because chemotherapy and radiation will involve the cervical lymph nodes, side effects will include alopecia, mucositis, and immunosuppression. The risk for other cancers is increased after chemotherapy and radiation for Hodgkin's lymphoma so long-term surveillance is crucial. ➧ Test-taking Tip: Note the key words "coping positively." Select the option that demonstrates either cognitive or behavioral effort to adapt to the stressful situation.

An infant diagnosed with hypothyroidism is prescribed levothyroxine sodium (Synthroid®). Which independent nursing intervention would assist the nurse in evaluating the effectiveness of this medication? 1. Monthly assessments of growth and development 2. Monthly serum calcium and thyroxin levels 3. Bimonthly catecholamine levels and electrocardiogram (ECG) 4. Absence of thyroid excess e.

ANSWER: 1 The nurse should independently monitor the medication's effectiveness by assessing for normal growth and development. If the medication is effective, the child will grow and develop at a normal rate for age. Serum calcium, thyroxin, catecholamines, and ECG require medical prescription. Assessing the absence of thyroid excess is too vague. ➧ Test-taking Tip: Note the key word "independent" and use the process of elimination to eliminate options 2 and 3. Eliminate any options that are vagu

A sexually active female adolescent has been diagnosed with hyperlipidemia. After several months of lifestyle changes, the levels have not significantly decreased, and a statin medication is prescribed. A nurse is educating the client about this class of medications. Which instruction should be included in the nurse's teaching plan for this client? 1. Discontinue therapy and contact the prescriber if having new-onset muscle aches or dark urine. 2. Continue therapy even if she becomes pregnant. 3. Take the medication in the morning because it would be most effective. 4. Discontinue lifestyle modifications because these are ineffective in treating the condition.

ANSWER: 1 The nurse should instruct the client to discontinue therapy and contact the prescriber if having muscle aches or dark urine. Muscle aches and dark urine could be a sign of a dangerous side effect of statins, rhabdomyolysis, which is the rapid breakdown of skeletal muscle tissue due to the chemical effects of the medication. The drug should be discontinued immediately and the prescriber notified. The drug should be discontinued if the client becomes pregnant because the drug is teratogenic. Oral contraceptive therapy should be initiated in conjunction with a statin in clients who are at risk for becoming pregnant. Statins are most effective if taken in the evening. The client should proceed with lifestyle modifications as these are to be used in conjunction with statin therapy in order to receive the greatest benefit of therapy. ➧ Test-taking Tip: Apply knowledge of the statin classification of antilipidemic medications to select the correct options.

A client who is receiving doxorubicin (Adriamycin®) for the first time to treat multiple myeloma develops flushing, facial swelling, headache, chills, and back pain. Which statement made by the nurse is best? 1. "These symptoms are uncomfortable for you, and I can give more medication for symptom control; these usually resolve in 1 day and are limited to the first dose." 2. "These symptoms are concerning. You may want to consider terminating treatment because these are signs of unacceptable toxicity." 3. "Next time you can receive premedication with ondansetron (Zofran®), an antiemetic to prevent these symptoms." 4. "Side effects will occur with chemotherapy. Focus on the goal of curing your cancer, and then the side effects will be more tolerable."

ANSWER: 1 This response demonstrates both compassion and competence, two aspects of caring. The nurse acknowledges the symptoms, offers treatment, and informs the client correctly that the symptoms are limited to the first dose. Responses in options 2, 3, and 4 do not demonstrate compassion and competence. The nurse is providing unsolicited advice, "consider terminating treatment," in option 2. Option 3 suggests that the nurse did not premedicate with the first dose of chemotherapy. Option 4 is belittling the client's symptoms. There is no cure for multiple myeloma. Treatment will control the illness and maintain the client's level of functioning for several years or more. ➧ Test-taking Tip: Note the key word "best." Consider the option that demonstrates caring.

health-care provider (HCP) adds a second medication for blood pressure control for a client whose blood pressure has not been well-controlled with one antihypertensive medication. If the HCP orders the following medication combinations, which combination should the nurse question? 1. Atenolol (Tenormin®) and metoprolol (Lopressor®) 2. Metolazone (Zaroxolyn®) and valsartan (Diovan®) 3. Captopril (Capoten®) and furosemide (Lasix®) 4. Bumetanide (Bumex®) and diltiazem (Cardizem®) .

ANSWER: 1 When two medications are used to treat hypertension, each medication should be from different drug classifications. Atenolol and metroprolol are both beta-adrenergic blockers and would essentially have the same mechanism of action. Metolazone is a thiazide-like diuretic, and valsartan is an angiotensin II receptor blocker (ARB). Captopril is an angiotensinconverting enzyme (ACE) inhibitor, and furosemide is a loop diuretic. Bumetanide is a loop diuretic, and diltiazem is a calcium channel blocker. ➧ Test-taking Tip: Recall that beta blockers end in "lol." Use this as a cue to identify the two medications that are within the same drug classification and would be inappropriately prescribed

A client with an abdominal aortic aneurysm is having a high resolution computed tomography (CT) scan to determine the feasibility for an endovascular repair. Which collaborative interventions should a nurse anticipate to decrease the client's likelihood of developing nephrotoxicity? SELECT ALL THAT APPLY. 1. Administration of sodium bicarbonate 1 hour before injection of the intravenous (IV) contrast dye 2. Administration of 0.9% NaCl at 100 mL per hour before and after the CT scan 3. Administration of acetylcysteine (Mucomyst®) orally before and after the study 4. Monitoring aPTT level before and after the CT scan 5. Placing the client on a low potassium diet

ANSWER: 1, 2, 3 The contrast dye used in a high resolution presents a risk to the client's renal function. Intravenous fluids are administered to maintain hydration and enhance excretion of the dye. Sodium bicarbonate is administered 1 hour before and 6 hours after the IV contrast dye. Acetylcysteine is administered orally the day before and the day of the CT scan to prevent acute renal failure. Both sodium bicarbonate and acetylcysteine are free-radical scavengers that sequester the contract by-products that are destructive to renal cells. The aPTT (activated thromboplastin time) is a measure of blood coagulation and is not related to nephrotoxicity. A low potassium diet may be ordered for a client with renal failure but is not a preventive measure. ➧ Test-taking Tip: Key words in the stem are "high resolution CT scan" and "decrease nephrotoxicity." Consider that high resolution CT involves the injection of a contrast media. Select options that will either enhance excretion or sequester the by-products of the contrast media. Eliminate options 4 and 5, which are irrelevant.

A child with Hodgkin's disease is treated with irradiation to the cervical area. The child's parent is concerned because the child lacks energy and is experiencing malaise. Based on this information, the nurse should further assess the child for: SELECT ALL THAT APPLY. 1. hypothyroidism. 2. anemia. 3. impaired nutrition. 4. difficulty swallowing. 5. difficulty voiding.

ANSWER: 1, 2, 3, 4 Irradiation to the cervical area could result in damage to the thyroid gland and cause hypothyroidism. Malaise and lack of energy can also be signs of anemia from decreased red blood cell production. Nutrition can be impaired with hypothyroidism, depression, or the effects of the radiation, which could influence the child's energy level. Though radiation results in few side effects, the inflammation from a mild skin reaction can cause difficulty swallowing. The cervical area is in the neck and is not associated with the renal system. ➧ Test-taking Tip: Visualize the area that is being treated with radiation before reading each of the options.

nurse is caring for a pediatric client recently diagnosed with hypertension. Which diagnostic tests should the nurse anticipate being ordered for this client? SELECT ALL THAT APPLY. 1. Complete blood count (CBC) 2. Serum chemistry 3. Renal ultrasound 4. Drug screen 5. Glucose tolerance test (GTT)

ANSWER: 1, 2, 3, 4 The nurse should anticipate that a CBC, serum chemistry, renal ultrasound, and drug screen may be ordered for this client. A CBC would be important to rule out anemia and a serum chemistry to evaluate for altered blood urea nitrogen, creatinine, and electrolytes, which could be consistent with chronic renal disease secondary to hypertension. A renal ultrasound may help identify a renal scar, congenital anomaly, or disparate renal size. Drug screening is important to identify substances associated with hypertension. If a metabolic condition such as diabetes mellitus is suspected as a causative factor, a fasting serum glucose level should be drawn and, based on the test results, the need for a GTT should be determined. ➧ Test-taking Tip: Use the process of elimination, ruling out th

A nurse is completing a health history and an assessment for a male adolescent client tentatively diagnosed with Hodgkin's lymphoma. Which findings should the nurse conclude support this diagnosis? SELECT ALL THAT APPLY. 1. Firm, nontender lymph node enlargement in the axillary area 2. Drenching night sweats 3. Unexplained fever with temperatures above 100.4°F (38°C) for 3 consecutive days 4. Unexplained weight loss of 10% or more in the previous 6 months 5. A diet consisting mostly of seafood and saturated fats 6. A brother who was also diagnosed with Hodgkin's disease when an adolescent

ANSWER: 1, 2, 3, 4, 6 Hodgkin's disease is characterized by painless enlarged lymph nodes most commonly in the cervical area and less frequently in the axillary and inguinal areas. Drenching night sweats, unexplained fever with temperatures above 100.4°F (38°C) for 3 consecutive days, and unexplained weight loss of 10% or more in the previous 6 months are three symptoms that are recognized by the Ann Arbor Staging System as having prognostic significance in Hodgkin's disease. There is a genetic predisposition with an increased incidence among same-sex siblings. There is no conclusive association between dietary habits and the development of Hodgkin's disease. ➧ Test-taking Tip: If uncertain, select options that suggest an illness. Apply knowledge that the malignancy begins in the lymphoid system.

A nurse is preparing a client for a thoracic aneurysm repair. Which assessment findings lead the nurse to suspect that a rupture has occurred? SELECT ALL THAT APPLY. 1. Severe chest pain radiating to the back 2. Abdominal distention 3. Hypotension 4. Dyspnea 5. Oliguria

ANSWER: 1, 3, 4, 5 A thoracic aneurysm that ruptures will cause pain in the thoracic area. Blood loss will lead to low blood pressure and scant urinary output. The pressure from the hemorrhage will interfere with the client's breathing. A thoracic aneurysm does not cause abdominal distention because the bleeding is in the thoracic area. ➧ Test-taking Tip: The focus of the question is signs and symptoms of a ruptured thoracic aneurysm. Think about each option and its relationship to bleeding into the thoracic cavity and loss of blood volume.

new nurse is managing the care of a pediatric client preparing for a cardiac catheterization under the supervision of an experienced nurse. Which factor identified by the new nurse demonstrates an understanding of the information that can be collected during cardiac catheterization? SELECT ALL THAT APPLY 1. Oxygen saturation of blood within the chambers and great vessels 2. Pressure of blood flow within the heart chambers 3. Cardiac output (CO) 4. Anatomic abnormalities 5. Ankle brachial index (ABI) 6. Ejection fraction

ANSWER: 1, 2, 3, 4, 6 In cardiac catheterization, a small radiopaque catheter is passed through the major vein in the arm, leg, or neck into the heart. Blood specimens can be obtained to determine oxygen saturation levels, and contrast dye can be injected for angiography and to assess for anatomic abnormalities such as septal defects or obstruction of flow. Pressure of blood flow in the heart chambers, CO, stroke volume, and ejection fraction can be evaluated during the procedure. ABI is a ratio of the ankle systolic pressure to the arm systolic pressure and an objective measurement of arterial disease that quantifies the degree of stenosis. It is not related to a cardiac catheterization procedure. ➧ Test-taking Tip: Apply knowledge of a cardiac catheterization procedure to answer this question. Eliminate the one option that is unrelated to a cardiac catheterization.

A clinic nurse is teaching a client who has been diagnosed with hypothyroidism. Which instructions should the nurse provide regarding the use of levothyroxine sodium (Synthroid®)? SELECT ALL THAT APPLY. 1. Take the medication 1 hour before or 2 hours after breakfast. 2. Obtain a pulse rate before taking the medication, and call the clinic if the pulse rate is greater than 100 beats per minute. 3. Report adverse effects of the medication, including weight gain, cold intolerance, and alopecia. 4. Use levothyroxine sodium (Synthroid®) as a replacement hormone for diminished or absent thyroid function. 5. Have frequent laboratory monitoring to be sure your levels of T3 and T4 decrease.

ANSWER: 1, 2, 4 Taking the medication on an empty stomach promotes regular absorption. It should be taken in the morning to mimic normal hormone release and prevent insomnia. During initial dosage adjustment, tachycardia could indicate a dose that is too high. The replacement hormone is used in primary or secondary atrophy of the gland, after thyroidectomy, after excessive thyroid radiation, after the administration of antithyroid medications, or in congenital thyroid defects. Weight gain and cold intolerance could indicate that the dose is too low. Alopecia may indicate that the dose is too high. T3 and T4 should rise with treatment. ➧ Test-taking Tip: Read each option carefully before selecting the correct options.

A child is neutropenic due to chemotherapy treatments. Which instructions should a nurse include when preparing the parents to take the child home? SELECT ALL THAT APPLY. 1. Prohibit visitors who have been recently vaccinated. 2. Keep the child's immediate surroundings free of plants and flowers. 3. Provide items such as goldfish, television, sanitized toys, or books for your child's playtime. 4. Arrange for the child to sleep alone, preferably in his or her own room. 5. Be sure the child bathes or showers daily. 6. Take your child's temperature, respiratory rate, and pulse four times daily.

ANSWER: 1, 2, 4, 5 If exposed to a recently vaccinated person, especially those vaccinated with a live virus, the child would be unable to mount an immune response and could develop an infection. Plants and flowers could harbor mold spores. Sleeping alone prevents exposure to those who may be developing an illness. Bathing or showering removes bacteria from the skin. Goldfish in the home should be placed in an area that is off limits to the child because they harbor mold spores. Temperature, respiratory rate, and pulse should be done daily; four times a day is unnecessary. ➧ Test-taking Tip: Recall that neutropenia is a reduction of circulating neutrophils, the most common type of granular white blood cell (WBC). With a reduction in WBCs, there is an increased risk of infection. Select options that will reduce the child's risk of infection.

A client with symptoms of intermittent claudication receives treatment with a peripheral percutaneous transluminal angioplasty procedure with placement of an endovascular stent. During a follow- up home visit, a nurse determines that the client is making lifestyle changes to decrease the likelihood of re-stenosis and arterial occlusion. Which observations of the client's actions support this conclusion? SELECT ALL THAT APPLY. 1. States participating in an exercise program 2. Abstaining from nicotine 3.Wearing support hose 4. States receiving foot care from a podiatrist 5. Following a low saturated fat diet 6. Taking the medication rosuvastatin calcium (Crestor®)

ANSWER: 1, 2, 5, 6 Reducing client risk factors in order to slow the arteriosclerotic process may delay progression of the disease. Exercising promotes collateral circulation. Smoking cessation, following a low saturated fat diet, and taking medications to lower cholesterol also deter the arteriosclerotic process. There is evidence that more than 30% of clients having procedures to improve claudication seek further intervention within a year. Wearing support hose may impede circulation. Receiving professional foot care is a positive factor but does not prevent the progressive nature of peripheral arterial disease. ➧ Test-taking Tip: The issue of the question is "factors to prevent re-occlusion after a peripheral percutaneous transluminal angioplasty with stent procedure." Use the process of elimination, eliminating options 3 and 4 because these do not reduce the client's risk for developing atherosclerosis.

registered nurse (RN) is acting as preceptor for a new graduate nurse during the new nurse's second week of orientation. Which clients should a charge nurse assign to the graduate nurse under the supervision of the experienced RN? SELECT ALL THAT APPLY. 1. A 16-year-old client with moderate chronic asthma to be discharged in 24 hours 2. A 5-year-old with a tracheostomy needing trach care every shift 3. A 12-year-old client who had surgery for a ruptured appendix with a temperature of 99°F (37.2°C) 4. An 8-year-old just admitted with a new diagnosis of leukemia 5. A 4-year-old diagnosed with hemophilia and admitted for a blood transfusion

ANSWER: 1, 3 Because the new nurse is at an early point in orientation, the new nurse should be assigned to clients who are stable and have routine care needs. The new nurse may also be assigned to the older children. While tracheostomy care may be a routine skill, a more experienced nurse should perform this care due to the age of the child. The child with a new diagnosis of leukemia should have an experienced nurse because the parents will likely have multiple questions and a comprehensive admission assessment will be required. A blood transfusion has a high potential for error and should be performed by an experienced nurse. ➧ Test-taking Tip: Consider the ages of the children in addition to the diagnoses when making assignments.

nurse teaches individuals at a seminar that essential hypertension, if untreated, predisposes a client to: SELECT ALL THAT APPLY. 1. stroke. 2. cirrhosis. 3. renal failure. 4. myocardial infarction. 5. peripheral arterial disease.

ANSWER: 1, 3, 4, 5 Sustained blood pressure elevation damages blood vessels, causing hyperplasia of arterioles. The end result is damage to the involved body organs: stroke (brain), renal failure (kidney), myocardial infarction (heart), and the peripheral arterial system. Cirrhosis is extensive scarring of the liver caused by irreversible reaction to liver inflammation and necrosis. Common causes include alcoholic liver disease and hepatitis B and C. ➧ Test-taking Tip: Focus on selecting the conditions that can occur from impaired blood supply.

15-year-old adolescent is scheduled to have total body irradiation in preparation for a bone marrow transplant. A nurse has completed teaching about care following irradiation. Which statements by the adolescent indicate correct understanding of the information? SELECT ALL THAT APPLY. 1. "I should report if I have any bleeding, such as after brushing my teeth, because my platelets will be low." 2. "I will work hard to improve my health by eating plenty of raw fruits and vegetables." 3. "To relieve the dry mouth, I can suck on lozenges or popsicles or drink cold liquids." 4. "I will need to take an antiemetic around the clock to help prevent nausea and vomiting." 5. "Once the irradiation is completed, I will no longer need to be in protective isolation." 6. "My friends know that I can't have live plants or flowers so they wanted to know if silk flowers are okay."

ANSWER: 1, 3, 4, 6 Irradiation results in bone marrow suppression and pancytopenia. Bleeding precautions are necessary. Xerostomia (dry mouth) is a side effect that can be combated by lozenges, liquids, or oral hygiene. Antiemetics are given around the clock to control nausea. Plants, flowers, and goldfish can harbor mold spores and are contraindicated. Visitors should check before bringing items from home. Raw fruits and vegetables should be avoided because these increase the risk of infection. Foods must be fully cooked. Protective isolation continues until after the bone marrow transplant. ➧ Test-taking Tip: Correct understanding is a true response item. Select only the options that would be true statements.

A nurse is planning care for a client admitted with a new diagnosis of persistent atrial fibrillation with rapid ventricular response. Although the client has had no previous cardiac problems, the client has been in atrial fibrillation for more than 2 days. The nurse should anticipate that the health-care provider is likely to initially order: SELECT ALL THAT APPLY. 1. oxygen. 2. immediate cardioversion. 3. administration of amiodarone (Cordarone®). 4. initiation of a IV heparin infusion. 5. immediate catheter-directed ablation of the AV node. 6. administration of a calcium channel antagonist such as diltiazem (Cardizem®).

ANSWER: 1, 3, 4, 6 The ineffective atrial contractions or loss of atrial kick with atrial fibrillation can decrease cardiac output. Administering oxygen enhances tissue oxygenation. Amiodarone is used for pharmacological cardioversion of the atrial fibrillation rhythm. The client is at risk for thrombi in the atria from stasis. Anticoagulant therapy is used to prevent thromboembolism. Diltiazem, a calcium channel antagonist, is prescribed to slow the ventricular response to atrial fibrillation. An alternative to a calcium channel antagonist would be the use of a beta blocker, such as esmolol, metoprolol, or propranolol. Cardioversion would only be considered if medications were ineffective in converting the client's rhythm and only after the presence of an atrial clot has been ruled out. Ablation of the AV node would only be considered if medications were ineffective in controlling the client's heart rate. ➧ Test-taking Tip: Carefully read the information provided in the stem. The key phrase is "initially order." The nurse should direct interventions at the client's potential complications from the arrhythmia. Note that both options 2 and 5 contain the words "immediate." Eliminate one or both of those options, because both procedures cannot be immediate.

A child is admitted in thyrotoxic crisis. Which manifestations should a nurse expect to observe during assessment? SELECT ALL THAT APPLY. 1. Delirium 2. Hypothermia 3. Bradycardia 4. Nausea 5. Vomiting

ANSWER: 1, 4, 5 Thyrotoxic crisis, or thyroid storm, is a medical emergency resulting from highly elevated circulating levels of thyroid hormone. Additional manifestations of thyrotoxic crisis are hyperpyrexia, tachycardia, hypertension, mental status changes, and multisystem organ failure. ➧ Test-taking Tip: Note the similarities in options 2 and 3; both are low (low temperature, low heart rate). Thyrotoxic crisis is extreme hyperthyroidism. Think about the effect of hyperthyroidism on the body and eliminate these options.

A client on a telemetry unit has a blood pressure (BP) of 88/40 mm Hg, a heart rate of 44 beats per minute, feels faint, and is pale and confused. When caring for this client, which tasks should a registered nurse (RN) delegate to a patient care assistant (PCA)? SELECT ALL THAT APPLY 1. Paging for the charge nurse 2. Paging for a respiratory therapist 3. Applying oxygen per protocol 4. Securing an automatic BP machine 5. Completing a head-to-toe assessment 6. Obtaining a cardiac rhythm strip that the nurse has sent for printing at a central location

ANSWER: 1, 4, 6 Because the client's condition is deteriorating, additional assistance is needed. The PCA should be able to page for the charge nurse, secure an automatic BP machine, and obtain a printed rhythm strip. There is no indication of respiratory distress, so it is unnecessary to page for a respiratory therapist. The RN should apply the oxygen and complete a focused assessment, not a complete head-to-toe assessment. ➧ Test-taking Tip: Focus on the client's symptoms to eliminate options that do not pertain, such as paging a respiratory therapist. RN-only responsibilities, including assessment and evaluation of information, should not be delegated to the PCA.

A nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which actions, to reduce radiation skin reactions, should the nurse explain to the client? SELECT ALL THAT APPLY. 1.Wear loose-fitting, soft clothing over the treated skin. 2. Use a straightedged razor to shave the hair in the treated area. 3. Swim only in swimming pools to avoid stagnant water. 4. Use only skin-care products suggested by the radiation staff. 5. Apply skin products immediately before radiation treatment. 6.Wash treated area gently with lukewarm water and mild soap. ated.

ANSWER: 1, 4, 6 Wearing loose-fitting, soft clothing over the treated skin, using only skin-care products suggested by the radiation staff, and washing the treated area gently with lukewarm water and mild soap are recommended skin-care activities to reduce radiation skin reactions. The use of electric razors for shaving a treated area is recommended. Clients are advised to avoid swimming in chlorinated water and to delay the application of skin-care products within 4 hours of radiation treatment. ➧ Test-taking Tip: Focus on the "effects of radiation" and concentrate on the relationship between each of the options and protection of the skin. Options 2, 3, and 5 have negative effects on the skin and can be elimin

Leukemic cells have invaded a 16-year-old male's testes and irradiation of the testes is planned. The client asks a nurse if this means he will be sterile. The nurse's best response to the client is based on knowing that: SELECT ALL THAT APPLY. 1. the irradiation to the testes will lead to sterilization. 2. the irradiation of the testes will decrease sperm production but not cause sterilization. 3. this is a question that only the oncologist and radiologist would be able to answer. 4. a lead shield will be used to protect the pelvic area and preserve reproductive organs. 5. if the male is past puberty and is forming sperm, sperm banking may be an option before treatment.

ANSWER: 1, 5 Because irradiation of the testes leads to sterilization, sperm banking might be suggested before chemotherapy and radiation to preserve sperm for reproduction later in life. No sperm will be produced after irradiation of the testes. A nurse would be expected to answer the client's question and not defer the question. Deferring could cause distrust between the client and nurse or lead the client to suspect that there is more that is not being told to him. The testes are reproductive organs of the male. ➧ Test-taking Tip: Narrow the options by using the process of elimination, eliminating either option 1 or option 2. Visualize the area to be irradiated and think about the function of the male testes.

In discussing bad news with a client about a diagnosis of cancer, which actions are most appropriate for a nurse to use at this time of emotional impact? SELECT ALL THAT APPLY. 1. Advocate expression of feelings. 2. Avoid using the word cancer. 3. Give the client as much information as possible. 4. Maintain a professional detachment. 5. Promote a broad time frame by avoiding a definite time scale. 6. Provide for privacy and adequate time with family present. circumstances.

ANSWER: 1, 5, 6 The current literature recommends advocating an expression of feelings, promoting a broad time frame, and providing privacy and adequate time with family present. The literature supports using the word cancer but advocates giving the client only as much information that he or she wants. Using a manner of professional detachment can offend the recipients of bad news. Using a gentle manner with a sense of reassurance is encouraged. ➧ Test-taking Tip: Focus on the phrase "discussing bad news." Options 2, 3, and 4 can be eliminated because they are not appropriate behaviors under the

A nurse is evaluating the blood pressure (BP) results for multiple clients with cardiac problems on a telemetry unit. Which BP reading suggests to the nurse that the client's mean arterial pressure (MAP) is abnormal and warrants notifying the physician? 1. 94/60 mm Hg 2. 98/36 mm Hg 3. 110/50 mm Hg 4. 140/78 mm Hg

ANSWER: 2 A MAP of less than 60 mm Hg indicates that there is inadequate perfusion to organs. The mean arterial pressure is calculated by the sum of the SBP + 2DBP and then divided by 3 [MAP = (SBP + 2DBP)/3]. Thus the MAP of 98/36 mm Hg is (98 + 72)/3 = 170/3 = 56.7. The mean arterial pressure of 94/60 is 71.3. The mean arterial pressure of 110/50 is 70. The mean arterial pressure of 140/78 is 98.7. ➧ Test-taking Tip: Focus on the issue of the question, a BP reading with a MAP of less than 60. Though a BP of 94/60 mm Hg and 140/78 mm Hg may warrant notifying the physician, the question is asking for a BP with an abnormal MAP (less than 70). Normal MAP is 70 to 100.

1012. A client is discovered to have a popliteal aneurysm. Because of the aneurysm, a nurse should closely monitor the client for: 1. thoracic outlet syndrome. 2. ischemia in the lower limb. 3. pulmonary embolism. 4. Raynaud's phenomenon. 2.

ANSWER: 2 A popliteal aneurysm (located in the space behind the knee) may cause ischemia in the leg distal to the aneurysm due to thrombus forming inside the aneurysm and potential emboli. Thoracic outlet syndrome is compression of the subclavian artery due to anatomic structures leading to pain and ischemia in the arm. Pulmonary embolism develops from deep venous thromboses in the leg or pelvic veins. Raynaud's phenomenon consists of vasospasms in small arteries of the extremities causing intermittent ischemia. ➧ Test-taking Tip: Apply knowledge of medical terminology (popliteal) and note the relationship to option

Prior to administering L-asparaginase to a 12-year-old child with acute lymphocytic leukemia, a nurse reviews the child's laboratory report. Which lab value should prompt the nurse to notify a physician before administering the chemotherapeutic agent? 1. Hemoglobin (Hgb) 11.8 mg/dL 2. Blood glucose 252 mg/dL 3. Total bilirubin 1.2 mg/dL 4. Absolute neutrophil count (ANC) 1,078

ANSWER: 2 An adverse effect of L-asparaginase is hyperglycemia, which may need to be treated with insulin before administration of another dose. The normal Hgb for ages 6 to 12 years is 11.5 to 15.5 g/dL and total bilirubin is 0.3 to 1.2 mg/dL. An ANC of 1,078 is acceptable for L-asparaginase administration. An ANC of less that 1,000 increases the child's risk of infection. ➧ Test-taking Tip: Eliminate options that are known to be within normal ranges. Of the remaining two options, 2 and 4, determine which would require intervention

physician documents in a client's postoperative progress notes that the client is experiencing a respiratory infection with a shift to the left in the white blood cell (WBC) differential count. Which finding by a nurse reviewing the client's laboratory report would support the physician's documentation? 1. Decreased WBC count 2. Increased band cells 3. Decreased hemoglobin 4. Increased C-reactive protein d with infection.

ANSWER: 2 An early indication of infection is an increase in the band cells, which are immature neutrophils in the WBC differential count. The increase is termed a shift to the left. The total WBC count should be elevated, not decreased. However, this does not describe the shift to the left. Decreased hemoglobin in a postoperative client is usually due to blood loss. An increased C-reactive protein indicates nonspecific inflammation and is not part of the WBC differential count. ➧ Test-taking Tip: Note the key words "shift to the left" and "WBC differential." Decreased hemoglobin and increased C-reactive protein do not pertain to the WBC. Increased C-reactive protein is opposite of what is expecte

A nurse is assessing a client who is taking atorvastatin (Lipitor®). For which manifestations should the nurse specifically assess? 1. Constipation and hemorrhoids 2. Muscle pain and weakness 3. Fatigue and dysrhythmias 4. Flushing and postural hypotension

ANSWER: 2 Atorvastatin is a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor (statin) used to lower lipid levels. Statins can cause muscle tissue injury manifested by muscle ache or weakness. Muscle injury can progress to myositis (muscle inflammation) or rhabdomyolysis (muscle disintegration). Bile acid sequestrants may cause constipation and hemorrhoids because they are not absorbed from the small intestine. Diarrhea, not constipation, is a side effect of statin medications. Side effects of niacin, a lipid-lowering agent, include flushing, dysrhythmias, and postural hypotension. ➧ Test-taking Tip:The key words are "specifically assess." The nurse should be monitoring for side effects. Select the option that includes the side effect for the HMG-CoA reductase inhibitors (statins).

A client diagnosed with Hodgkin's lymphoma develops radiation pneumonitis 3 months after radiation treatment. For which symptoms of radiation pneumonitis should a nurse observe the client? 1. Tachypnea, hypotension, and fever 2. Cough, fever, and dyspnea 3. Bradypnea, cough, and decreased urine output 4. Cough, tachycardia, and altered mental status se item.

ANSWER: 2 Cough, fever, and dyspnea are classic symptoms in radiation pneumonitis due to a decrease in the surfactant in the lung. Hypotension, decreased urine output, and altered mental status are symptoms that are not common in radiation pneumonitis. ➧ Test-taking Tip: Note the key words "radiation pneumonitis," and focus on the association with respiratory symptoms. Options 1, 3, and 4 can be eliminated because these options each contain a nonrespiratory respon

A 6-year-old child is diagnosed with pheochromocytoma. Which manifestations should lead a nurse to conclude that this child is in crisis? 1. Systolic blood pressure of 120 mm Hg 2. Rhabdomyolysis 3. Urine output of 30 mL/hr 4. Hyperexcitability

ANSWER: 2 During a pheochromocytoma crisis, there is skeletal muscle destruction (rhabdomyolysis). There is also profound hypertension, up to 250 mm Hg; acute renal failure with less than 30 mL/hr urine output; and decreased level of consciousness (not hyperexcitability). ➧ Test-taking Tip: Eliminate options that are within normal or near normal parameters for a 6-year-old child

In reviewing a physician's orders for a postoperative client who underwent gynecological surgery, which order should a nurse determine is specifically written with the intent to prevent postoperative thrombophlebitis and pulmonary embolism? 1. Have the client dangle the legs the evening of surgery 2. Administer enoxaparin (Lovenox®) 40 mg subcutaneously daily 3. Administer hydromorphone (Dilaudid®) 1 to 4 mg IV every 3 to 4 hours as needed (prn) 4. Encourage coughing and deep breathing (C&DB) every hour while awake

ANSWER: 2 Enoxaparin is an anticoagulant that potentiates the inhibitory effect of antithrombin on factor Xa and thrombin. Early postoperative ambulation instead of dangling is a major preventive technique for thrombophlebitis. Hydromorphone is a narcotic analgesic for pain control. Coughing and deep breathing promote lung expansion and prevent atelectasis and pneumonia. ➧ Test-taking Tip: Note the key words "specifically written," and then eliminate options 1, 3, and 4 because they are not specific to preventing postoperative thrombophlebitis and pulmonary embolism. Knowledge of medications is needed to answer this question.

Following diagnostic testing for an enlarged cervical lymph node, a health-care provider informs a 20-year-old female client of a diagnosis of Hodgkin's disease and explains the disease process and recommended treatment. Which statement, overhead by a nurse when the client telephoned her parents, indicates that the client understands the diagnosis and treatment? 1. "I am so relieved; I was worried that I had cancer and there wasn't anything that could be done to treat it." 2. "I have a good chance of being cured with radiation therapy, chemotherapy, or a combination of both." 3. "I will need to have a laparotomy to stage the disease before I can start irradiation and chemotherapy." 4. "I am so upset; I wanted to go to college, marry, and raise a family. Now, I won't be able to do any of this."

ANSWER: 2 Hodgkin's lymphoma, which peaks at 20 years of age, is potentially curable with radiation therapy alone or with a combination of several chemotherapeutic agents. The overall 10-year survival rate is as high as 90%. However, 30% of persons who survive pediatric Hodgkin's lymphoma develop a secondary malignancy 30 years after their Hodgkin's lymphoma is diagnosed. Hodgkin's disease is a B-cell malignant disorder (cancer) that affects the reticuloendothelial and lymphatic systems. A laparotomy and splenectomy are no longer performed to determine the staging. However, if lesions found on imaging performed for staging are suspicious and if the findings might alter the treatment regimen, then a biopsy may be performed. There is no indication that the client has an advanced stage of lymphoma. ➧ Test-taking Tip: Select the statement that is a true statement. Eliminate options that include a client's emotional response to the diagnosis.

Elevated homocysteine levels are associated with the development of arteriosclerosis and venous thrombosis. A clinic nurse should teach a client that the dietary therapy to decrease homocysteine levels includes eating foods rich in: 1. monosaturated fats. 2. B-complex vitamins. 3. vitamin C. 4. calcium.

ANSWER: 2 Homocysteine interferes with the elasticity of the endothelial layer in blood vessels. Foods rich in B-complex vitamins, especially folic acid, have been found to lower serum homocysteine levels. Monosaturated fats, vitamin C, and calcium are included in a healthy diet but have not been found to affect the homocysteine levels. ➧ Test-taking Tip: Key words in the stem are "decrease homocysteine." The question is "What foods would lower high levels of homocysteine?"

A client with leukemia asks a nurse to explain how donor cells are obtained for peripheral blood stem cell transplantation (PBSCT). Which statement by the nurse is correct? 1. "A large amount of bone marrow tissue is harvested from a donor's hip bone under general anesthesia in the operating room." 2. "Stem cells are collected from the donor's blood, which goes through a machine, removes the stem cells, and then returns the blood back to the donor." 3. "Stem cells are collected from a donor through a process called apheresis, which removes the stem cells from the blood. This typically takes 10 to 15 minutes." 4. "Stem cells are obtained similar to other blood donations, where the blood is collected and then administered to you immediately following collection."

ANSWER: 2 In PBSCT, stem cells are collected through apheresis via a machine that removes stem cells and returns the blood back to the donor. The cells that are collected can be frozen and stored until ready to be transplanted. Option 1 describes the process of obtaining donor cells by traditional harvesting, not PBSCT. Administering blood to the client immediately would be unsafe. While the process is called apheresis, the process takes from 4 to 6 hours and not 10 to 15 minutes. Too much blood would be removed to obtain the number of stem cells if whole blood were collected. ➧ Test-taking Tip: Use the process of elimination and eliminate an option that refers to the bone marrow and not peripheral blood, an action that is unsafe and an option that addresses an insufficient amount of time for stem cell collection.

A nurse evaluates that a client recognizes foods that are high in calcium when the client selects: 1. 1 cup whole milk, 1 cup spinach, and 3 ounces sardines. 2. 1 cup low-fat yogurt, 1 cup broccoli, and 3 ounces sardines. 3. 1⁄2 cup 2% cottage cheese, 1 cup spinach, and 3 ounces frozen tofu. 4. 1 medium baked potato with 1 tbsp fat-free sour cream, 1 cup spinach, and 3 ounces tofu.

ANSWER: 2 One cup of low-fat plain yogurt has 448 mg of calcium, 1 cup of broccoli has 60 mg, and 3 ounces of sardines have 324 mg, for a total of 832 mg of calcium. One cup of whole milk has 300 mg of calcium, 1 cup of spinach has 30 mg calcium, and 3 ounces of sardines have 324 mg, for a total of 654 mg. A half cup of 2% cottage cheese has 78 mg calcium, 1 cup of spinach has 30 mg, and 3 ounces tofu has 310 mg, for a total of 418 mg. A medium baked potato has 38 mg of calcium, 1 tbsp of low-fat sour cream has 20 mg, 1 cup of spinach has 30 mg, and 3 ounces tofu has 310 mg, for a total of 398 mg calcium. ➧ Test-taking Tip: Use the process of elimination, noting that options 1 and 2 both contain sardines and 3 and 4 both contain tofu. Next, look at the dairy content in each option. Eliminate options 3 and 4 because the volume of dairy content is low. Select option 2, knowing that low-fat plain yogurt has more calcium than whole milk.

Prednisone is ordered three times a day for a child receiving chemotherapy. Which is the best schedule for a nurse to suggest to a parent? 1. 6 a.m., 2 p.m., and 10 p.m. 2. 8 a.m., 1 p.m., and 6 p.m. 3. 10 a.m., 6 p.m., and 2 a.m. 4. 11 a.m., 4 p.m., and 9 p.m.

ANSWER: 2 Prednisone should be taken with meals or snacks to decrease or prevent gastrointestinal upset. This schedule is the closest of the options to meal time, yet it spaces the medication for effectiveness. While options 1 and 2 space the medication over a 24-hour time period, it is not given consistently in relation to meals. Option 4 would be administering prednisone before meals and at bedtime. ➧ Test-taking Tip: Note that only one option gives the medication closest to meal time.

A female client is being treated with radioactive iodine (RAI) therapy for an enlarged thyroid gland. The client asks if there are any precautions that are needed during RAI therapy. Which is the nurse's best response? 1. "No precautions are necessary. You receive radiation in the form of a capsule that will target and destroy the thyroid tissue only." 2. "Though a pregnancy test has confirmed that you are not pregnant, use contraceptives or abstain from sexual intercourse to avoid conceiving during treatment." 3. "Because maximum effects may not be seen for 6 months, you will need to continue taking the antithyroid medication and propranolol until the effects of radiation become apparent." 4. "Although RAI is usually effective, a few individuals will need life-long thyroid hormone replacement due to posttreatment hypothyroidism."

ANSWER: 2 Pregnancy should be postponed for at least 6 months after treatment. RAI is contraindicated during pregnancy because it crosses the placenta. Approximately 5% of individuals require more than one dose to destroy overactive thyroid cells. Precautions about avoiding pregnancy should be advised. Almost all of the radioactive iodine that enters and is retained by the body is concentrated in the thyroid gland and destroys thyroid tissue without jeopardizing other radiosensitive tissues. Symptoms of hyperthyroidism may subside in 3 to 4 weeks, but the maximum effects may not be seen for 3 to 4 months. Clients should continue with the antithyroid medication and propranolol. Almost 80% of individuals experience posttreatment hypothyroidism. ➧ Test-taking Tip:The key word is "precaution." Eliminate option 4. Though correct, it does not address a precaution during RAI therapy.

A client with Raynaud's disease is seen in a vascular clinic 6 weeks after nifedipine (Procardia®) has been prescribed. A nurse evaluates that the medication has been effective when which findings are noted? 1. The client's blood pressure is 110/68 mm Hg. 2. The client states experiencing less pain and numbness. 3. The client states that tolerance to heat is improved. 4. The client walks without claudication.

ANSWER: 2 Raynaud's disease is a disease in which cutaneous arteries in the extremities have recurrent episodes of vasospasm with blanching and then redness. The episodes are brought on by cold and result in pain and numbness. Nifedipine, a calcium channel blocker, causes vasodilation, which reduces pain and numbness. Nifedipine is used as an antihypertensive agent but that is not the purpose here. The client is at risk to develop hypotension as an adverse effect. Tolerance to cold, not heat, should improve. Claudication is not associated with Raynaud's disease but is associated with arteriosclerotic changes in the larger arteries. ➧ Test-taking Tip:The issue of the question is "expected effects of Procardia® on Raynaud's disease." Consider the action of nifedipine and how it relates to the symptoms of Raynaud's disease.

nurse reviews the symptoms of acute graft occlusion with a client who has had a revascularization graft procedure of the lower extremity. Which symptom of acute arterial occlusion stated by the client indicates further teaching is needed? 1. Severe pain 2. Redness and warmth along the incisions 3. Paresthesia 4. Inability to move the foot

ANSWER: 2 Redness and warmth along the incision line is associated with inflammation or infection, not graft occlusion. Lack of blood supply to a body extremity may result in pain, pallor, pulselessness, paresthesia (numbness), paralysis (decreased ability to move), and poikilothermia (coolness). ➧ Test-taking Tip: Key words in the stem are "acute arterial occlusion." Focus on the symptoms associated with decreased circulation and eliminate all but option 2.

In assessing a 75-year-old African American client, a nurse notes a blood pressure (BP) of 158/90 mm Hg. In planning care for this client, which interpretation by the nurse is correct? 1. Blood pressure tends to increase with age, so this elevation is considered acceptable and confers no special risk. 2. This reading indicates stage 1 hypertension, so health-promoting lifestyle modifications and medications are needed. 3. This reading indicates prehypertension, so only health-promoting lifestyle modifications are needed. 4. This reading indicates stage 2 hypertension, which is treatable only with thiazide-type diuretics, regardless of diet or exercise.

ANSWER: 2 The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure's recommended BP levels list stage 1 hypertension as a systolic blood pressure of 140 to 159 mm Hg or a diastolic blood pressure of 90 to 99 mm Hg. Although BP increases with age, hypertension is a risk factor for cardiovascular disease and thus not an acceptable BP. Most clients with hypertension will require antihypertensive medications to achieve goal BP of less than 140/90 mm Hg. The client's BP is higher than the prehypertension stage (120-139/80-89). Stage 2 hypertension is a systolic BP of 160 or higher or a diastolic BP of 100 or higher. Lifestyle modifications are needed in all hypertensive states. ➧ Test-taking Tip: Knowledge of blood pressure guidelines is needed to select the answer.

nurse is caring for multiple clients on a medical unit. Which client, who has been diagnosed with a lower extremity deep venous thrombosis (DVT), should the nurse plan for possible placement of a filter in the inferior vena cava to protect against pulmonary embolism? 1. A 22-year-old female who has been taking oral contraceptives 2. A 65-year-old client admitted with a bleeding gastric ulcer 3. A 55-year-old client who had a total knee joint replacement 4. A 52-year-old female who had a vaginal hysterectomy 6 weeks earlier

ANSWER: 2 The client with the bleeding gastric ulcer is not a candidate for anticoagulant therapy and, therefore, needs the inferior vena cava filter to prevent an embolus from the DVT reaching the pulmonary circulation. The other clients have no contraindications listed for anticoagulant therapy. ➧ Test-taking Tip: The issue of the question is "criteria for clients with DVT to be treated with a vena cava filter instead of anticoagulation." Consider each option separately regarding risk from anticoagulation.

A hospitalized client, identified to be at risk for thromboembolic disease, has anti-embolism hose ordered. A nurse discusses the correct use of the stockings. Which direction should the nurse include in teaching this client? 1. If ambulating 10 times daily for 5 minutes at a time, wearing the hose is unnecessary. 2. The most appropriate time to apply the hose is before standing to get out of bed in the morning. 3. If the hose becomes painful to the skin underneath, notify the nurse and request pain medication. 4. Only cross the legs while wearing the antiembolism hose; otherwise keep the legs uncrossed.

ANSWER: 2 The most appropriate time to apply anti-embolism stockings is before the client arises from bed. This maximizes the compression effect, thus lessening venous distension and development of edema. Frequent ambulation is a positive intervention to prevent thromboembolic disease but should be used in addition to wearing the anti-embolism stockings. If the stockings cause skin discomfort to the client, the stockings and skin underneath must be assessed. The stockings may need to be removed and then reapplied without twisting or wrinkles in the stockings. Crossing the legs impedes circulation and should be avoided with or without the elastic stockings. ➧ Test-taking Tip: The issue of the question is the correct use of anti-embolism stockings. Evaluate each option regarding safe use. Eliminate option 1 since it contradicts use of the elastic stockings.

Following a shift report on an oncology unit, a nurse determines that which client should be assessed first? 1. A client with breast cancer who has an order for ondansetron (Zofran®) 8 mg intravenously (IV) 30 minutes prior to chemotherapy 2. A client just admitted with a temperature of 101°F (38.3°C), diaphoresis, and an absolute neutrophil count of 98/mm3 3. A client with breast cancer who is scheduled for external beam radiation in 15 minutes 4. A client with stomatitis associated with tonsilar cancer who receives gastrostomy tube feedings

ANSWER: 2 The newly admitted client should be assessed first because the client is neutropenic, showing signs of infection, and microorganisms from other clients would be less likely to be transmitted to the client if seen first. The client should be placed on neutropenic precautions. The client is at risk for severe sepsis if the absolute neutrophils count is less than 100/mm3. In option 1, no time is noted for the chemotherapy treatment. In option 3, if the shift report indicates that the client has been stable, assessment can wait until the client returns or the client can be seen after first assessing the neutropenic client. The tube feeding can be initiated after the most critical clients are assessed. ➧ Test-taking Tip: Use the nursing process to establish priorities. The most critical patient should be assessed first.

An agitated client is admitted to the emergency department (ED) with tachycardia, dyspnea, and intermittent chest palpitations. The client has a blood pressure of 170/110 mm Hg and heart rate of 130 beats per minute. The client's health history reveals thinning hair, recent 10-lb. weight loss, increased appetite, fine hand and tongue tremors, hyperreflexic tendon reflexes, and smooth moist skin. A physician writes orders for the client. Which order should the nurse implement first? 1. Obtain 12-lead electrocardiogram (ECG). 2. Administer propranolol (Inderal®) 2 mg intravenously q10-15min or until symptoms are controlled. 3. Administer propylthiouracil (PTU) 600 mg oral loading dose followed by 200 mg orally q4h. 4. Obtain thyroid-stimulating hormone (TSH), free T4, and cardiac enzyme levels.

ANSWER: 2 The nurse should first administer propranolol as ordered by the physician. Propranolol is a beta-adrenergic blocker for symptomatic relief of thyrotoxicosis and decreasing peripheral conversion of T4 to T3. It controls cardiac and psychomotor manifestations within minutes. A beta blocker is also a first-line treatment for a client with acute coronary syndrome. Dysrhythmias can occur from beta-adrenergic receptor stimulation caused by excess thyroid hormone or following an acute coronary syndrome. PTU will inhibit the synthesis of thyroid hormone. Clinical effects may be seen as soon as 1 hour after administration. Decreased TSH and elevated free T4 confirm the diagnosis of hyperthyroidism. Elevated cardiac enzymes confirm the diagnosis of acute coronary syndrome. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) to establish priority. Controlling the client's blood pressure and heart rate is priority.

After seeing a primary care provider for a routine appointment, a 48-year-old client tells a nurse that she experienced pain in the calf of her left leg earlier in the week, but she is pain-free now. The nurse assesses the client and finds the dorsalis pedis pulses palpable and no pain upon dorsiflexion bilaterally. A few varicose veins are visible in each leg. There is very slight swelling in the left foot and none in the right foot. Which is the best action by the nurse? 1. Ask the client if she has been walking more lately. 2. Notify the primary care provider. 3. Ask the client if she has thought about taking a baby aspirin once a day. 4. Explain to the client that there are no significant findings but to call the office if the pain returns.

ANSWER: 2 The nurse should notify the primary care provider about the client's additional concern. A possible deep venous thrombosis (DVT) is taken seriously because it can lead to pulmonary embolism (PE). Clients with DVT may be asymptomatic. Unilateral swelling of one leg, a classic symptom of DVT, is suggested with the slight swelling in the left foot. The primary care provider may order a noninvasive test, venous ultrasound, to determine whether the client has a DVT. With the unilateral swelling in the extremities, the nurse does not need additional assessment data (recent activity level). Advising aspirin is not within the scope of nursing and has possible negative consequences. Waiting until the pain returns would delay diagnosis, needed treatment, and expose the client to risk of PE if the client has a DVT. ➧ Test-taking Tip: Key words in the stem are "pain in the calf" and "very slight swelling in the left foot, none in the right." The phrase "best action" identifies the need to prioritize. Consider the assessment in the stem carefully, noting that the negative Homan's sign is not significant. Research has shown that the Homan's sign is not an accurate indicator of the presence of a DVT. Consider the consequences of each action. Notifying the primary care provider offers the safest option. Therefore, select option 2.

A nurse is assessing a 6-year-old child newly diagnosed with acute lymphocytic leukemia (ALL). Which assessment findings should the nurse expect based on the child's diagnosis? SELECT ALL THAT APPLY. 1. Alopecia 2. Petechiae 3. Anorexia 4. Insomnia 5. Bleeding gums 6. Pallor

ANSWER: 2, 3, 5, 6 Petechiae, a sign of capillary bleeding, and bleeding gums result from decreased platelet production and the ability of the blood to clot. Anorexia occurs from enlarged lymph nodes and vague abdominal pain from inflammation within the intestinal tract. Pallor occurs from decreased production of erythrocytes. Alopecia (hair loss) may occur with chemotherapy but is not an expected sign with a new diagnosis. Because of the bone marrow depression, fatigue and increased time sleeping are signs associated with ALL. ➧ Test-taking Tip: Recall that in leukemia the proliferation of immature white blood cells depress bone marrow production, decreasing erythrocytes, platelets, and the formation of mature white blood cells. Therefore, select options that relate to the functions of these blood cells.

A nurse is caring for a male client the night before the client is scheduled for an amputation. The client has a 7-year history of peripheral artery disease. Recent surgeries have failed to revascularize the client's leg. The client tells the nurse that he is a failure and all the efforts of his family and physician have been wasted. The most appropriate action by the nurse at this time is to: 1. explain that the hospital staff will help him through the surgery and recovery. 2. stay with the client, listen carefully, and encourage him to express his feelings. 3. offer to contact pastoral care. 4. offer to contact the primary care provider to obtain an antidepressant.

ANSWER: 2 The nurse should offer compassionate understanding to the client by being present and listening. This provides an opportunity for the client to express his feelings and begin to deal with the amputation and his loss. The other responses offer solutions without dealing with the emotional needs and loss the client is experiencing. ➧ Test-taking Tip: The issue of the question is a client facing an amputation after enduring chronic peripheral arterial diseases. The question calls for a caring intervention by the nurse. Apply the therapeutic communication skills, including silence and presence, in answering this question.

A nurse is working with a certified nursing assistant (CNA) and a licensed practical nurse (LPN) in providing care to a group of clients. Which tasks should the nurse assign to the CNA and LPN? 1. CNA to perform simple dressing changes; LPN to assess and care for two noncomplex clients 2. CNA to empty and record urinary catheter bag drainage; LPN to administer oral and intramuscular medications 3. CNA to assist clients with hygiene; LPN to provide postmortem care and meet with a deceased client's family 4. CNA to take and document vital signs on all clients; LPN to complete the discharge paperwork to be reviewed with two clients

ANSWER: 2 The scope of practice for a CNA includes measuring and recording intake and output and for the LPN to administer oral and intramuscular medications. A CNA is able in some facilities to perform a simple dressing change, but if the registered nurse (RN) changes it the RN would be able to assess the incision. An LPN should not be assessing clients. A CNA is able to assist with hygiene, but meeting with the family of a deceased client should be completed by the RN and not the LPN. A CNA is able to take and document vital signs, but the RN should be completing discharge paperwork to be reviewed with the clients. The discharge paperwork often includes a review of the care plan and addressing unmet needs of the client. ➧ Test-taking Tip: Eliminate options that include aspects of the RN role that should not be delegated, including assessment, evaluation, and education.

An experienced nurse and a new nurse are providing preoperative care for a 5-year-old child diagnosed with Wilms' tumor. The experienced nurse should intervene when observing the new nurse: 1. inform the child that water is not allowed because the procedure will be performed soon. 2. palpate the child's abdomen during assessment. 3. provide the child with a doll for play that has removable kidneys. 4. state to the child, "You'll get some medicine that you breathe or get through your arm to make you sleep."

ANSWER: 2 Wilms' tumor (nephroblastoma) is an intrarenal abdominal tumor. Palpating the abdomen can potentially spread the cancerous cells. A 5-year-old child would typically be NPO for 2 hours prior to the procedure, although this time period can vary. Play therapy is an appropriate means for teaching the child about the surgical procedure and assisting the child to cope. When explaining the surgery and anesthesia, words that the child understands should be used. ➧ Test-taking Tip: Consider both the age of the child and the type of tumor when reading the options.

A clinic nurse evaluates that a client's levothyroxine (Synthroid®) dose is too low when which findings are noted? SELECT ALL THAT APPLY. 1. Increased appetite 2. Decreased sweating 3. Apathy and fatigue 4. Paresthesias 5. Fine tremor of fingers and tongue 6. Slowed mental processes

ANSWER: 2, 3, 4, 6 Levothyroxine is used in treating hypothyroidism. Symptoms of hypothyroidism appear if the dose is too low and include decreased sweating, apathy and fatigue, paresthesias, and slowed mental processes. Increased appetite and fine tremors are signs of hyperthyroidism and can indicate the dose is too high. ➧ Test-taking Tip: Recall that hypothyroidism is characterized by a slowing of body processes. Eliminate options 1 and 5 because these reflect increased sympathetic stimulation.

A client receiving chemotherapy is experiencing persistent nausea and occasional vomiting. Based on these symptoms, which interventions should a nurse add to this client's plan of care? SELECT ALL THAT APPLY. 1. Change the client's diet to full liquid. 2. Offer small amounts of food frequently. 3. Administer ondansetron (Zofran®) 1 hour prior to chemotherapy treatments. 4. Encourage liquid consumption throughout the day. 5. Serve a big meal before all chemotherapy treatments. 6. Offer foods that are mild smelling or odorless.

ANSWER: 2, 3, 4, 6 Small meals can be less nauseating than a large, heavy meal. Realistic intake goals are set for the client. Ondansetron is an antiemetic, serotonin receptor antagonist, used to decrease nausea and vomiting caused by chemotherapy. Other medications include metoclopramide (Reglan®) and dexamethasone (Decadron®). Liquids are encouraged to replace fluids lost through emesis. Foods with a strong odor or that are fatty, greasy, or gas forming can increase nausea. A liquid diet does not reduce nausea. A small meal should be served 2 hours prior to chemotherapy. ➧ Test-taking Tip: Read each option carefully. The issue of the question is interventions to reduce nausea

A nurse is discussing healthy lifestyle practices with a client who has chronic venous insufficiency. Which practices should be emphasized with this client? SELECT ALL THAT APPLY. 1. Avoid eating an excess of dark green vegetables. 2. Elevate the legs while sitting. 3.Wear elastic stockings (TEDS®) daily, applying them before getting out of bed. 4. Increase standing time and shift weight from one leg to the other when standing in one place. 5. Sleep with legs elevated above the level of the heart.

ANSWER: 2, 3, 5 Chronic venous insufficiency develops because of damaged valves in the veins, resulting in venous hypertension. Interventions focus on management of edema by elevating the legs and wearing elastic stockings. Eating excessive amounts of dark green vegetables could affect the anticoagulant effect of warfarin, but there is no indication the client is taking an anticoagulant. Clients who have chronic venous insufficiency should avoid prolonged standing. ➧ Test-taking Tip: Recall that venous insufficiency impairs return of blood to the heart. Select options that will improve venous return

Which points should the nurse plan to include when teaching a client receiving a thiazide diuretic? SELECT ALL THAT APPLY. 1. Take the radial pulse before setting up the medication. 2. Include fruits such as melons and bananas in the diet. 3. Report side effects such as muscle cramps, nausea, or a skin rash. 4. Self-administer the last dose at bedtime when fluid tends to be at the highest levels. 5. Keep appointments for laboratory monitoring, including serum electrolytes, glucose, creatinine, blood urea nitrogen (BUN), and uric acid levels. 6. Minimize intake of high-fat foods because thiazide diuretics can increase serum cholesterol, low-density lipoprotein (LDL), and triglyceride levels.

ANSWER: 2, 3, 5, 6 Thiazide diuretics can cause hypokalemia. Encouraging potassiumrich foods can help maintain potassium levels. Muscle cramps are a sign of possible medication side effects of hypokalemia and hypocalcemia. Nausea and rash are also medication side effects. Laboratory results to be monitored during thiazide diuretic therapy include serum electrolytes, glucose, creatinine, BUN, and uric acid levels because thiazide diuretics are excreted mainly unchanged by the kidneys and can increase glucose levels. Reminders regarding keeping appointments promote medication adherence. Thiazide diuretics can increase serum cholesterol, LDL, and triglyceride levels, so teaching the client to minimize high-fat foods will help maintain cholesterol levels. It is unnecessary for a client to monitor the pulse before taking thiazide diuretics. A diuretic taken at bedtime can cause nocturia and loss of sleep. The usual timing of the last daily dose of a diuretic is at suppertime. ➧ Test-taking Tip: Recall that thiazide diuretics lower blood pressure through diuresis, which can result in hypokalemia. Focus on the common thiazide diuretic, hydrochlorothiazide, and its effects and side effects when reading each of the option

A nurse is working with a certified nursing assistant (CNA) providing care for four clients on a busy telemetry unit. All four clients are in need of immediate attention. The CNA is a senior nursing student who has been administering medications and performing procedures during clinical experiences as a student nurse. The charge nurse supervising care on the telemetry unit determines that care is appropriate when the registered nurse (RN) working with the CNA delegates: SELECT ALL THAT APPLY. 1. administering acetaminophen (Tylenol®) to the client with an elevated temperature. 2. taking vital signs on the client newly admitted with a diagnosis of heart failure. 3. finishing the discharge instructions so the client with a new pacemaker implant can go home. 4. changing a client's chest tube dressing because it got wet when the water pitcher overturned. 5. providing a sponge bath for the client with the elevated temperature. 6. checking the lung sounds of the client whose chest tube drainage system was tipped over and then righted

ANSWER: 2, 5 Legally a student nurse employed as a nursing assistant in a facility is only allowed to perform tasks listed in the job description of a nursing assistant even though the student nurse has received instruction and acquired competence in administering medications and performing sterile procedures. The tasks of a nursing assistant include taking vital signs and bathing clients. Medication administration, teaching, sterile procedures, and assessments are not within the nursing assistant's scope of practice. ➧ Test-taking Tip: Read the information given in the question carefully. The issue of the question is tasks that the RN can legally delegate to a CNA who is also a student nurse. Delegated tasks must be within the job description of the nursing assistant.

client is on a low-fat diet for weight reduction and hyperlipidemia. The client asks a nurse to recommend foods high in protein. Which food should the nurse recommend? 1. 1 hard-boiled egg 2. 1 cup of cooked broccoli 3. 1⁄2 cup 1% cottage cheese 4. 1 ounce cheddar cheese

ANSWER: 3 A half cup of cottage cheese supplies 16 grams of protein. The grams of protein content of the other foods listed are egg (6), broccoli (4), and cheddar cheese (7). ➧ Test-taking Tip: Determine what the question is asking about: high-protein foods. Knowledge of the protein content of foods is necessary to answer this question.

A client, following a total hip replacement, asks a nurse why she is receiving enoxaparin (Lovenox®) for prevention of deep vein thrombosis (DVT) when, with her last hip surgery, she received heparin subcutaneously. What is the nurse's best response? 1. "Enoxaparin is less expensive and easier to administer than the heparin." 2. "There is less risk of bleeding with enoxaparin, and it doesn't affect your laboratory results." 3. "Enoxaparin is a low-molecular-weight heparin that lasts twice as long as regular heparin." 4. "Enoxaparin can be administered orally whereas heparin is only administered by injection."

ANSWER: 3 Because enoxaparin is more specific in inhibiting active factor X, the response is more stable and the effect is two to four times longer than that of heparin. The cost of enoxaparin is more than twice the cost of the equivalent dose of heparin per injection. Both enoxaparin and heparin are administered by subcutaneous injection, and both are available in prefilled syringes for injection. Both enoxaparin and heparin increase activated partial thromboplastin time (aPTT). Enoxaparin is only administered subcutaneously. ➧ Test-taking Tip: Focus on the issue: the difference between enoxaparin and heparin. Note that options 1, 2, and 4 are similar, addressing the supposed benefits of enoxaparin, whereas option 3 is different, describing the action of enoxaparin. The option that is different is usually the answer

A 31-year-old male client seeks care at a vascular clinic because of painful fingers and toes. He is diagnosed with Buerger's disease (thromboangiitis obliterans). A nurse is teaching the client ways to prevent progression of the disease. Which prevention measure should be the nurse's initial focus when teaching the client? 1. Avoiding exposure to cold 2. Maintaining meticulous hygiene practices 3. Abstaining from all tobacco products in all forms 4. Following a low-fat diet

ANSWER: 3 Buerger's disease is an uncommon vascular occlusive disease that affects the medial and small arteries and veins, initially in the distal limbs. It is strongly associated with tobacco smoking, which causes vasoconstriction. The most important action to communicate to the client is that he must abstain from tobacco in all forms to prevent progression of the disease. The other interventions are correct but not as important as abstaining from tobacco. Avoiding exposure to cold will reduce the pain. Meticulous hygiene and a low-fat diet are also positive actions to follow. ➧ Test-taking Tip:The key words are "painful fingers and toes" and "prevent progression of the disease." The words "initial focus" identify the need to prioritize. Recall that the etiology of Buerger's disease is unknown so avoiding agents that cause vasoconstriction is priority.

A hospitalized client has been receiving clonidine (Catapres®) 0.1 mg via transdermal patch once every 7 days. When bathing the client, a nursing assistant removes the patch thinking it is tape. Eight hours later, an on-coming nurse discovers that the transdermal patch is no longer on the client as prescribed. Based on this information, which assessment finding should be most concerning to the nurse? 1. Skin tear noted on the client's upper chest. 2. Excruciating headache reported. 3. Blood pressure is 182/100 mm Hg. 4. Electrocardiogram shows a heart rate of 120 beats per minute.

ANSWER: 3 Clonidine is an antihypertensive medication. Rebound hypertension occurs from abrupt withdrawal. Immediate intervention is required to lower the blood pressure. Though a skin tear is concerning and could have occurred during removal, it is not the most concerning. Headache can occur from the abrupt removal of clonidine, but is not the most concerning. Tachycardia is an adverse effect of clonidine. ➧ Test-taking Tip:The key words are "most concerning." Use the ABCs (airway, breathing, circulation) to determine the most concerning finding. Select option 3 because it pertains to circulation.

primary care provider prescribes lisinopril (Zestril®, Prinivil®) to treat a client with hypertension. The client returns to the clinic for a follow-up appointment. A nurse should evaluate the client for adverse effects by asking the client if he or she is experiencing: 1. muscle weakness. 2. bleeding gums. 3. persistent cough. 4. petechiae.

ANSWER: 3 Coughing is a common adverse effect of angiotensin-converting enzyme (ACE) inhibitors and warrants discontinuing the medication. The cough occurs from the action of ACE inhibitors in inhibition of kinase II and accumulation of bradykinin. Muscle weakness can be associated with statin therapy and warrants discontinuing the medication. Bleeding gums and petechiae are associated with bleeding. Petechiae are signs of low platelet counts. ➧ Test-taking Tip: Use the suffix "-pril" as a cue that the medication is an ACE inhibitor. Evaluate each option for relevance to the ACE inhibitor and then use the process of elimination to rule out incorrect options. Eliminate options that pertain to bleeding

client is taking metalazone (Zaroxolyn®) and diltiazem (Cardizem®) for treatment of hypertension. A home health nurse is reviewing the medications with the client. Which client statement indicates that the client needs teaching about these medications? 1. "I make sure that I eat foods high in potassium every day." 2. "Because metalazone makes me urinate more, I take my last dose at suppertime." 3. "I take my medications with a healthy breakfast of eggs, toast, grapefruit juice, and milk." 4. "Because ibuprofen (Motrin®) seems to affect my urine output, I prefer to take acetaminophen (Tylenol®) for pain."

ANSWER: 3 Grapefruit juice should be avoided because it inhibits the metabolism of diltiazem and can cause toxicity. Thiazide diuretics can result in hypokalemia. Consuming foods daily that are high in potassium is recommended. Diuretics should be avoided at bedtime to avoid nocturia and the loss of sleep. NSAIDs such as ibuprofen can decrease the diuretic and antihypertensive effects of thiazide diuretics. ➧ Test-taking Tip:The key words are "needs teaching." Select the option that is a false statement.

Which recommendation should a nurse teach to a client diagnosed with hypoparathyroidism? 1. Avoid milk and milk products. 2. Avoid carbonated beverages. 3. Ensure a calcium intake of 1,000 to 1,500 mg/day. 4. Perform isometric rather than weight-bearing exercises.

ANSWER: 3 Hypoparathyroidism is decreased function of the parathyroid glands, leading to decreased levels of parathyroid hormone (PTH). In the absence of adequate PTH activity, the ionized calcium concentration in the extracellular fluid falls. The client should be taught to ensure an adequate calcium intake, or supplements may be required. Dairy products are the primary source of calcium and should be increased in the presence of hypoparathyroidism. Carbonated beverages do not impact calcium, but alcohol and caffeinated beverages inhibit calcium absorption. Weight-bearing exercises can decrease the loss of calcium and should be recommended. ➧ Test-taking Tip: Apply knowledge that hypoparathyroidism may result in hypocalcemia. Recall that adequate calcium intake is required to prevent hypocalcemia.

Which assessment findings for a client who is status post-thyroidectomy should direct a nurse to check the client's serum calcium level? 1. Fatigue, decreased cardiac function, and tetany 2.Weakness, tachycardia, and disorientation 3. Muscle cramps, paresthesia, and Trousseau's sign 4.Weakness, edema, and orthostatic hypotension

ANSWER: 3 Muscle cramps, paresthesia, and a positive Trousseau's sign are common manifestations of hypo- or hypercalcemia because of the irritation to the neuromuscular system. Tachycardia is most often associated with abnormal serum magnesium levels. Fatigue is associated with sodium, potassium, and phosphorus imbalances. Hypotension relates most often to volume changes rather than electrolyte imbalances. ➧ Test-taking Tip: Focus on calcium's effect on the neuromuscular system to select the correct option.

A nurse notes redness, swelling, and warmth of and around the incision when assessing a client's leg incision 48 hours after femoral popliteal bypass surgery. The nurse's best analysis should be that the incision is: 1. healing normally for the second postoperative day. 2. showing signs of rejection of the suture materials. 3. inflamed and could indicate the presence of an infection. 4. infected and showing signs of wound dehiscence.

ANSWER: 3 Redness, swelling, and warmth are signs of inflammation and could indicate the presence of an infection. Other signs of an infection include excessive pain or tenderness on palpation and purulent or odorous drainage. Slight crusting, a pink color to the incision line, and slight swelling under the sutures or staples are normal findings for the second postoperative day due to inflammation from the surgical procedure. Though these findings could indicate rejection of the sutures, rejection occurs less frequently than a wound infection. If the wound is dehiscing, bloody or serosanguineous drainage would also be present. ➧ Test-taking Tip: Use the process of elimination and focus on the findings (redness, swelling, and warmth

A nurse is counseling a client with cardiac disease who has limited food refrigeration capabilities and prefers using canned vegetables. Which nutrient excess should the nurse caution the client about when eating mainly canned, rather than fresh, vegetables? 1. Potassium 2. Vitamin A 3. Vitamin C 4. Sodium

ANSWER: 4 Canned vegetables, even those low in sodium, have higher sodium levels than fresh or frozen. Potassium and vitamins A and C are not a concern in the processing of canned vegetables. ➧ Test-taking Tip: Key words are "excessive" and "canned." Think about how canned vegetables are preserved.

An error occurs and an admission order for a client to be on a venous thromboembolic protocol is not processed. Two days later, a nurse notices the omitted order for heparin 5,000 units subcutaneous every 8 hours. Which statement best describes appropriate follow-up? 1. "I am so glad I didn't make that mistake, that other nurse is going to be in trouble." 2. "I am too busy to complete a variance report. I'll do it next week." 3. "I need to contact the physician and complete a variance report." 4. "I will contact the supervisor immediately about this error."

ANSWER: 3 Reporting systems rely on nurses to recognize and report errors. Recent emphasis has been placed on making error reporting "blame-free" and determining how the system can be used to reduce errors. Variance reports should be completed right away for appropriate follow-up. It may be appropriate to contact the supervisor also, but it is the responsibility of the nurse to first notify the physician and document the event in a variance report. ➧ Test-taking Tip: Focus on "appropriate follow-up." Eliminate options that do not demonstrate follow-up. Of the remaining options, determine which is best. Content Area: Management of Care; Category of Health

client's blood pressure is being taken at a screening clinic. Which client statement to a nurse demonstrates awareness of having a risk factor for hypertension? 1. "My doctor told me my body mass index is 23." 2. "I usually have a glass of wine or two to unwind when I come home from work." 3. "I should get my blood pressure checked more often because I am African American." 4. "I have colds during the winter, so I see my physician to get the flu vaccine every year." n.

ANSWER: 3 Research of clients with hypertension has shown that clients who are aware of their personal risk factors are more motivated to achieve adequate control of blood pressure. Being African American is a known risk factor for hypertension. A body mass index (BMI) of 25 or higher is considered a risk factor for hypertension. A BMI of 23 is normal. Excessive alcohol intake is a risk factor for hypertension; consuming two glasses of wine daily increases the risk for hypertension. Having frequent colds and taking the influenza vaccine does not increase the risk for hypertension. Medications for treating colds, if taken frequently, can increase the risk for hypertension. ➧ Test-taking Tip: Key words in the stem are "risk factors." Evaluate each option to determine whether it describes an awareness of a risk factor for hypertensio

A hospital nurse is teaching coworkers how to prevent varicose veins. Which recommendation by the nurse is most accurate? 1. Wear low-heeled comfortable shoes 2. Move your legs back and forth often 3.Wear support hose or thromboembolic deterrent stockings (TEDS). 4.Wear clean, white cotton socks with tennis shoes

ANSWER: 3 Support or compression hose help decrease edema and increase circulation back to the heart, thereby preventing varicose veins. Low-heeled shoes and clean white cotton socks with tennis shoes will decrease foot discomfort but will not prevent varicose veins. Leg movement helps prevent deep vein thrombosis, but not varicose veins. ➧ Test-taking Tip: Use the process of elimination, ruling out options 1 and 4 because they address the feet. Eliminate option 2 after noting that back-and-forth movement of the legs is not the same as dorsiflexion and plantar flexion and will not promote return of blood to the heart.

The report of a chest x-ray of a client who has had aortic femoral bypass graft surgery indicates that the client has atelectasis. Which priority intervention should a nurse plan to include in the client's care? 1. Assessing breath sounds 2. Monitoring oxygen saturation 3. Assisting the client to use the incentive spirometer every hour 4. Monitoring respiratory rate

ANSWER: 3 The chest x-ray indicates atelectasis—collapse of the alveoli that result from shallow breathing. Planning to assist the client to use the incentive spirometer every hour should reinflate the alveoli. The intervention to treat the atelectasis is the priority. Assessing breath sounds, oxygen saturation, and respiratory rate are correct assessments but are not interventions that will improve the atelectasis. ➧ Test-taking Tip:The key word "priority" indicates the need to prioritize. Evaluate each option separately to determine whether it will improve the atelectasis. Eliminate options 1, 2, and 4 because these refer only to assessment and monitoring, which will not decrease the atelectasis.

A nurse in the postanesthesia care unit (PACU) is monitoring a client who has had a repair of an aortic aneurysm with graft surgery. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. The most appropriate initial action for the nurse is to: 1. recheck the pulse in 15 minutes. 2. reposition the leg. 3. notify the surgeon. 4. remove the surgical dressing.

ANSWER: 3 The nurse should notify the surgeon immediately. The loss of the pulse could signify graft occlusion or embolization. The surgeon needs to reassess the client. The primary nursing intervention in the PACU is continual surveillance of clients. Rechecking the pulse in 15 minutes could allow ischemia to progress. The leg should already be in an appropriate position, so repositioning is not indicated. There is no need to remove the abdominal dressing because of an absent pulse. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) to establish that circulation is a priority concern. Thus, notifying the surgeon would be the most immediate action so that the impaired circulation can be corrected.

A client returns to a unit after undergoing placement of a vena cava filter. When caring for this client, a nurse should anticipate: 1. beginning anticoagulation therapy as soon as possible. 2. assessing the dressing over the abdominal incision. 3. checking the orders to determine the client's ordered activity. 4. forcing oral fluids to promote excretion of the dye used during the procedure.

ANSWER: 3 The procedure for placement of a vena cava filter is done percutaneously; usually through the subclavian or femoral vein approach. The client will have activity included in the postprocedural orders. Anticoagulation is not necessary if a vena cava filter is in place. There is no abdominal incision with the percutaneous approach. Dye is not used during the procedure. ➧ Test-taking Tip:Think about how the procedure is performed and the potential complications before making a selection. Recall that a percutaneous approach is used.

A nurse collects the following assessment data on a client who has no known health problems: blood pressure (BP) 135/89 mm Hg; body mass index (BMI) 23; waist circumference 34 inches; serum creatinine 0.9 mg/dL; serum K 4.0 mEq/L; low-density lipoprotein (LDL) cholesterol 200 mg/dL; high-density lipoprotein (HDL) cholesterol 25 mg/dL; and triglycerides 180 mg/dL. Which order from the client's health-care provider should the nurse anticipate? 1. 1,500-calorie regular diet. 2. No added salt, low saturated fat, low-potassium diet. 3. Hydrochlorothiazide (HydroDIURIL®) 25 mg twice daily. 4. Atorvastatin (Lipitor®) 20 mg daily.

ANSWER: 4 Atorvastatin is used to manage hypercholesterolemia. It lowers the total serum LDL cholesterol and triglycerides and slightly increases HDL cholesterol by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, an enzyme that is responsible for catalyzing an early step in the synthesis of cholesterol. For persons with 0-1 risk factors, the goal for LDL is less than 160 mg/dL (4.14 mmol/L), and drug therapy is considered when LDL is greater than or equal to 190 mg/dL (4.91 mmol/L). Normal triglycerides are 40 to 150 mg/dL (0.45-1.69 mmol/L). A low-calorie diet is not indicated. The normal BMI is 18.5 to 24.9. While a low-saturated-fat diet in option 2 is indicated, a low-potassium diet is not because the serum K of 4.0 mEq/L is normal. The client's BP is slightly elevated but would be initially treated with lifestyle changes, not a diuretic. ➧ Test-taking Tip: Focus on the data provided in the situation and identify the abnormal findings. If unable to identify the abnormal data because of lack of knowledge of normal lab values, note that the client's serum cholesterol level analysis includes more data than other problems. Conclude that these are abnormal data and then use "lipids" as a key to identifying the correct option. Review laboratory values and cardiac medications if you had difficulty with this question.

Which nursing diagnosis should a nurse include when developing a plan of care for a client with hypothyroidism? 1. Diarrhea related to gastrointestinal hypermotility 2. Imbalance nutrition: less than body requirements related to calorie intake insufficient for metabolic rate 3. Activity intolerance related to increased metabolic rate 4. Anxiety related to forgetfulness, slowed speech, and impaired memory loss

ANSWER: 4 Disturbed thought processes can cause the client to be anxious. Diarrhea, imbalance nutrition related to insufficient calories, and activity intolerance related to increased metabolic rate are nursing diagnoses appropriate for hyperthyroidism. ➧ Test-taking Tip: Focus on the issue: nursing diagnoses for hypothyroidism. Look for key words in each option. Eliminate option 1 because of the key word "hypermotility." Eliminate option 2 because of the key phrase "calorie intake insufficient." Eliminate option 3 because of the key phrase "increased metabolic rate."

A client tests positive for factor V Leiden (FVL). A nurse recognizes that because the genetic trait is associated with venous thromboembolism (VTE) the client is: 1. also at a greater risk for myocardial infarction. 2. more likely to be of African American heritage. 3. at risk for premature death. 4. at risk for VTE if taking estrogen as an oral contraceptive or hormone replacement.

ANSWER: 4 FVL is a genetic trait that increases risk of VTE. There is no associated risk of arterial thrombosis associated with myocardial infarction. FVL is predominantly found in Caucasians and is common in older adult clients. ➧ Test-taking Tip: Key words in the stem are "genetic trait" and "VTE." Use the process of elimination because it is well known that the risk of thromboembolism is associated with taking oral contraceptives.

A client taking medication for treatment of essential hypertension has a serum potassium level of 3.2 mEq/L. A nurse is reviewing the list of medications being taken by the client. Which medication on the list should the nurse conclude to be the causative factor for this serum potassium level? 1. Spironolactone (Aldactone®) 2. Potassium chloride (K-Dur®) 3. Enalapril (Vasotec®) 4. Hydrochlorothiazide (Esidrix®, HydroDIURIL®)

ANSWER: 4 Hydrochlorothiazide is a thiazide diuretic that blocks sodium and water reabsorption in the distal tubule of the kidney and promotes potassium excretion, putting the client at risk for hypokalemia. Spironolactone acts by inhibiting sodium reabsorption in exchange for potassium (potassium-sparing diuretic). Potassium chloride is a potassium supplement. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that causes some clients to retain potassium. ➧ Test-taking Tip: Hypokalemia is a below normal level of potassium in the blood. Consider each medication separately, its action, and relationship to potassium. Use the medication name as a clue to identify the thiazide diuretic. Thiazide diuretics promote potassium excretion.

A nurse suspects that a 10-year-old client diagnosed with non-Hodgkin's lymphoma (NHL) has superior vena cava syndrome when assessing that the client has: 1. thrombocytopenia and leukocytosis. 2. hyperuricemia, hypocalcemia, and hyperphosphatemia. 3. tingling and paresthesias of the lower extremities and pain on light touch. 4. cyanosis of the upper chest, neck, face, upper extremity edema, and distended neck veins.

ANSWER: 4 Mediastinal tumors, especially from NHL, may cause compression of the great vessel (superior vena cava syndrome). Signs of compression include cyanosis of the upper chest, neck, face, upper extremity edema, and distended neck veins. Thrombocytopenia and leukocytosis increases the risk for vascular damage and life-threatening hemorrhage. Hyperuricemia, hypocalcemia, and hyperphosphatemia are signs of tumor lysis syndrome. A mass obstructing the spinal cord can be manifested by symptoms of tingling and paresthesias of the lower extremities and pain on light touch. ➧ Test-taking Tip: Recognize that the options present signs and symptoms of life-threatening complications that may develop in children with cancer. Think about the possible complications and then use the process of elimination.

A nurse is administering medications to a pediatric client with hypertension. Which oral antihypertensive medication ordered for a child should the nurse question? 1. ACE inhibitor 2. Calcium channel blocker 3. Diuretic 4. Nitrate

ANSWER: 4 Nitrates are used to treat angina and not prescribed to treat hypertension in children. ACE inhibitors, beta blockers, calcium channel blockers, angiotensin-receptive blockers, and diuretics are all oral antihypertensive medications used in treating hypertension in children. ➧ Test-taking Tip: Think about the action of each class of medications. Eliminate options that are known antihypertensive medications.

A registered nurse (RN), working on a telemetry unit for 2 years, is discharged for jeopardizing client safety by consistently failing to notify the physician when the health status of a client has changed. The RN applies at another health-care facility and the facility calls the nurse manager for a reference check. Which statement by the nurse manager is most appropriate? 1. "The RN resigned due to safety concerns such as failure to notify the physician when the health status of clients changed." 2. "The RN is uncomfortable communicating with physicians. Otherwise, the nurse's work meets standards of care." 3. "I need to consult with the hospital attorney to determine if any information can be provided." 4. "The nurse worked at this facility on the telemetry unit for 2 years but was discharged."

ANSWER: 4 Only factual information should be provided. The former employee has not consented to provide additional information. Option 1 is incorrect information. The RN was discharged. Option 2 suggests that the employee's failure to notify is related to discomfort with communication which could be an incorrect conclusion. Option 3 is inappropriate. The nurse manager should know the policies of the agency. ➧ Test-taking Tip: Select the option that provides the most factual information.

For a client experiencing severe cancer pain (pain intensity of 7 to 10 on a scale of 0 to 10, where 0 equals no pain and 10 equals the worst possible pain), which medication should a nurse plan to administer? 1. Meperidine (Demerol®) 2. Propoxyphene (Darvon®) 3. Pentazocine (Talwin®) 4. Oxycodone (Oxycontin®)

ANSWER: 4 Opioids, such as oxycodone, remain the most frequently prescribed pain medication for severe pain in cancer. Meperidine and propoxyphene are not recommended because these medications cause central nervous system toxicity from metabolites. Pentazocine is used for moderate pain only, and it can cause confusion and hallucinations in older adults and clients with renal impairment. ➧ Test-taking Tip: Think about medications used for "severe pain" as opposed to mild or moderate pain. Option 1 is used for mild or moderate pain and can be eliminated. Knowing the side effects of options 2 and 3 would eliminate them as options

A client is suspected of having a fat embolism following a pelvic fracture from a motor vehicle accident. A nurse should assess for which sign that is specific to a fat emboli? 1. Dyspnea 2. Chest pain 3. Delirium 4. Petechiae

ANSWER: 4 Petechiae (small purplish hemorrhagic spots on the skin) are thought to be due to transient thrombocytopenia. They can occur over the chest, anterior axillary folds, hard palate, buccal membranes, and conjunctival sacs. The other symptoms are not specific to fat emboli but are associated with blood emboli. Dyspnea and chest pain can occur when pulmonary or cardiac vessels are occluded. Cerebral disturbances, due to hypoxia and the lodging of emboli in the brain, vary from headache and mild agitation to delirium. ➧ Test-taking Tip: Note the key word "specific." This should direct you to option 4

A nurse is caring for a client who is experiencing symptoms associated with pheochromocytoma. Which intervention should be included in the care of this client? 1. Offer distractions such as television or music. 2. Encourage frequent intake of oral fluids. 3. Assist with ambulation at least three times a day. 4. Administer nicardipine (Cardene®) to control hypertension.

ANSWER: 4 Pheochromocytoma is characterized by a tumor of the adrenal medulla that produces excessive catecholamines (epinephrine and norepinephrine). The increased catecholamines result in hypertension. Until the tumor can be surgically removed, calcium channel blockers are used to control blood pressure and other excess catecholamine symptoms. Noise can increase sympathetic nervous system stimulation and provoke a hypertensive and anxiety attack. A calm environment and reduced activity is needed to prevent hypertensive crisis prior to surgery. ➧ Test-taking Tip: Knowledge of pheochromocytoma is needed to answer this question. Use medical terminology to decipher the meaning of the term. Recall that "oma" refers to tumor.

A hospitalized child diagnosed with leukemia is being discharged after an initial treatment with chemotherapy. A nurse is teaching the parents about the allopurinol (Zyloprim®), which the child will continue to take at home. The nurse explains that the purpose of this medication is to: 1. help promote the child's sleep. 2. treat the joint pain and swelling caused by the child's gout. 3. prevent the child from developing gouty arthritis. 4. protect the child's kidneys by reducing the formation of uric acid.

ANSWER: 4 Rapid cell destruction from chemotherapy results in a high level of uric acid being excreted during treatment. This can plug the glomeruli and renal tubules, causing loss of kidney function. While allopurinol can cause drowsiness, this is not the purpose for this child. There is no indication that the child has gout or is likely to develop gout. ➧ Test-taking Tip: Focus on the knowledge that chemotherapy will destroy multiple cells increasing uric acid levels. Use this cue to select the correct option.

A client seeks medical attention because of pain that develops while walking. An ankle-brachial index (ABI) test is ordered, and the results show that the client has ratios of 1.4 and 1.3 bilaterally. Based on these results, a nurse determines that the client: 1. has severe peripheral arterial disease. 2. would benefit from the medication ticlopidine hydrochloride (Ticlid®). 3. is experiencing pain that is psychological in origin. 4. needs further medical consultation to determine the cause of pain.

ANSWER: 4 The client requires further medical consultation because the ABI (comparison of blood pressure in ankle to the brachial blood pressure) is normal in each leg. A result of less than 0.9 is diagnostic of peripheral arterial disease. Based on the results of the ABI, the client has normal arterial circulation and would not benefit from ticlopidine hydrochloride. There is no information relating the pain to a psychological concern. ➧ Test-taking Tip: Apply knowledge of normal ABI values (greater than 0.9) to select the correct option.

1013. A nurse admits a client to a hospital and obtains a nursing history. The client tells the nurse that he had an endovascular repair of an abdominal aortic aneurysm found 1 year earlier during a routine screening. The nurse understands that this procedure consists of: 1. excision of the aneurysm and placement of a graft percutaneously. 2. an angioplasty with placement of a stent around the outside of the aorta. 3. placement of a filter within the aneurysm to block clots from becoming emboli. 4. placement of a stent graft inside the aorta that excludes the aneurysm from circulation.

ANSWER: 4 The endovascular repair consists of placement of the endovascular stent graft inside the aorta extending above and below the aneurysmal area to seal it off from the circulation. The aneurysm is left in place. Angioplasty (ballooning of plaque from the inside) is not involved and the stent is placed inside the aorta. Filters are not involved. ➧ Test-taking Tip: Apply knowledge of medical terminology: the prefix "endo-" means internal. Use the process of elimination, eliminating all but options 3 and 4. Then eliminate option 3 after noting the word "repair" in the question.

A nurse is caring for a client who has been repeatedly hospitalized in hypertensive crisis for failing to take prescribed antihypertensive medications. The client states, "I stop taking the blood pressure medication when my blood pressure is okay because I can't afford the medications." Which nursing diagnosis is the best for the nurse to include in the client's plan of care? 1. Knowledge deficit related to medication actions 2. Ineffective health maintenance related to repeated hospital admissions 3. Ineffective therapeutic regimen management related to poor blood pressure control 4. Noncompliance related to the cost of medications

ANSWER: 4 The goal of client teaching should be considered before selecting a nursing diagnosis. Because the goal of teaching should be to remove barriers to complying with the treatment plan, the nursing diagnosis is noncompliance. Though options 1, 2, and 3 may be appropriate, option 4 is best because the client is not taking the medication due to its cost. ➧ Test-taking Tip:The key word is "best." Focus on the information provided in the situation and match it with the second half of the nursing diagnosis to select the best option

Two days ago, a client had a femoral-popliteal artery bypass graft surgery. A priority nursing action at this time should be to: 1. monitor intake and output. 2. report any edema that develops in the operative leg. 3. maintain the client at a 60-degree sitting position when resting in bed. 4. monitor the dorsalis pedis and posterior tibial pulses bilaterally every 4 hours.

ANSWER: 4 The priority nursing action should be to monitor the pulses in the feet to detect graft occlusion. Intake and output is important but not the priority. Because of the surgery and improved circulation, edema in the operative leg is an expected outcome. Bending from the hip or knee should be limited to avoid graft occlusion. ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation) to select the priority action of circulation and option 4.

A nurse is assessing a blood pressure of an adult client with a manual sphygmomanometer. The nurse places the bell diaphragm of the stethoscope over the brachial artery and pumps the cuff up to 180 mm Hg. The valve is released to allow a drop of 2 mm Hg per second. At 162 mm Hg the nurse hears the first tapping sound. The sound becomes muffled at 148 mm Hg. The sound changes to a soft thumping at the 138 mm Hg. The sound fades to a muffled blowing sound at 128 mm Hg and is last heard at 94 mm Hg. There is silence at 92 mm Hg. The nurse should document the blood pressure as: 1. 138/92 mm Hg. 2. 148/94 mm Hg. 3. 162/92 mm Hg. 4. 162/94 mm Hg.

ANSWER: 4 The systolic blood pressure is elicited at the pressure where the first clear tapping sound is heard. The diastolic blood pressure is elicited at the pressure where the last sound is heard. ➧ Test-taking Tip: Consider the skill of auscultation of blood pressure. Phase 1 of Korotkoff sounds begins when the first faint clear tapping sound is heard (systolic blood pressure). The sounds change as the cuff is deflated through phases 2, 3, 4, and 5 and then silence. The diastolic blood pressure is the pressure at which the last sound is heard.

A physician documents that a client, diagnosed with stage III non-Hodgkin's lymphoma (NHL), is experiencing "B symptoms." A nurse interprets this to mean that the client has: 1. bleeding associated with low platelets counts. 2. a B lymphocyte malignancy and has progressed to an untreatable stage. 3. symptoms from exposure to a viral infection, such as Epstein-Barr virus. 4. recurrent fever, drenching night sweats, and an unintentional weight loss of 10% or more.

ANSWER: 4 Typically, NHL is not diagnosed until it progresses to stage III or IV because the client is asymptomatic. One-third of persons with NHL will have "B symptoms" at stage III or IV. Options 1, 2, and 3 do not describe "B symptoms." Most NHLs involve the B lymphocytes; only 5% involve the T lymphocytes. Treatment varies and depends on the actual classification of the disease, the stage, prior treatment (if any), and the person's ability to tolerate therapy. Although the cause of NHL is unknown, there is an increased incidence in people with viral infections. ➧ Test-taking Tip: Select the option that focuses on symptoms (note plural).

An 85-year-old female client seeks medical attention in an emergency department because of chest pain. She tells a nurse that the chest pain is stabbing through the chest into her back. Her blood pressure is 230/130 mm Hg. The nurse realizes that these findings are most suggestive of 1. pulmonary embolism. 2. subclavian steal syndrome. 3. acute arterial occlusion. 4. aortic dissection.

ANSWER: 4 With aortic dissection, the intimal layer of the aorta is torn and blood enters and further separates the layers of the aorta. This causes ripping, moving pain as the process occurs. The blood pressure is significantly elevated until complications occur. Pulmonary embolism produces sudden dyspnea with pleuritic chest pain (occurs with breathing movement). Acute arterial occlusion produces sudden pain in the area distal to the occlusion with loss of pulses. Subclavian steal syndrome is a slowly developing condition that produces weakness and ischemia in an upper extremity. ➧ Test-taking Tip: The issue of the question is that the condition causes severe stabbing chest and back pain, and elevated blood pressure. The back pain, along with the other symptoms, should be a clue that this involves the aorta. Select the only option that pertains to the aorta.