EXIT HESI Review

Famotidine 20 mg IVBP is prescribed for a client with a duodenal ulcer. The medication is diluted in 50 mL of 5% dextrose and is to infuse over 15 minutes. At what rate should the infusion control device be set. Record your answer using a whole number.

200 mL/hr

A client eats a meal that contains 13 g of fat, 31 g of carbs, and 5 g of protein. What is the client's total caloric intake for this meal?

261 calories

What type of interview is most appropriate when the nurse admits a client to the clinic? A) Directive B) Exploratory C) Problem solving D) Information giving

B) Exploratory

What potential complication does the nurse anticipate when admitting a client with the diagnosis of severe prolapse of the uterus? A) Edema B) Fistulas C) Exudate D) Ulcerations

D) Ulcerations

Genetic testing is being discussed with a couple at the fertility clinic. What is the nurse's best response when they express concerns? A) "You should be tested because it will be to your benefit." B) "Environmental factors can have an impact on genetic factors." C) "This type of testing will determine if you'll need in vitro fertilization." D) "If you have a gene for a disease there is a probability that your children will inherit it."

B) "Environmental factors can have an impact on genetic factors."

A client with schizophrenia, paranoid type, is readmitted involuntarily to the hospital because family members state that he has threatened to harm them physically. When exploring feelings about the readmission, the client angrily shouts, "You're one of them. Leave me alone!" How should the nurse respond? A) "Try not to be afraid. I will not hurt you." B) "I can see you are upset. We can talk more later." C) "I am not one of them, and I am here to help you." D) "Your family and the staff are trying to help you."

B) "I can see you are upset. We can talk more later."

A registered nurse is teaching the student nurse the precautions to follow when blood samples are collected. Which statement made by the student nurse indicates effective learning? A) "I can place the specimen with other samples." B) "I can use a single-lumen line to obtain samples." C) "I should not reveal the test procedure to the client." D) "I should not place the blood samples collected for adrenaline on ice."

B) "I can use a single-lumen line to obtain samples." - Usage of double- or triple-lumen lines for obtaining samples may contaminate the sample. Therefore, only single-lumen lines should be used. The samples should be stored separately to avoid contamination. The procedure of testing should be discussed with the client to obtain proper results. Blood samples drawn for catecholamines must be placed on ice and taken to the laboratory immediately.

A client is hospitalized with a tentative diagnosis of pancreatic cancer. On admission the client asks the nurse, "Do you think I have anything serious, like cancer?" What is the nurse's best reply? A) "What makes you think you have cancer?" B) "I don't know if you do; let's talk about it." C) "Why don't you discuss this with your healthcare provider?" D) "You needn't worry now; we won't know the answer for a few days."

B) "I don't know if you do; let's talk about it."

A child has cystic fibrosis. Which statement by the parents about their plan for the child's dietary regimen provides evidence that they understand the nurse's instructions? A) "I will restrict fluids during mealtimes." B) "I will discontinue the use of salt while cooking." C) "I should provide high-calorie foods between meals." D) "I should eliminate whole milk products from the diet."

C) "I should provide high-calorie foods between meals." - Children with cystic fibrosis require 150% more calories than the average child. Fluids should not be restricted because patients with CF have thick secretions and fluids will thin them out. There is no need to eliminate salt or dairy from the diet.

A nurse is counseling a postmenopausal obese client how to prevent bone loss. Which statements indicate understanding of the strategies to prevent bone loss. Select all that apply. A) "I must go on a strict diet." B) "I will take 400 mg of vitamin D daily." C) "I should take 1200 mg of calcium daily." D) "Swimming or bike riding 5 times a week is good for me." E) "Joining an aerobics class 3 times a week will help my bones."

C) "I should take 1200 mg of calcium daily." E) "Joining an aerobics class 3 times a week will help my bones."

During a prenatal visit, a client at 36 weeks' gestation tells a nurse that she has painful, irregular contractions. What should the nurse recommend? A) Lie down until they stop B) Time them for at least 1 hour C) Walk around until they subside D) Take 1 over-the-counter analgesic

C) Walk around until they subside - Walking around until the contractions subside will differentiate true from false labor.

In which order should the nurse implement these actions when withdrawing a solution from an ampule?

Flick the stem several times with a finger. Wrap the neck with a protective device. Break the neck by pressing thumbs outward. Stabilize ampule on a firm surface. Withdraw the solution using a filter needle. - Flicking the stem ensures all medication is in the bottom of the ampule. Wrapping the neck with a protective device (such as a small gauze pad or alcohol prep pad) protects fingers from trauma as the glass tip is broken off. Snapping the neck of the ampule quickly and outwards minimizes the nurse's risk of injury from shattering glass. Stabilizing the ampule assists in maintaining sterility as the needle is placed to withdraw the solution. Withdrawing the solution with a filter needle protects against aspirating microscopic glass into the syringe.

A client had a suprapubic prostatectomy. Which type of tube can the nurse expect the client to have when he returns to his room from the PACU? A) Cystostomy B) NG C) Nephrostomy D) Ureterostomy

A) Cystostomy

What clinical indicators should a nurse identify when assessing a client with pyrexia (fever)? Select all that apply. A) Dyspnea B) Flushed face C) Precordial pain D) Increased pulse rate E) Increased blood pressure

B) Flushed face D) Increased pulse rate

When teaching irrigation of a colostomy, how many inches above the stoma should the nurse teach the client to hold the container? A) 15 cm (6 inches) B) 25 cm (10 inches) C) 30 cm (12 inches) D) 45 cm (18 inches)

C) 30 cm (12 inches)

A nurse is instructing a group of volunteer nurses on the technique of administering the smallpox vaccine. What injection method should the nurse teach? A) Z-track B) IV C) SQ D) Intradermal scratch

D) Intradermal scratch

A nurse is caring for a child with spasmodic croup. Which clinical finding alerts the nurse that immediate nursing intervention is required? A) Irritability B) Hoarseness C) Barking cough D) Rapid respirations

D) Rapid respirations

Dopamine (Intropin), 5 mcg/kg/min, is prescribed for a client who weighs 105 kg. The nurse mixes 400 mg of dopamine in 250 mL D5W for IV administration via an infusion pump. What is the hourly rate that the nurse should set on the pump?

20 mL/hr

A client admitted to the ED has ketones in the blood and urine. Which situation associated with this physiologic finding should be the nurse's focus when collecting additional data about this client? A) Starvation B) Alcoholism C) Bone healing D) Positive nitrogen balance

A) Starvation - In starvation there are inadequate carbohydrates available for immediate energy, and stored fats are used in excessive amounts, producing ketones.

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

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

A client receives spinal anesthesia during labor and birth. Twenty-four hours later, she tells a nurse that she has a headache. Which statements indicate to the nurse that the headache is a reaction to the anesthesia? Select all that apply. A) "I have ringing in my ears." B) "It improves when I lie down." C) "Bright lights really bother my eyes." D) "It gets better as soon as I walk a while." E) "My head hurts more when I am sitting watching tv." F) My head hurts more when I am lying on my side breastfeeding."

A) "I have ringing in my ears." B) "It improves when I lie down." C) "Bright lights really bother my eyes." E) "My head hurts more when I am sitting watching tv."

When encouraging a client to cough and deep breath after a bilateral mastectomy, the client says, "Leave me alone! Don't you know I'm in pain?" What is the nurse's best response? A) "I know it hurts to cough, but try to use the IS." B) "We'll start this tomorrow; I will give you something for your pain." C) "I understand that you are in pain; rest now, and I'll come back later." D) "Your pain is to be expected, but you must attempt to expand your lungs."

A) "I know it hurts to cough, but try to use the IS."

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

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

The nurse is teaching a nursing student about caring for a client who is undergoing blood studies for antidiuretic hormone stimulation. Which statements made by the nursing student indicate effective instruction? Select all that apply. A) "I will assess the pulse rate after rehydrating the client." B) "I will perform the test if the serum sodium level is high." C) "I will perform the test if the osmolarity is 200 mOsm (mmol)/kg." D) "I will hydrate the client with oral fluids before performing the test." E) "I will discontinue the test if the client's weight loss is greater than 4.4 lbs (2 kg)."

A) "I will assess the pulse rate after rehydrating the client." C) "I will perform the test if the osmolarity is 200 mOsm (mmol)/kg." E) "I will discontinue the test if the client's weight loss is greater than 4.4 lbs (2 kg)." - The client's pulse rate and blood pressure should be assessed after rehydration for orthostatic hypertension after the procedure to ensure adequate fluid volume. The test should be performed if the serum osmolarity is less than 300 mOsm (mmol)/kg to avoid severe dehydration in clients who have central or nephrogenic diabetes insipidus. The test should be discontinued if the client's weight loss is greater than 2 kg. The test should not be performed if the serum sodium levels are high because severe dehydration may develop in central or nephrogenic diabetes insipidus clients. The client should have nothing by mouth before the test. Oral fluids are given to the client to rehydrate if the client is experiencing dehydration during the test.

After assessing a client, the nurse anticipates that the client has hyperpituitarism. Which questions asked by the nurse helps confirm the diagnosis? Select all that apply. A) "Is there any change in your vision?" B) "Do you experience severe headaches?" C) "Are you suffering with frequent urination?" D) "Do you eat more than five times a day?" E) "Is there any change in your menstrual cycle?

A) "Is there any change in your vision?" B) "Do you experience severe headaches?" E) "Is there any change in your menstrual cycle? - Hyperpituitarism manifests with vision disturbances and severe headaches. Due to hypersecretion of prolactin in females, a change in menstrual cycle may also be observed. Frequent urination is observed in a client with diabetes insipidus. Clients with diabetes mellitus experience intense hunger.

Which instructions should the nurse provide to an adolescent female client who is initiating treatment with isotretinoin (Accutane) for acne vulgaris? (Select all that apply.) A) "Notify the health care provider immediately if you think you are pregnant." B) "If your acne gets worse, stop the medication and call the health care provider." C) "Take a daily multiple vitamin to prevent deficiencies and promote dermal healing." D) "Dermabrasion for deep acne scars should be postponed for 1 month after therapy is stopped." E) "If you begin crying more than usual and feel sad, stop the drug and call the health care provider." F) "Before, during, and after therapy, two effective forms of birth control must be used at the same time."

A) "Notify the health care provider immediately if you think you are pregnant." E) "If you begin crying more than usual and feel sad, stop the drug and call the health care provider." F) "Before, during, and after therapy, two effective forms of birth control must be used at the same time." - (A, E, and F) are correct. Isotretinoin (Accutane) has been found to cause pregnancy category D drug-related birth defects, premature births, and fetal death (A), which necessitates the use of effective birth control methods before, during, and after therapy (F). Accutane is associated with sadness (E), depression, suicidal ideations, and other serious mental health problems. An initial exacerbation of acne (B) is common when starting drug therapy. Accutane is a retinoid related to vitamin A, and taking additional multivitamin supplements (C) can predispose the client to vitamin A toxicity. The client should stop taking Accutane at least 6 months before cosmetic procedures, such as dermabrasion (D), because the drug can increase the chances of scarring.

A client with diabetes asks the nurse whether the new forearm stick glucose monitor gives the same results as a fingerstick. What is the nurse's best response to this question? A) "There is no difference between readings." B) These types of monitors are meant for children." C) "Readings are on a different scale for each monitor." D) "Faster readings can be obtained from a fingerstick."

A) "There is no difference between readings."

A nurse is teaching an adolescent about type 1 diabetes and self-care. Which client questions indicate a need for additional teaching in the cognitive domain? Select all that apply. A) "What is diabetes?" B) "What will my friends think?" C) "How do I give myself an injection?" D) "Can you tell me how the glucose monitor works?" E) "How do I get the insulin from the vial into the syringe?"

A) "What is diabetes?" D) "Can you tell me how the glucose monitor works?" - Option C falls in the affective domain. Option E falls into the psychomotor domain.

Before discharge, a client who had a colostomy for colorectal cancer questions the nurse about resuming activity. What should the nurse teach the client about activity? A) "With guidance, a near-normal lifestyle, include complete sexual function, is possible." B) "Activities of daily living should be resumed as soon as possible so you avoid being depressed." C) Most sports activities, except for swimming, can be resumed based on your overall physical condition." D) "After surgery, changes in activities must be made to accommodate for physiologic changes caused by the operation."

A) "With guidance, a near-normal lifestyle, include complete sexual function, is possible."

A client who is scheduled to have an abdominal panhysterectomy asks the nurse how the surgery will affect her periods. How should the nurse respond? A) "You will not have any more periods." B) "Your periods will become more regular." C) "Your periods will become lighter until they disappear." D) "You will notice that the time between periods will be longer."

A) "You will not have any more periods."

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

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

As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider? A) A 6-month-old with failure to thrive that has a closed anterior fontanel. B) A 24-month-old with gastroenteritis that has a closed posterior fontanel. C) A 2-month-old with chickenpox that has an open posterior fontanel. D) A 28-month-old with hydrocephalus that has an open anterior fontanel.

A) A 6-month-old with failure to thrive that has a closed anterior fontanel. - At six months of age the anterior fontanel should be open, and it should not be closed until approximately 18 months of age. (B and C) are normal findings. A child with hydrocephalus may have a delayed closing of the fontanel (D).

A nurse is caring for a client after a left pneumonectomy for cancer. The nurse palpates the client's trachea routinely. What is the rationale for this nursing intervention? A) A mediastinal shift may have occurred B) Nodular lesions may demonstrate metastasis C) Tracheal edema may lead to an obstructed airway D) The cuff on the endotracheal tube may be overinflated

A) A mediastinal shift may have occurred

Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A) A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B) Pneumonia, with a sputum culture of gram-negative bacteria C) Urinary tract infection, with positive blood cultures D) Culture of a diabetic foot ulcer shows gram-positive cocci

A) A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) - The client with colonized MRSA (A) is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy (B), which makes recovery very difficult. Positive blood cultures (C) indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer (D) at high risk for poor healing and bone infection.

Which clinical indicators identified by the nurse support the probably presence of fecal impaction in a client? Select all that apply. A) Abdominal cramps B) Fecal liquid seepage C) Hyperactive bowel sounds D) Bright red blood in the stool E) Decreased number of bowel movements

A) Abdominal cramps B) Fecal liquid seepage C) Hyperactive bowel sounds

A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response? A) Accept the client's behavior B) Explore the situation with the client C) Withdraw from contact with the client D) Tell the client the reason for the staff's actions

A) Accept the client's behavior - At this time, the client is using this behavior as a coping mechanism, and accepting the client's behavior is the best action by the nurse.

A nurse is caring for a client with diabetes who is scheduled for a radiographic study requiring contrast. What should the nurse expect the HCP to prescribe? A) Acetylcysteine before the test B) Renal-friendly contrast medium for the test C) Forced diuresis with mannitol after the test D) Hydration with dextrose and water throughout the test

A) Acetylcysteine before the test - Acetylcysteine is an antioxidant that scavenges oxygen free radicals, which are released when contrast medium causes cell death to renal tubular tissue; it also induces slight vasodilation.

An adult client has prescriptions for morphine sulfate 2.5 mg IV q6h and ketorolac (Toradol) 30 mg IV q6h. Which action should the nurse implement? A) Administer both medications according to the prescription. B) Hold the ketorolac to prevent an antagonistic effect. C) Hold the morphine to prevent an additive drug interaction. D) Contact the healthcare provider to clarify the prescription.

A) Administer both medications according to the prescription. - Morphine and ketorolac (Toradol) can be administered concurrently (A), and may produce an additive analgesic effect, resulting in the ability to reduce the dose of morphine, as seen in this prescription. Toradol is an antiinflammatory analgesic, and does not have an antagonistic effect with morphine (B), like an agonist-antagonist medication would have. An additive analgesic effect is desirable (C), because it allows a reduced dose of morphine. This prescription does not require any clarification, and can be administered safely as written (D).

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

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

The nurse places a heating pad on the lower leg of a client with peripheral vascular disease (PVD). When the heating pad is removed, the client's skin is blistered and a full-thickness burn is evident. What consequence can occur based on the nurse's action? A) All elements are present to find the nurse liable for damages. B) The injury was not foreseeable therefore the nurse is not liable. C) Client harm occurred which is enough evidence to prove liability. D) The standard of care was not breached so the nurse is not liable.

A) All elements are present to find the nurse liable for damages. - The nurse has a duty to deliver safe care. If that duty is breached, the injury foreseeable, and the client suffers harm, then the elements for establishing liability are present (A). In caring for a client with PVD, the nurse should anticipate that heat injury (B) is possible and provide the standard of care to prevent harm (D). Client harm (C) represents only one element and should not be the lone criteria for determining liability.

A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas? A) Ammonia level B) Culture and sensitivity C) WBC count D) AST level

A) Ammonia level

A client with a third-degree uterine prolapse is scheduled for a vaginoplasty. What should the nurse anticipate the surgeon will order? A) Encourage ambulation B) Elevate the foot of the bed C) Apply moist compresses to the uterus D) Support the prolapsed uterus with a sanitary pad

C) Apply moist compresses to the uterus

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

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

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

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

A client enters the emergency department, reporting shortness of breath and epigastric distress. What should be the triage nurse's first intervention? A) Assess vital signs B) Insert a saline lock C) Place client on oxygen D) Draw blood for troponins

A) Assess vital signs

An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement? A) Assist the client to walk to the bathroom and do not leave the client alone. B) Request that the UAP assist the client onto a bedpan. C) Ask if the client needs to have a bowel movement or void. D) Assess the client's bladder to determine if the client needs to urinate.

A) Assist the client to walk to the bathroom and do not leave the client alone. - Barbiturates cause central nervous system (CNS) depression and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom (A). A bedpan (B) is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, (C) is irrelevant in terms of meeting this client's safety needs. There is no indication that this client cannot voice her or his needs, so assessment of the bladder is not needed (D).

A spouse spends most of the day with a client who is receiving chemotherapy for an inoperable cancer. The spouse says to the nurse, "What can I do to help?" How can the nurse support the client's spouse? A) Assist the couple to maintain open communication B) Offer the couple a description of the disease progression C) Instruct the spouse about the action of the mediations D) Meet privately with the spouse to explore feelings

A) Assist the couple to maintain open communication

The nurse notes a client's postoperative leg is cool with a capillary refill greater than 4 seconds and calls the healthcare provider. After 30 minutes of not receiving a return call from the healthcare provider, which action should the nurse take first? A) Attempt to recall the same healthcare provider. B) Notify the hospital's on call nursing supervisor. C) Continue to monitor and call if there is a change. D) Describe the problem to the answering service.

A) Attempt to recall the same healthcare provider. - The healthcare provider may have inadvertently not received the first call, so (A) is the best action to take first. According to the TeamSTEPPS, two attempts should be made to notify the provider before proceeding through the chain of command (B). (C) should be implemented, but these assessment findings require immediate medical action. Although (D) is an option, the client's urgent condition needs treatment.

A nurse is providing discharge instructions for a client with a diagnosis of GERD. What should the nurse advise the client to do to limit symptoms of GERD? Select all that apply. A) Avoid heavy lifting B) Lie down after eating C) Avoid drinking alcohol D) Eat small, frequent meals E) Increase fluid intake with meals F) Wear an abdominal binder or girdle

A) Avoid heavy lifting C) Avoid drinking alcohol D) Eat small, frequent meals

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

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

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

A) Butorphanol (Stadol) - Butorphanol (Stadol) (A) is a mixed agonist-antagonist analgesic resulting in good analgesia but with less respiratory depression, nausea, and vomiting compared with opioid agonist analgesics (B, C, and D).

A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. A) Cool skin B) Photophobia C) Constipation D) Periorbital edema E) Decreased appetite

A) Cool skin C) Constipation D) Periorbital edema E) Decreased appetite - Cool skin is related to the decreased metabolic rate associated with insufficient thyroid hormone. Constipation results from a decrease in peristalsis related to the reduction in the metabolic rate associated with hypothyroidism. Periorbital and facial edemas are caused by changes that cause myxedema and third-space fluid effusion seen in hypothyroidism. Decreased appetite is related to metabolic and gastrointestinal manifestations of the hypothyroidism. Photophobia is associated with exophthalmos that occurs with hyperthyroidism.

A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority? A) Call the healthcare provider immediately if his nail beds appear blue. B) Check his fingers hourly for the first 48 hours to see that he is able to move them without pain. C) Be sure his arm remains above his heart for the first 24 hours. D) Take his temperature q4h for the next two days and call if an elevation is noted.

A) Call the healthcare provider immediately if his nail beds appear blue. - Cyanosis (A) indicates impaired circulation to fingers and should be reported immediately. Although the actions described in (B, C, and D) may be indicated, they are implemented rather excessively--and might tend to frighten the parents. It is not necessary to check the child's ability to move his fingers hourly for 2 days (B). Elevating the arm above the heart will help to decrease swelling but (C) is stated in a frightening way. It is not necessary to take the child's temperature q4h unless indicated by other symptoms.

A nurse is caring for a client with a history of COPD. WHat complications are most commonly associated with COPD? A) Cardiac problems B) Joint inflammation C) Kidney dysfunction D) Peripheral neuropathy

A) Cardiac problems

A nurse is teaching about excellent food sources of vitamin A for a client who is deficient in this vitamin. WHich foods should the nurse include in the teaching? Select all that apply. A) Carrots B) Oranges C) Tomatoes D) Skim milk E) Leafy greens

A) Carrots E) Leafy greens

Which action should the nurse implement when providing nasogastric (NG) feeding to an unresponsive client? A) Check residual volume every four hours. B) Stimulate the gag reflex every eight hours. C) Administer small amounts of the formula. D) Give the feeding while the client is supine.

A) Check residual volume every four hours. - The gastric residual volume should be assessed every four hours (A) to evaluate absorption of the feeding and to determine delayed gastric emptying. (C) is not indicated unless the client cannot tolerate the prescribed volume of feeding. (B and D) are contraindicated. Stimulating the gag reflex (B) and administering NG feedings while the client is supine (D) increases the risk of aspiration.

What should the nurse do when collecting a 24-hour urine specimen? A) Check to verify if a preservative is needed B) Weigh the client before starting the collection C) Discard the last voided specimen of the 24-hour period D) Assess the client's intake and output for the previous 24-hour period

A) Check to verify if a preservative is needed

A client with type 1 diabetes has an above-the-knee amputation because of severe lower extremity arterial disease. What is the nurse's primary responsibility two days after surgery when preparing the client to eat dinner? A) Checking the client's serum glucose level B) Assisting the client out of bed into a chair C) Placing the client in the high-Fowler position D) Ensuring the client's residual limb is elevated

A) Checking the client's serum glucose level - Because the client has type 1 diabetes, it is essential that the blood glucose level be determined before meals to evaluate the level of control of diabetes and the possible need for insulin coverage. To prevent flexion contractures of the hip, the client should not sit for a prolonged time; this is not the priority. Raising the head of the bed flexes the hips, which may result in hip flexion contractures; this is not the priority. Ensuring the client's residual limb is elevated may result in a hip flexion contracture and should be avoided.

Which measurements should be used to accurately calculate a pediatric medication dosage? (Select all that apply.) A) Child's height and weight. B) Adult dosage of medication. C) Body surface area of child. D) Average adult's body surface area. E) Average pediatric dosage of medication. F) Nomogram determined mathematical constant.

A) Child's height and weight. C) Body surface area of child. F) Nomogram determined mathematical constant. - Correct selections are (A, C, and F). The most accurate calculations of pediatric dosages use the child's height and weight (A). The child's BSA is calculated using the square root of weight in kg times height in cm divided by 3600 or the square root of weight in lb times height in inches divided by 3131 (C), then the child's BSA is multiplied by the recommended published dose per BSA. The nomogram (F) is used to plot the child's height and weight, and the point at which they intersect is the BSA mathematical constant used to calculate the child's dose. (B, D, and E) are not used to calculate pediatric dosages.

A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information? A) Children need to retain a sense of initiative without impinging on the rights and privileges of others. B) Negative feelings of doubt and shame are characteristic of 4-year-old children. C) Role conflict is a common problem of children this age. She is just wondering where she fits into society. D) At this age children compete and like to produce and carry through with tasks. She is just competing with her mother.

A) Children need to retain a sense of initiative without impinging on the rights and privileges of others. - Children aged 3 to 6 are in Erickson's "Initiative vs. Guilt" stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative without impinging on the rights of others (A). (B) describes the "Autonomy vs. Shame and Doubt," stage (1 to 3 years of age). (C) describes an adolescent (12 to 18 years of age), the "Identity vs. Role Confusion" stage. (D) describes a child 6 to 12 years of age, the "Industry vs. Inferiority" stage.

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

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

A nurse is assessing a client with a diagnosis of hemorrhoids. Which factors in the client's history probably played a role in the development of the client's hemorrhoids. Select all that apply. A) Constipation B) Hypertension C) Eating spicy foods D) Bowel incontinence E) Numerous pregnancies

A) Constipation E) Numerous pregnancies

What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. A) Count the client's respirations B) Document the intensity of the client's pain C) Withhold the medication if the client reports pruritus D) Verify the number of doses in the locked cabinet before administering the prescribed dose E) Discard the medication in the client's toilet before leaving the room if the medication is refused

A) Count the client's respirations B) Document the intensity of the client's pain D) Verify the number of doses in the locked cabinet before administering the prescribed dose - Pruritus is a common side effect that can be managed with antihistamines. The nurse should NOT discard the opioid in the patient's room. Any waste of an opioid must be witnessed by another nurse.

While preparing a client for her first Pap smear, a nurse determines that she appears anxious. What should the nurse include as part of the teaching plan? A) Current statistics on the incidence of cervical cancer B) Description of the early symptoms of cervical cancer C) Explanation of why there is a small risk for cervical cancer D) Written instructions about the purpose of a pap smear

A) Current statistics on the incidence of cervical cancer

The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain? A) Description of vomiting episodes in past 24 hours. B) Number of wet diapers in last 24 hours. Incorrect C) Feeding and sleep schedule. D) Amount of formula consumed during the past 24 hours.

A) Description of vomiting episodes in past 24 hours. - A description of the vomiting episodes (A) will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant. (B and C) provide related information but are not as helpful as (A). (D) may be related to the vomiting, but the nurse should first obtain a better description of the vomiting episodes.

Which intervention is most important for a nurse to implement prior to administering atropine PO? A) Determine the presence of 5 to 35 bowel sounds/min. B) Assess the blood pressure, both lying and standing. C) Verify that the client's tendon reflexes are 2+. D) Have the client rate his or her pain on a 0 to 10 scale.

A) Determine the presence of 5 to 35 bowel sounds/min. - Anticholinergic drugs, such as atropine, have antispasmodic and antisecretory properties, which relax the gastrointestinal tract, and are therefore contraindicated in a client with intestinal atony (A). Anticholinergic drugs do not have an effect on (B) (used to determine dehydration) or (C). Atropine itself has no analgesic effect; it is used with opioids to potentiate their effect (D).

Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply. A) Diarrhea B) Listlessness C) Weight loss D) Bradycardia E) Decreased appetite

A) Diarrhea C) Weight loss

A client has an anterior and posterior surgical repair of a cystocele and rectocele and returns from the PACU with an indwelling catheter in place. What should the nurse tell the client about the primary reasons for the catheter? A) Discomfort is minimized B) Bladder tone is maintained C) Urinary retention is prevented D) Pressure on the suture line is relieved E) Hourly urine output can be easily measured

A) Discomfort is minimized C) Urinary retention is prevented D) Pressure on the suture line is relieved

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

A) Document that the client responds to painful stimulus. - The client has demonstrated a purposeful response to pain, which should be documented as such (A). Response to painful stimulus is assessed after response to verbal stimulus, not before (B). There is no indication for placing the client on seizure precautions (C). Reporting (D) is nonpurposeful movement.

A nurse is assessing a client with a diagnosis of hypothyroidism. Which clinical manifestation should the nurse expect when assessing this client? Select all that apply. A) Dry skin B) Brittle hair C) Weight loss D) Resting tremors E) Heat intolerance

A) Dry skin B) Brittle hair

A nurse is caring for a client with cholelithasis and obstructive jaundice. When assessing this client, the nurse should be alert for which common clinical indication associated with this condition? Select all that apply. A) Ecchymosis B) Yellow sclera C) Dark brown stool D) Straw-colored urine E) Pain in the right upper quadrant

A) Ecchymosis B) Yellow sclera E) Pain in the right upper quadrant

The nurse is providing care for a client with small-cell carcinoma of the lung who develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What clinical findings correspond with the secretion of antidiuretic hormone (ADH)? Select all that apply. A) Edema B) Polyuria C) Bradycardia D) Hypotension E) Hyponatremia

A) Edema E) Hyponatremia - Edema results as fluid is retained because of the increased secretion of antidiuretic hormone. ADH causes water retention, which dilutes serum electrolytes such as sodium, with a resultant hyponatremia. A decreased urine output occurs with SIADH because ADH causes reabsorption of fluid in the kidney glomeruli. The increased fluid volume associated with SIADH results in tachycardia, tachypnea, and crackles. The increased fluid volume associated with SIADH results in hypertension, not hypotension.

Fludrocortisone is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse instruct the client to report? Select all that apply. A) Edema B) Rapid weight gain C) Fatigue in the afternoon D) Unpredictable changes in mood E) Increased frequency of urination

A) Edema B) Rapid weight gain

A chemotherapeutic regimen with doxorubicin HCl (Adriamycin) is being planned for a client recently diagnosed with cancer. What diagnostic test results should the nurse review prior to initiating this treatment? A) Electrocardiogram (ECG) B) Arterial blood gases (ABGs) C) Serum cholesterol level D) Pelvic ultrasound

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

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

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

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A) Encourage the client to see the clinic's grief counselor. B) Determine if the client has a family history of suicide attempts. C) Inquire about whether the life partner was suffering from AIDS. D) Consult with the health care provider about the client's need for antidepressant medications.

A) Encourage the client to see the clinic's grief counselor. - The client is exhibiting normal grieving behaviors, so referral to a grief counselor (A) is the most important intervention for the nurse to implement. (B) is indicated, but is not a high-priority intervention. (C) is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated (D), depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one.

A nurse is working with a client who has the diagnosis of borderline personality disorder with antisocial behavior. What personality traits should the nurse expect the client to exhibit. Select all that apply. A) Engaging B) Indecisive C) Withdrawn D) Manipulative E) Perfectionist

A) Engaging D) Manipulative

What nursing actions best promote communication when obtaining a nursing history? Select all that apply. A) Establishing eye contact B) Paraphrasing the client's message C) Asking "why" and "how" questions D) Using broad, open-ended statements E) Reassuring the client that there is no cause for alarm F) Asking questions that can be answered with a "yes" or "no"

A) Establishing eye contact B) Paraphrasing the client's message D) Using broad, open-ended statements

A client with a brain tumor develops a urine output of 300 mL/hr, dry skin, and dry mucous membranes. Which nursing intervention is the most appropriate to perform for this client? A) Evaluate urine specific gravity. B) Implement fluid restrictions. C) Provide emollients to the skin to prevent breakdown. D) Slow down the intravenous (IV) fluids and notify the primary healthcare provider

A) Evaluate urine specific gravity. - Urine output of 300 mL/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce antidiuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There is no indication to reduce fluids. Providing emollients to prevent skin breakdown is important but does not assist with determining the underlying cause of the increased urine output. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

A client who has just had a kidney transplant is transferred from the PACU to the ICU. How often should the nurse in the ICU monitor the client's urinary output? A) Every hour B) Every 2 hours C) Every half hour D) Every 15 minutes

A) Every hour

A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include that will decrease the risk of complications? Select all that apply. A) Examining the feet daily B) Wearing well-fitting shoes C) Performing regular exercise D) Powdering the feet after showering E) Visiting the HCP weekly F) Testing bathwater with the toes before bathing

A) Examining the feet daily B) Wearing well-fitting shoes C) Performing regular exercise

A client with hyperlipidemia receives a prescription for niacin (Niaspan). Which client teaching is most important for the nurse to provide? A) Expected duration of flushing. B) Symptoms of hyperglycemia. C) Diets that minimize GI irritation. D) Comfort measures for pruritis.

A) Expected duration of flushing - Flushing of the face and neck, lasting up to an hour, is a frequent reason for discontinuing niacin. Inclusion of this effect in client teaching (A) may promote compliance in taking the medication. While (B, C, and D) are all worthwhile instructions to help clients minimize or cope with normal side effects associated with niacin (Niaspan), flushing is intense and causes the most concern for the client.

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

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

A nurse is counseling a couple in the fertility clinic. Which aspect of the protocol is the most stressful for the couple? A) Planning when to have intercourse B) Obtaining the necessary specimens C) Visiting the fertility clinic frequently D) Taking daily basal body temperatures

A) Planning when to have intercourse

A client is diagnosed with hyperthyroidism and is treated with 131I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms should be included in the teaching? Select all that apply. A) Fatigue B) Dry skin C) Insomnia D) Intolerance to heat E) Progressive weight gain

A) Fatigue B) Dry skin E) Progressive weight gain - Fatigue is caused by a decreased metabolic rate associated with hypothyroidism. Dry skin most likely is caused by decreased glandular function associated with hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decrease in the metabolic rate because of insufficient thyroid hormone. Insomnia is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone.

A nurse is caring for an underweight adolescent girl who is diagnosed with anorexia nervosa. WHat are common characteristics of girls with this disorder that the nurse should identify when obtaining a health history and performing a physical assessment. Select all that apply. A) Fatigue B) Pyrexia C) Tachycardia D) Heat intolerance E) Secondary amenorrhea

A) Fatigue E) Secondary amenorrhea

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

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

A client who had surgery for a ruptured appendix develops peritonitis. What clinical findings related to peritonitis should the nurse expect the client to exhibit. Select all that apply. A) Fever B) Hyperactivity C) Extreme hunger D) Urinary retention E) Abdominal muscle rigidity

A) Fever D) Urinary retention

To avoid a false positive result for fecal occult blood in a stool specimen, the nurse should instruct the client to avoid ingestion of which substances prior to collecting a sample? (Select all that apply.) A) Fish. B) Beef. C) Vitamin C tablets. D) Turkey. E) Ibuprofen (Advil). F) Coffee.

A) Fish. B) Beef. C) Vitamin C tablets. E) Ibuprofen (Advil). - Correct selections are (A, B, C, and E). The fecal occult blood test, or guaiac test, measures microscopic amounts of blood in the feces. False positive results can occur from food products such as fish (A), beef and other red meats (B), green vegetables, vitamin C supplements (C), aspirin, and nonsteroidal antiinflammatory medications, including ibuprofen (E). (D and F) do not affect the results of fecal occult blood testing.

An active adolescent is admitted to the hospital for surgery for an ileostomy. WHen planning a teaching session about self-care, the nurse includes sports that should be avoided by this client. Which should be included on the list of sports to avoid? Select all that apply. A) Football B) Swimming C) Ice hockey D) Track events E) Cross-country skiing

A) Football C) Ice hockey

Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her HCP. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? A) Give the infant to the client and instruct her regarding the infant's care B) Explain to the client that she can leave, but her infant must remain in the hospital C) Emphasize to the client that the infant is a minor and legally must remain until orders are received D) Tell the client that hospital policy prevents the staff from releasing the infant until ready to discharge

A) Give the infant to the client and instruct her regarding the infant's care - When a client signs herself and her infant out of the hospital, she is legally responsible for her infant.

When a developmental appraisal is performed on a 6-month-old infant, which observation is most important to the nurse in light of a diagnosis of hydrocephalus? A) Head lag B) Positive Babinski reflex C) Inability to sit unsupported D) Absence of the grasp reflex

A) Head lag

The cervix of a client in labor is dilated 8 cm. She tells the nurse that she has the desire to push and is becoming increasingly uncomfortable. She requests pain medication. How should the nurse respond? A) Help her to take panting breaths B) Prepare the birthing bed for the birth C) Assist her out of bed to the bathroom D) Administer the prescribed butorphanol (Stadol)

A) Help her to take panting breaths

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A) Help the client dangle his legs. B) Apply compression stockings. C) Assist with passive leg exercises. D) Ambulate three times a day.

A) Help the client dangle his legs. - The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling (A), which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. (B) is indicated for venous insufficiency (C) and indicated for bed rest. Ambulation (D) is indicated to facilitate collateral circulation and may improve long-term complaints of pain.

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? A) Hepatitis C B) Influenza type B C) MMR D) DTaP

A) Hepatitis C

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply. A) Hirsutism B) Menorrhagia C) Buffalo hump D) Dependent edema E) Migraine headaches

A) Hirsutism C) Buffalo hump

A client with cancer of the colon had surgery for a resection of the tumor and the creation of a colostomy. During the 6-week postoperative checkup, the nurse teaches the client about nutrition. The nurse evaluates that learning has taken place when the client states, "I should follow a diet that is: A) Rich in protein B) Low in fiber content C) As close to usual as possible D) Higher in calories than before

C) As close to usual as possible

The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indication(s) best supports the client's need for insertion of an indwelling urinary catheter? (Select all that apply.) A) Hourly urine output B) Bladder distention C) Urinary incontinence D) Intraoperative bladder decompression E) Urine sample for culture

A) Hourly urine output B) Bladder distention D) Intraoperative bladder decompression - Continuous bladder drainage using an indwelling catheter is indicated for monitoring hourly urinary output (A), bladder distention (B), and bladder decompression (D) related to urinary retention under anesthesia. Less invasive measures, such as a condom catheter or bladder training for urinary incontinence (C) or midstream collection of urine for culture (E) are not indicated based on the client's description.

When planning care for a client with polycystic kidney disease, which collaborative problem has the highest priority? A) Hypertension. B) Calculi formation. C) Acute renal failure. D) Infection.

A) Hypertension. - Blood pressure control (A) has the highest priority, which is necessary to reduce cardiovascular complications and slow the progression of renal dysfunction, which can contribute to (B, C, and D).

A nurse is caring for a client who had an adrenalectomy. For what clinical response should the nurse monitor while steroid therapy is being regulated? A) Hypotension B) Hyperglycemia C) Sodium retention D) Potassium excretion

A) Hypotension - After an adrenalectomy, adrenal insufficiency causes hypotension because of fluid and electrolyte imbalances.

What should the nurse consider when obtaining informed consent from a 17-year-old adolescent? A) If the client is allowed to give consent B) The client cannot make informed decisions about health care C) If the client is permitted to give voluntary consent when parents are not available D) The client probably will be unable to choose between alternatives when asked to consent

A) If the client is allowed to give consent - A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent.

A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client's roommate has just turned on the shower in full force. What term best describes this experience? A) Illusion B) Delusion C) Dissociation D) Hallucination

A) Illusion - An illusion is a misperception of an actual stimulus

Three days after birth, a breastfeeding newborn becomes jaundice. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin level. The test result is 12 mg/DL. The nurse explains that it is physiologic jaundice, a benign condition which is caused by: A) Immature liver function B) An inability to synthesize bile C) An increased maternal hemoglobin level D) High hemoglobin with low hematocrit levels

A) Immature liver function

A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. WHat should the nurse conclude is the reason why metabolic acidosis develops with kidney failure? A) Inability of the renal tubules to secrete hydrogen ions to conserve bicarbonate B) Depressed RR by metabolic wastes, causing CO2 retention C) Inability of the renal tubules to reabsorb water to dilute the acid contents of blood D) Impaired glomerular filtration, causing retention of sodium and metabolic waste products

A) Inability of the renal tubules to secrete hydrogen ions to conserve bicarbonate

Which instruction(s) should the nurse give to a female client who just received a prescription for oral metronidazole (Flagyl) for treatment of trichomonas vaginalis? (Select all that apply.) A) Increase fluid intake, especially cranberry juice. B) Do not abruptly discontinue the medication; taper use. C) Check blood pressure daily to detect hypertension. D) Avoid drinking alcohol while taking this medication. E) Use condoms until treatment is completed. F) Ensure that all sexual partners are treated at the same time.

A) Increase fluid intake, especially cranberry juice. D) Avoid drinking alcohol while taking this medication. E) Use condoms until treatment is completed. F) Ensure that all sexual partners are treated at the same time. - Correct selections are (A, D, E, and F). Increased fluid intake and cranberry juice (A) are recommended for prevention and treatment of urinary tract infections, which frequently accompany vaginal infections. It is not necessary to taper use of this drug (B) or to check the blood pressure daily (C), as this condition is not related to hypertension. Flagyl can cause a disulfiram-like reaction if taken in conjunction with ingestion of alcohol, so the client should be instructed to avoid alcohol (D). All sexual partners should be treated at the same time (E) and condoms should be used until after treatment is completed to avoid reinfection (F).

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

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

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

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

Which clinical indicators can the nurse expect when assessing a client with Cushing syndrome? Select all that apply. A) Lability of mood B) Slow wound healing C) A decrease in the growth of hair D) Ectomorphism with a moon face E) An increased resistance to bruising

A) Lability of mood B) Slow wound healing

A nurse applies an ice pack to a client's leg for 20 minutes. What clinical indicator helps the nurse determine the effectiveness of the treatment? A) Local anesthesia B) Peripheral vasodilation C) Depression of VS D) Decreased viscosity of blood

A) Local anesthesia

A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin (Pitocin) infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign should the nurse monitor with greater frequency than the typical unit protocol? A) Maternal temperature B) Fetal blood pressure C) Maternal respiratory rate D) Fetal heart rate E) Maternal temperature

A) Maternal temperature - (A) should be monitored frequently as a primary indicator of infection. This client's rupture of membranes (ROM) occurred at least 20 hours ago (12 hours before coming to the hospital, in addition to 8 hours since hospital admission). Delivery is not imminent, and there is an increased risk of the development of infection 24 hours after ROM. (B) cannot be established with standard bedside monitoring. (C) is not specifically related to ROM. (D) is always monitored during labor; this situation would not prompt the nurse to increase FHR monitoring.

A client with arthritis increases the dose of ibuprofen to abate joint discomfort. After several weeks the client becomes increasingly weak. The HCP determines that the client is severely anemia and admits the client to the hospital. What clinical indicators does the nurse expect to identify when performing an assessment? Select all that apply. A) Melena B) Tachycardia C) Constipation D) Clay-colored stools E) Painful BM

A) Melena B) Tachycardia

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which classic signs of hepatic coma should the nurse assess this client? Select all that apply. A) Mental confusion B) Increased cholesterol C) Brown-colored stools D) Flapping hand tremors E) Hyperactive DTRS

A) Mental confusion D) Flapping hand tremors

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

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

A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply.) A) Monitor the the infant's weight and number of wet diapers per day. B) Increase the infant's intake per feeding by 1 to 2 ounces per week. C) Mix the dose of prophylactic antibiotic in a full bottle of formula. D) Allow the infant to rest and refeed on demand or every 2 hours. E) Use a softer nipple or increase the size of the nipple opening.

A) Monitor the the infant's weight and number of wet diapers per day. B) Increase the infant's intake per feeding by 1 to 2 ounces per week. D) Allow the infant to rest and refeed on demand or every 2 hours. E) Use a softer nipple or increase the size of the nipple opening. - Correct responses are (A, B, D, and E). Neonates who have VSD may fatigue quickly during feeding and ingest inadequate amounts. They should be monitored for weight gain and at least 6 wet diapers per day (A). A one-month old infant should ingest 2 to 4 ounces of formula per feeding and progress to about 30 ounces per day by 4-months of age (B). Due to fatigue, the infant should rest, but feed at least every 2 hours to ensure adequate intake (D). A softer (preemie) nipple or a larger slit in the nipple (E) helps to reduce the sucking effort and energy expenditure, thus allowing the infant to ingest more with less effort. Antibiotic prophylaxis is recommended for infants with VSDs, but should not be mixed in a bottle of formula (C) because it is difficult to ensure that the total dose is consumed.

Which is an independent nursing action that should be included in the plan of care for a client after an episode of ketoacidosis? A) Monitoring for signs of hypoglycemia as a result of treatment B) Withholding glucose in any form until the situation is corrected C) Giving fruit juices, broth, and milk as soon as the client is able to take fluids orally D) Regulating insulin dosage according to the amount of ketones found in the client's urine

A) Monitoring for signs of hypoglycemia as a result of treatment - During treatment for acidosis, hypoglycemia may develop; careful observation for this complication should be made by the nurse. Whole milk and fruit juices are high in carbohydrates which are contraindicated in DKA (Option C).

What is the priority nursing intervention on admission of a primigravida in labor? A) Monitoring the fetal heart rate B) Asking the client when she last ate C) Obtaining the client's health history D) Determining if membranes have ruptured

A) Monitoring the fetal heart rate - Monitoring the fetus for signs of distress typically takes priority.

A client is diagnosed with Crohn's disease, and parenteral vitamins are prescribed. The client asks why the vitamin has to be given IV rather than by mouth. What rationals for this route should the nurse include in a response to the question? Select all that apply. A) More rapid action results B) They are ineffective orally C) They decrease colon irritability D) Intestinal absorption may be inadequate E) Allergic responses are less likely to occur

A) More rapid action results B) They are ineffective orally D) Intestinal absorption may be inadequate

Thiamine (Vitamin B1) and niacin (Vitamin B3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in a teaching plan? A) Neuronal activity B) Bowel elimination C) Efficient circulation D) Prothrombin development

A) Neuronal activity

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

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

A client returns to the postoperative unit after a gastroduodenostomy (Billroth I) for treatment of a perforated ulcer. The healthcare provider's prescriptions include morphine with a patient-controlled analgesia (PCA), nasogastric tube (NGT) to low intermittent nasogastric suction, and IV fluids and antibiotics. The client complains of increasing abdominal pain 12 hours after returning to the surgical unit. The nurse determines the client has no bowel sounds, and 200 ml of bright red nasogastric drainage is in the suction canister in the past hour. What is the priority action the nurse should implement? A) Notify the healthcare provider. B) Irrigate the nasogastric tube per prescription. C) Assess the client's use of the PCA device. D) Splint the abdomen to relieve pressure on the incision.

A) Notify the healthcare provider. - Although nasogastric aspirate can be bright red initially, the color should gradually darken over the first 24 hours. A sudden increase in the volume of bright red gastric drainage indicates bleeding, and the healthcare provider should be notified immediately (A). (B, C, and D) should be implemented, but the client's complaints of pain and signs of bleeding require immediate action to prevent hemorrhagic shock.

A nurse is assessing a client who is experiencing postmenopausal bleeding. The tentative diagnosis is endometrial cancer. Which findings in the client's history are risk factors associated with endometrial cancer? Select all that apply. A) Obesity B) Mullparity C) Cigarette smoking D) Early onset of menopause E) Family history of endometrial cancer F) Previous hormonal replacement therapy

A) Obesity E) Family history of endometrial cancer F) Previous hormonal replacement therapy

Contraceptives that have estrogen-like and/or progesterone like compounds are prepared in a variety of forms. Which contraceptives should the nurse identify as having a hormonal component? Select all that apply. A) Oral contraceptives B) Diaphragms C) Cervical caps D) Female condoms E) Foam spermicides F) Transdermal agents

A) Oral contraceptives E) Foam spermicides F) Transdermal agents

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

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

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? A) Orient the client to the unit environment B) Have a copy of hospital regulations available C) Explain that there is no reason to be concerned D) Reassure the client that the staff is available to answer questions

A) Orient the client to the unit environment

A nurse is caring for a client who had insertion of radium for cancer of the cervix. For what radium reaction should the nurse assess the client? A) Pain B) Nausea C) Excoriation D) Restlessness

A) Pain

A nurse is caring for a client who is admitted with urethral colic and hematuria. The client also has stage 1 HTN and is overweight. The decrease in which clinical indicator associated with this client's status should the nurse be most concerned about at this time? A) Pain B) Weight C) Hematuria D) HTN

A) Pain

A nurse is assessing a client who is being admitted for a surgical repair of a rectocele. What signs or symptoms does the nurse expect the client to report? Select all that apply. A) Painful intercourse B) Crampy abdominal pain C) Bearing-down sensation D) Urinary stress incontinence E) Recurrent UTI's

A) Painful intercourse C) Bearing-down sensation

Which glands secrete hormones that regulate metabolism of carbohydrates, proteins, and fats? Select all that apply. A) Pancreas B) Thyroid gland C) Adrenal cortex D) Adrenal medulla E) Parathyroid gland

A) Pancreas B) Thyroid gland C) Adrenal cortex - The pancreas secretes insulin and glucagon, which affects the body's metabolism of carbohydrates, proteins, and fats. The thyroid gland secretes thyroid hormones T3 and T4 that regulate carbohydrates, proteins, and fat metabolism. Cortisol is a glucocorticoid secreted by the adrenal cortex that affects carbohydrates, proteins, and fat metabolism. Adrenal medulla secretes catecholamines, which do not affect metabolism of carbohydrates, proteins, and fats. Hormones secreted by the parathyroid gland mainly regulate calcium and phosphorus metabolism.

When a disaster occurs, the nurse may have to treat mass hysteria first. Which response indicates that an individual should be cared for first? A) Panic B) Coma C) Euphoria D) Depression

A) Panic

A child with cystic fibrosis is receiving ticarcillin disodium (Ticar) for Pseudomonas pneumonia. For which adverse effect should the nurse assess and report promptly to the health care provider? A) Petechiae B) Tinnitus C) Oliguria D) Hypertension

A) Petechiae - Adverse effects of ticarcillin disodium (Ticar) include hypothrombinemia and decreased platelet adhesion, which can result in the presence of petechiae (A). (B, C, and D) are not adverse effects primarily associated with the administration of Ticar.

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A) Place the client in a side-lying position. B) Pull the auricle upward and outward. C) Hold the dropper 6 cm above the ear canal. D) Place a cotton ball into the inner canal. E) Pull the auricle down and back.

A) Place the client in a side-lying position. B) Pull the auricle upward and outward. - The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated with growth hormone therapy, should the nurse plan to describe to the child and his family? A) Polyuria and polydipsia. B) Lethargy and fatigue. C) Increased facial hair. D) Facial bone structure changes.

A) Polyuria and polydipsia. - Signs and symptoms of diabetes or hyperglycemia (A) need to be reported. Those receiving growth hormone should be monitored to detect elevated blood sugars and glucose intolerance. (B) is associated with any number of heath alterations, but is not associated with the growth hormone therapy. (C and D) are normal changes that occur with 12-year-old males.

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A) Pulse characteristics B) Open airway C) Entrance and exit wounds D) Cervical spine injury

A) Pulse characteristics - Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity (A) is a priority. Because the client is talking, he has an open airway (B), so that assessment is not necessary. Assessing for (C and D) should occur after assessing for adequate circulation.

Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis? A) Receives long-term steroid therapy B) Has a history of hypoparathyroidism C) Engages in strenuous physical activity D) Consumes high doses of the hormone estrogen

A) Receives long-term steroid therapy - Increased levels of steroids increase bone demineralization.

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

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

What should the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Select all that apply. A) Refrain from smoking around the infant. B) Refrain from co-sleeping or bed-sharing. C) Position the infant on the side while sleeping. D) Use soft pillows to support the infant while sleeping. E) Refrain from placing stuffed toys on the infant's bed.

A) Refrain from smoking around the infant. B) Refrain from co-sleeping or bed-sharing. E) Refrain from placing stuffed toys on the infant's bed. - The nurse should instruct the parents to avoid exposing the infant to cigarette smoke because the chemicals place the infant at a greater risk for sudden infant death syndrome (SIDS). Co-sleeping or bed-sharing is also associated with SIDS. The nurse should ask the parents to refrain from placing stuffed toys on the infant's bed as a precautionary measure against SIDS. The infant should be positioned on his or her back to reduce the incidence of SIDS. Parents should not use soft mattresses or pillows in the infant's crib to reduce the risk for SIDS.

A client with diabetes states, "I cannot eat big meals; I prefer to snack throughout the day." What information should the nurse include in a response to this client's statement? A) Regulated food intake is basic to control B) Salt and sugar restriction is the main concern C) Small, frequent meals are better for digestion D) Large meals can contribute to weight problems

A) Regulated food intake is basic to control

A nurse is providing dietary teaching for a client who is receiving a high-protein diet while recovering from an acute episode of colitis. What should the nurse include in the rationale for this diet? A) Repairs tissues B) Slows peristalsis C) Corrects the anemia D) Improves muscle tone

A) Repairs tissues

Minocycline (Minocin), 50 mg PO every 8 hours, is prescribed for an adolescent girl diagnosed with acne. The nurse discusses self-care with the client while she is taking the medication. Which teaching points should be included in the discussion? (Select all that apply.) A) Report vaginal itching or discharge. B) Take the medication at 0800, 1500, and 2200 hours. C) Protect skin from natural and artificial ultraviolet light. D) Avoid driving until response to medication is known. E) Take with an antacid tablet to prevent nausea. F) Use a nonhormonal method of contraception if sexually active.

A) Report vaginal itching or discharge. C) Protect skin from natural and artificial ultraviolet light. D) Avoid driving until response to medication is known. F) Use a nonhormonal method of contraception if sexually active. - Correct selections are (A, C, D, and F). Adverse effects of tetracyclines include superinfections, photosensitivity, and decreased efficacy of oral contraceptives. Therefore, the client should report vaginal itching or discharge (A), protect the skin from ultraviolet light (C), and use a nonhormonal method of contraception (F) while on the medication. Minocycline (Minocin) is known to cause dizziness and ataxia, so until the client's response to the medication is known, driving (D) should be avoided. Tetracyclines should be taken around the clock (B) but exhibit decreased absorption when taken with antacids, so (E) is contraindicated.

A hospitalized client is receiving pyridostigmine for control of myasthenia gravis. In the middle of the night, the nurse finds the client weak and barely able to move. Which additional clinical findings support the conclusion that these responses are related to pyridostigmine? Select all that apply. A) Respiratory depression B) Distension of the bladder C) Decreased blood pressure D) Fine tremor of the fingers E) High-pitched gurgling bowel sounds

A) Respiratory depression C) Decreased blood pressure E) High-pitched gurgling bowel sounds

A client has a thyroidectomy for cancer of the thyroid. When evaluating for nerve injury, what should the client be asked to do? A) Speak B) Swallow C) Purse the lips D) Turn the head

A) Speak - The laryngeal nerve is close to the operative site and can be damaged inadvertently. Loss of the gag reflex occurs with general anesthesia; the ability to swallow signifies its return. The ability to purse the lips tests the seventh cranial (facial) nerve, which is not affected in thyroid surgery. The nerves involved in turning the head are not near the thyroid gland.

The nurse witnesses a male client's signature for surgical consent for a Billroth II procedure after the surgeon discusses the procedure and its implication with the client. After signing the consent, the client questions the importance of a change in his diet postoperatively. What action should the nurse implement? A) Review information about dumping syndrome. B) Have the client sign another consent. C) Notify the surgeon about the client's comment. D) Explain the surgical procedure.

A) Review information about dumping syndrome. - Further review of information about potential dumping syndrome (A), which is managed postoperatively with dietary modification after a Billroth II procedure (partial gastrectomy), should be explained to address the client's expressed concern. (B) is not necessary since informed consent verifies the client's understanding of surgical risks and the surgical procedure. (C) is not indicated because the client does not question his consent for the surgery. (D) may be indicated if the client asks for further interpretation of the surgeons's explanation.

Which client is most likely to be at risk for spiritual distress? A) Roman Catholic woman considering an abortion B) Jewish man considering hospice care for his wife C) Seventh-Day Adventist who needs a blood transfusion D) Muslim man who needs a total knee replacement

A) Roman Catholic woman considering an abortion - In the Roman Catholic religion, any type of abortion is prohibited (A), so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith (B). Jehovah's Witnesses prohibit blood transfusions, not Seventh-Day Adventists (C). There is no conflict in the Muslim faith with regard to joint replacement (D).

The nurse is assessing a client admitted to the hospital with a tentative diagnosis of an adrenal cortex tumor. When assessing the client, which of these are signs of Cushing disease? Select all that apply. A) Round face B) Dependent edema in the feet and ankles C) Increased fatty deposition in the extremities D) Thin, translucent skin with bruising E) Increased fatty deposition in the neck and back

A) Round face B) Dependent edema in the feet and ankles D) Thin, translucent skin with bruising E) Increased fatty deposition in the neck and back - Changes in fat distribution may result in a round face and fat pads on the neck, back, and shoulders. There are increased levels of steroids and aldosterone, causing sodium and water retention in clients with Cushing syndrome. This increased fluid retention results in dependent peripheral edema. Skin changes result from increased blood vessel fragility and include bruises and thin or translucent skin. The extremities appear thinner from muscle wasting and weakness, not thicker from fatty deposition. Hypertension, not hypotension, is expected because of sodium and water retention.

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

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

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

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

A nurse is teaching sterile technique to a family member of a client who is to be discharged with a large abdominal wound that requires a dressing change twice a day. What does the family member do during a return demonstration that indicates further teaching is necessary? A) Sets the sterile field on the client's linens at the front of the bed B) Touches the outer inch of the sterile field when placing it on a flat surface C) Checks expiration dates on the sterile packages before donning sterile gloves D) Picks up wet gauze with sterile plastic forceps, holding the tips lower than the wrist

A) Sets the sterile field on the client's linens at the front of the bed

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) A) Shave the area where the TENS will be placed. B) Obtain small needles for insertion. C) Place the TENS unit directly over or near the site of pain. D) Explain to the client that drowsiness may occur immediately after using TENS. E) Describe the use of TENS for postoperative procedures such as dressing changes.

A) Shave the area where the TENS will be placed. C) Place the TENS unit directly over or near the site of pain. E) Describe the use of TENS for postoperative procedures such as dressing changes. - The correct choices are (A, C, and E). The TENS unit consists of a battery-operated transmitter, lead wires, and electrodes. The electrodes are placed directly over or near the site of pain (C), and hair or skin preparations should be removed before attaching the electrodes (A). The TENS unit is useful for managing postoperative pain or pain associated with postoperative procedures, such as removing drains or changing dressings (E). Electrodes are used, not needles (B) and, unlike with opioids, pain relief is achieved without drowsiness (D).

A nurse is teaching clients to determine the time of ovulation by taking the basal temperature. What change is expected to occur in the basal temperature during ovulation? A) Slight drop and then rises B) Sudden rise and then drops C) Marked rise and remains high D) Marked drop and remains lower

A) Slight drop and then rises

A client is recovering from an acute episode of alcoholism that included esophageal involvement. What are the components of a therapeutic diet that are most appropriate for the nurse to include in the teaching plan for this client? Select all that apply. A) Soft diet B) Regular diet C) Low-protein diet D) High-protein diet E) Low-carbohydrate diet F) High-carbohydrate diet

A) Soft diet D) High-protein diet F) High-carbohydrate diet

Oxytocin (Pitocin) augmentation via IV piggyback (IVPB) is prescribed for a client in labor after a period of ineffective uterine contractions. What nursing interventions are most important if strong contractions that last 90 seconds or longer occur? Select all that apply. A) Stop the infusion B) Turn the client on her side C) Notify the HCP D) Verify the length of contractions E) Administer oxygen via a face mask

A) Stop the infusion B) Turn the client on her side C) Notify the HCP D) Verify the length of contractions E) Administer oxygen via a face mask

A nurse is monitoring for clinical manifestations of infection in a client with a diagnosis of Addison disease. Which body mechanism related to infections process does the nurse conclude is impaired as a result of this disease? A) Stress response B) Electrolyte balance C) Metabolic process D) Respiratory function

A) Stress response - Because of diminished glucocorticoid production, there is a decreased response to stress, reducing the ability to fight infection.

A homeless person is brought into the ED after prolonged exposure to cold weather. WHat clinical manifestations of hypothermia does the nurse anticipate? Select all that apply. A) Stupor B) Erythema C) Increased anxiety D) Rapid respirations E) Paresthesia in the affected body parts

A) Stupor E) Paresthesia in the affected body parts

During the initial nursing assessment history, a client tells the nurse that he is taking tetracycline hydrochloride (Sumycin) for urethritis. Which medication taken concurrently with Sumycin could interfere with its absorption? A) Sucralfate (Carafate) B) Hydrochlorothiazide (Diuril) C) Acetaminophen (Tylenol) D) Phenytoin (Dilantin)

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

A client is being treated for osteoporosis with alendronate (Fosamax), and the nurse has completed discharge teaching regarding medication administration. Which morning schedule would indicate to the nurse that the client teaching has been effective? A) Take medication, go for a 30 minute morning walk, then eat breakfast. B) Take medication, rest in bed for 30 minutes, eat breakfast, go for morning walk. C) Take medication with breakfast, then take a 30 minute morning walk. D) Go for a 30 minute morning walk, eat breakfast, then take medication.

A) Take medication, go for a 30 minute morning walk, then eat breakfast. - Alendronate (Fosamax) is best absorbed when taken thirty minutes before eating in the morning. The client should also be advised to remain in an upright position for at least thirty minutes after taking the medication to reduce the risk of esophageal reflux and irritation. (A) is the best schedule to meet these needs. (B, C, and D) do not meet these criteria.

The health care provider prescribes oral contraceptives for a client who wants to prevent pregnancy. Which information is the most important for the nurse to provide to this client? A) Take one pill at the same time every day until all the pills are gone. B) Use condoms and foam instead of the pill while on any antibiotics. C) Limit sexual intercourse for at least one cycle after starting the pill. D) Use another contraceptive if two or more pills are missed in one cycle

A) Take one pill at the same time every day until all the pills are gone. - To maintain adequate hormonal levels for contraception and enhance compliance, oral contraceptives should be taken at the same time each day (A). There is no strong pharmacokinetic evidence that shows a relationship between the category of broad-spectrum antibiotic use and altered hormone levels in oral contraceptive users, so (B) is not indicated at this time. Abstinence (C) is the best method to prevent pregnancy during the first cycle. If a client misses two pills during the first week (D), the client should take two pills a day for 2 days and finish the package while using a backup method of birth control until her next menstrual cycle.

A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100° F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take? A) Tell the student to proceed directly to his regularly scheduled class. B) Call the parent and suggest re-taking the student's temperature at home. C) Give the student a glass of cool fluids, then retake his temperature. D) Send the student to class, but re-verify his temperature after lunch.

A) Tell the student to proceed directly to his regularly scheduled class. - This student has just completed football practice, and increased muscle activity increases body heat production. A temperature of 100° F is normal for this student at this time. The student should attend class (A) since no further nursing action is required. (B) would alarm the parents unnecessarily. (C) would provide a false reading of body temperature. (D) is unnecessary since these findings are within normal limits.

Which situation requires intervention by the nurse who is caring for a terminally ill client in a hospital? A) The case manager notifies the family that the critical pathway requires transfer to a hospice facility. B) The case manager notifies the social worker of the client's financial needs related to hospice care. C) The social worker describes the client's feelings of grief to the spiritual counselor. D) The social worker provides information about long-term care facilities to the client.

A) The case manager notifies the family that the critical pathway requires transfer to a hospice facility. - Critical pathways provide care guidelines, rather than required methods of care. The nurse should intervene in the situation described in (A) to ensure that the client and family are aware of options available. (B, C, and D) reflect appropriate actions by members of the interdisciplinary team, and require no intervention by the nurse.

Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse? A) The color of the dialysate outflow is opaque yellow. B) The dialysate outflow is greater than the inflow. C) The inflow dialysate feels warm to the touch. D) The inflow dialysate contains potassium chloride.

A) The color of the dialysate outflow is opaque yellow. - Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider (A). (B and C) are desired. (D) is commonly done to prevent hypokalemia.

A nurse is caring for a client in albor. What client response indicates that the transition phase of labor probably has begun? A) Assume the lithotomy position B) Perspires that he has a flushed face C) Indicates back and perineal pain D) Exhibits decrease in frequency of contractions

B) Perspires that he has a flushed face

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

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

An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while this monitor is in place? A) The most comfortable position can be assumed B) Monitoring is more accurate in the side-lying position C) The monitor leads can be detached when sitting on the bedpan D) Maintaining a supine position holds the internal electrodes in place

A) The most comfortable position can be assumed

A nurse checking the perineum of a client with a radium implant for cervical cancer observes the packing protruding from the vagina. Why must the nurse notify the HCP to remove it immediately? A) The radioactive packing will injure healthy tissue B) Removal of the packing will prevent excessive blood loss C) The exposure of radium to the environment will diminish its effectiveness D ) Removal of the packing will minimize life-threatening contact with the radiation

A) The radioactive packing will injure healthy tissue

A client with schizophrenia has been experiencing hallucinations. During what client behaviors should the nurse expect the hallucinations to be more frequent? A) Trying to rest B) Playing sports C) Watching television D) Interacting with others

A) Trying to rest

The clinic nurse is taking the history for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain? A) Type of reaction to loud noises. B) Any surgeries on the ears since birth. C) Drainage from the infant's ears. D) Number of ear infections since birth.

A) Type of reaction to loud noises. - Ototoxicity diminishes hearing acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing an infant's reaction to loud noises (A) helps to determine an infant's risk for a hearing deficit related to a history of the mother taking an ototoxic drug, such as aspirin, while pregnant. (B, C, and D) are not associated with exposure to aspirin in utero.

A client is admitted to the surgical unit from the PACU with a Salem sump NG tube that is to be attached to wall suction. Which nursing action should the nurse implement when caring for this client? A) Use NS to irrigate the tube B) Employ sterile technique when irrigating the tube C) Withdraw the tube quickly when decompression is terminated D) Allow the client to have small sips of ice water unless nauseated

A) Use NS to irrigate the tube

To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement? A) Use a happy-face/sad-face pain scale. B) Ask the mother if she thinks the analgesic is working. C) Assess for changes in the child's vital signs. D) Teach the child to point to a numeric pain scale.

A) Use a happy-face/sad-face pain scale. - A 4-year-old can readily identify with simple pictures (A) to show the nurse how he/she is feeling. (B) could be used to validate what the child is telling the nurse via the "faces" pain scale, but it is best to elicit the child's assessment of his/her pain level. (C) may not accurately reflect the effectiveness of pain medication as they can also be affected by other variables, such as fear. (D) requires abstract number skills beyond the level of a 4-year-old.

A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery? A) Use a pillow to keep the legs abducted B) Elevate the client's affected limb on a pillow C) Turn the client using the log-rolling technique D) Place a trochanter roll along the entire extremity

A) Use a pillow to keep the legs abducted

A category X drug is prescribed for a young adult female client. Which instruction is most important for the nurse to teach this client? A) Use a reliable form of birth control. B) Avoid exposure to ultra violet light. C) Refuse this medication if planning pregnancy. D) Abstain from intercourse while on this drug.

A) Use a reliable form of birth control. - Drugs classified in the category X place a client who is in the first trimester of pregnancy at risk for teratogenesis, so women in the childbearing years should be counseled to use a reliable form of birth control (A) during drug therapy. (B) is not a specific precaution with Category X drugs. The client should be encouraged to discuss plans for pregnancy with the healthcare provider, so a safer alternative prescription (C) can be provided if pregnancy occurs

A female client with rheumatoid arthritis take ibuprofen (Motrin) 600 mg PO 4 times a day. To prevent gastrointestinal bleeding, misoprostol (Cytotec) 100 mcg PO is prescribed. Which information is most important for the nurse to include in client teaching? A) Use contraception during intercourse. B) Ensure the Cytotec is taken on an empty stomach. C) Encourage oral fluid intake to prevent constipation. D) Take Cytotec 30 minutes prior to Motrin.

A) Use contraception during intercourse. - Cytotec, a synthetic form of a prostaglandin, is classified as pregnancy Category X and can act as an abortifacient, so the client should be instructed to use contraception during intercourse (A) to prevent loss of an early pregnancy. (B) is not necessary. A common side effect of Cytotec is diarrhea, so constipation prevention strategies are usually not needed (C). Cytotec and Motrin should be taken together (D) to provide protective properties against gastrointestinal bleeding.

A client is diagnosed with hyperthyroidism and is experincing exophthalmia. Which measures should the nurse include when teaching this client how to manage the discomfort associated with exophthalmia? Select all that apply. A) Use tinted glasses B) Use warm, moist compresses C) Elevated the HOB 45 degrees D) Tape eyelids shut at night if they do not close E) Apply a petroleum-based jelly along the lower eyelid

A) Use tinted glasses C) Elevated the HOB 45 degrees D) Tape eyelids shut at night if they do not close

A newborn with acquired herpes simplex virus infection is being discharged. Which developmental pattern is important for the nurse to teach the parents to monitor? A) Visual clarity B) Renal function C) Long bone growth D) Responses to sounds

A) Visual clarity - Ocular disease is common in patients with herpes simplex virus infections.

How should the nurse prepare an IV piggyback medication for administration to a client receiving an IV infusion? Select all that apply. A) Wear clean gloves to check the IV site B) Rotate the bag after adding the medication C) Use 100 mL of fluid to mix the medication D) Change the needle before adding the medication E) Place the IVPB at a lower level than the existing IV F) Use sterile technique when preparing the medication

A) Wear clean gloves to check the IV site B) Rotate the bag after adding the medication F) Use sterile technique when preparing the medication

The nurse is preparing the 0900 dose of losartan (Cozaar), an angiotensin II receptor blocker (ARB), for a client with hypertension and heart failure. The nurse reviews the client's laboratory results and notes that the client's serum potassium level is 5.9 mEq/L. What action should the nurse take first? A) Withhold the scheduled dose. B) Check the client's apical pulse. C) Notify the healthcare provider. D) Repeat the serum potassium level.

A) Withhold the scheduled dose. - The nurse should first withhold the scheduled dose of Cozaar (A) because the client is hyperkalemic (normal range 3.5 to 5 mEq/L). Although hypokalemia is usually associated with diuretic therapy in heart failure, hyperkalemia is associated with several heart failure medications, including ARBs. Because hyperkalemia may lead to cardiac dysrhythmias, the nurse should check the apical pulse for rate and rhythm (B), and the blood pressure. Before repeating the serum study (D), the nurse should notify the healthcare provider (C) of the findings.

A nurse is assessing a male newborn. Which characteristics should alert the nurse to conclude that the newborn is a preterm infant? Select all that apply. A) Wrinkled, thin skin B) Multiple sole creases C) Small breast bud size D) Presence of scrotal rugae E) Pinna remaining flat when folded

A) Wrinkled, thin skin C) Small breast bud size E) Pinna remaining flat when folded

After being medicated for anxiety, a client says to a nurse, "I guess you are too busy to stay with me." How should the nurse respond? A) "I'm so sorry, but I need to see other clients." B) "I have to go now, but I will come back in 10 minutes." C) "You'll be able to rest after the medicine starts working." D) "You'll feel better after I've made you more comfortable."

B) "I have to go now, but I will come back in 10 minutes." - The response "I have to go now, but I will come back in 10 minutes" demonstrates that the nurse cares about the client and will have time for the client's special emotional needs. This approach allays anxiety and reduces emotional stress. Saying "I'm so sorry, but I need to see other clients" indicates that the nurse's other tasks are more important than the client's needs. Telling the client "you'll be able to rest after the medicine starts working" is false reassurance and not therapeutic. Saying "you'll feel better after I've made you more comfortable" does not respond to the client's need and cuts off communication.

After a teaching session, the nurse evaluates the client's understanding of hypoparathyroidism. Which statement made by the client indicates the need for further education? A) "I should eat an orange a day." B) "I should include yogurt in my diet." C) "I should perform mild exercises daily." D) "I should sit outside in the sun."

B) "I should include yogurt in my diet." - Further education is needed for the client. Clients with hypoparathyroidism have hypocalcemia. In order to replenish the calcium levels of the body, the client should consume foods that are rich in calcium. However, foods rich in phosphorus such as yogurt, processed cheese, and milk should be avoided. All the other comments are correct and require no further education by the nurse. Oranges are good source of vitamin C and fibers. They help to improve healing and remove wastes from the body. Exercising is good for overall health. Sitting in the sun allows exposure of the client to sunlight, which is a natural source of vitamin D. Vitamin D helps in the absorption of calcium from the gastrointestinal tract.

The registered nurse is teaching a nursing student about nursing care principles for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education? A) "I should encourage fluid intake." B) "I should provide conditional positive support." C) "I should promote social interaction based on abilities." D) "I should provide ongoing assistance to family caregiver."

B) "I should provide conditional positive support." - When caring for cognitively impaired older adult, the nurse should provide unconditional positive support and respect. The nurse should encourage the client to drink fluids. The nurse should promote social interactions based on abilities. The nurse should provide ongoing assistance to family caregivers, educate them in nursing care techniques, and inform them about community resources.

At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 tonight?" What is the nurse's best response? A) "I will give one capsule tonight before bedtime." B) "I will get a prescription so that the medication can be taken." C) "Does your HCP know about your child's allergy?" D) "Did you ask your HCP if your child should have this tonight?"

B) "I will get a prescription so that the medication can be taken." - Legally, a nurse cannot administer medications without a prescription from a legally licensed individual.

A client is learning alternative site testing for glucose monitoring. Which client statement indicates to the nurse that additional teaching is necessary? A) "I need to rub my forearm vigorously until warm before testing at this site." B) "The fingertip is prefered for glucose monitoring if hyperglycemia is suspected." C) "Alternative site testing is unsafe if I am experiencing a rapid change in glucose levels." D) "I have to make sure that my current glucose monitor can be used at an alternative site."

B) "The fingertip is prefered for glucose monitoring if hyperglycemia is suspected." - The fingertip is prefered for glucose monitoring if HYPOGLYCEMIA is suspected, not hyperglycemia.

Parents are considering a bone marrow transplant for the child who has recurrent leukemia. THe parents ask the nurse for clarification about the procedure. What is the best response by the nurse? A) "It is rarely performed in children." B) "The immune system must be destroyed before a transplant can take place." C) "The hematopoietic stem cells are surgically implanted in the bone marrow." D) "It is a simple procedure with little preparation needed, and the stem cells are infused as in a blood transfusion."

B) "The immune system must be destroyed before a transplant can take place."

A CBC, urinalysis, and x-ray examination of the chest are ordered for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse? A) "Don't worry; these tests are routine." B) "They are done to identify other health risks." C) "They determine whether surgery will be safe." D) "I don't know; your health care provider ordered them."

B) "They are done to identify other health risks."

During the postpartum period a client with heart disease and type 2 diabetes asks a nurse, "Which contraceptives will I be able to use to prevent pregnancy in the near future?" How should the nurse respond? A) "You may use oral contraceptives because they are almost completely effective in preventing pregnancy." B) "You should use foam with a condom to prevent pregnancy because this is the safest method for women with your illness." C) "You will find that the intrauterine device is best for you because it prevents a fertilized ovum from implanting in the uterus." D) "You do not need to worry about becoming pregnant in the near future because women with your illness usually become infertile."

B) "You should use foam with a condom to prevent pregnancy because this is the safest method for women with your illness."

A client on a psychiatric unit who has been hearing vices is receiving a neuroleptic medication for the first time. The client takes the cup of water and the pill and stares at them. What is the most therapeutic statement the nurse can make? A) "You have to take your medicine." B) "Your doctor wants you to have this medicine. Swallow it." C) "There must be a reason why you don't want to take your medicine." D) "This is the medication that your doctor ordered for you to make you well."

B) "Your doctor wants you to have this medicine. Swallow it."

The charge nurse working the 3 to 11 shift of a 24-bed medical unit in a large acute care hospital is making assignments. Currently, there are 20 clients on the unit and 4 admissions are scheduled to arrive during the shift. Besides the charge nurse, the staff consists of two experienced practical nurses (PN) and one unlicensed assistive personnel (UAP) who has worked on the unit for 10 years. Taking into consideration the acuity of each client, which distribution of clients is the best assignment for the nurse to make? A) 10 clients and 2 admissions to each of the PNs. Have the UAP take all vital signs and collect all I&Os. B) 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions. C) 8 clients to each of the PNs, 4 clients to the charge nurse, and the 4 admissions to the UAP. D) 8 clients to each of the PNs, 4 admissions to the charge nurse, and 4 low-acuity clients to the UAP.

B) 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions. - Considering acuity level, it is best for the nurse to assign 10 clients to each of the PNs, have the UAP take vial signs and collect I&Os and the charge nurse care for the new admissions since they will all require assessment by the RN (B). The charge nurse should take admissions (A). The UAP is not qualified to conduct an admission assessment (C). The UAP, even with 10 years experience, is not qualified to take responsibility for total care of clients (D).

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

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

A Harris flush is ordered to reduce a client's flatus after abdominal surgery. How many inches should the nurse insert the rectal catheter? A) 2 B) 4 C) 6 D) 8

B) 4

A client with cellulitis is recovering at home after experiencing a severe reaction to a new prescription for ampicillin (Unisyn) that was administered by a home health nurse. The client's allergies to penicillin and sulfonamide are noted in all critical areas of the home health record. What consequence can occur based on the nurse's action? A) None since the action did not result in the client's wrongful death. B) A malpractice suit based on lack of reasonable and prudent care. C) Disciplinary action initiated by the state's nurse licensing board. D) An intentional tort based on failure to note the client's allergies.

B) A malpractice suit based on lack of reasonable and prudent care. - Medication errors involving failure to provide reasonable and prudent care, including improper documentation of medication administration, failure to recognize side effects or contraindications, and negligence in verifying a client's allergies, may result in a malpractice suit against the nurse (B). (A) does not take into account the client's documented allergies and reaction. Actions of discipline by licensing agencies (C) focus on repeated incompetent practice or substance abuse, not single error occurrences. An intentional tort (D) is a civil wrong made against a person that willfully violates another's rights, such as assault, battery, and/or false imprisonment.

The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that A) Only an RN should be assigned to monitor this child's temperature. B) A tympanic measurement of temperature will provide the most accurate reading. C) The licensed practical nurse should be instructed to obtain rectal temperatures on this child. D) The healthcare provider should be asked to prescribe the method for measurement of the child's temperatures.

B) A tympanic measurement of temperature will provide the most accurate reading. - (B) A tympanic membrane sensor is an excellent site because both the eardrum and hypothalamus (temperature-regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for management--sterile procedures should be assigned to licensed personnel. Management skills will be tested on the NCLEX! An RN is not required (A). Rectal temperature measurement (C) is less accurate because of the possibility of stool in the rectum. (D) is unnecessary.

When assessing an adolescent who recently overdosed on acetaminophen (Tylenol), it is most important for the nurse to assess for pain in which area of the body? A) Flank. B) Abdomen. C) Chest. D) Head.

B) Abdomen. - Acetaminophen toxicity can result in liver damage; therefore, it is especially important for the nurse to assess for pain in the right upper quadrant of the abdomen (B), which might indicate liver damage. (A, C, and D) are not areas where pain would be anticipated.

A client is admitted with a tentative diagnosis of pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolyte balance, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply. A) Provide a low-fat diet B) Administer analgesics C) Teach relaxation exercises D) Encourage walking in the hall E) Monitor cardiac rate and rhythm F) Observe for signs of hypercalcemia

B) Administer analgesics C) Teach relaxation exercises E) Monitor cardiac rate and rhythm

Which nursing interventions require the use of standard precautions? A) Giving a back rub B) Administering the first bath to a newborn C) Emptying a portable wound drainage system D) Interviewing a client in the ED E) Obtaining the BP of a client who is HIV positive

B) Administering the first bath to a newborn C) Emptying a portable wound drainage system

A client is scheduled for emergency abdominal surgery. What is the priority preoperative nursing objective when caring for this client? A) Recording accurate vital signs B) Alleviating the client's anxiety C) Teaching about early ambulation D) Maintaining the client's nutritional status

B) Alleviating the client's anxiety

A male client gives a copy of his living will to the nurse upon admission to the hospital. What action should the nurse implement if the client is unable to express his desire about life-prolonging measures? A) Ask the spouse to make decisions regarding life-saving measures. B) Allow the client to die with dignity and without life-prolonging techniques. C) Administer medications to ensure a painless death and end the client's suffering. D) Implement all measures of technical assistance and equipment to prolong life.

B) Allow the client to die with dignity and without life-prolonging techniques. - A living will is an advance directive that is prepared when an individual is competent to make decisions about end-of-life care that specifies withholding resuscitative measures that prolong life (B). The spouse can make decisions regarding the client's care (A) if there is a legal power-of-attorney document, not a living will. (C) is not a function of a living will. An individual should be provided life-support (D) unless a living will is available to define a client's wishes to withhold treatment that prolongs life.

A client has a diagnosis of hemorrhoids. Which signs and symptoms does the nurse expect the client to report. Select all that apply. A) Flatulence B) Anal itching C) Blood in stool D) Rectal pressure E) Pain when defecating

B) Anal itching C) Blood in stool D) Rectal pressure E) Pain when defecating

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

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

The nurse is assessing a 13-year-old girl with suspected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview? A) Have you lost any weight in the last month? B) Are you experiencing any type of nervousness? C) When was the last time you took your synthroid? D) Are you having any problems with your vision?

B) Are you experiencing any type of nervousness? - Assessing the client's physiological state upon admission is a priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism (B). Weight loss (even with a hearty appetite) (A) occurs in those with hyperthyroidism, but assessing the client's neurological state has a higher priority. Hormone replacement is not administered to a client who is already producing too much thyroid (C). The client may have exophthalmus (bulging eyes) but hyperthyroidism does not cause vision problems (D).

A primiparous client has been in labor for 15 hours. Two hours ago, vaginal examination revealed the cervix dilated to 5 cm, 100% effaced, and the presenting part at station 0. Five minutes ago, the vaginal examination reveals no change in the cervix or decent of the fetus. Which labor pattern should the nurse document to describe the client's progress? A) Protracted descent. B) Arrest of active phase. C) Prolonged latent phase. D) Protracted active phase.

B) Arrest of active phase. - Arrest of active phase (B) is indicated if there is no change in the dilation of the cervix for 2 hours or more in a primigravida. Prolonged latent phase (C) is labor lasting longer than 20 hours in a primigravida. Protracted active phase (D) occurs when dilatation of the cervix is less than 1.2 cm/hour. Protracted descent (A) occurs when the fetus decends less than 1 cm/hour into the pelvis.

Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; Paco2, 30 mm Hg; HCO3, 25 mEq/L; Pao2, 96 mm Hg. Which intervention should the nurse implement based on these results? A) Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B) Assess the client for pain and administer pain medication as prescribed. C) Encourage the client to take short shallow breaths for 5 minutes. D) Prepare to administer sodium bicarbonate IV over 30 minutes.

B) Assess the client for pain and administer pain medication as prescribed. - These ABGs reveal respiratory alkalosis (B), and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A Pao2 of 96 mm Hg does not indicate the need for an increase in oxygen administration (A). The Paco2 indicates mild hyperventilation, so (C) is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate (D) is indicated for the treatment of metabolic acidosis, not respiratory alkalosis.

A client is in the ICU after sustaining a T2 spinal cord injury. Which priority interventions should the nurse include in the client's plan of care? Select all that apply. A) Minimizing environmental stimuli B) Assessing for respiratory complications C) Monitoring and maintaining blood pressure D) Initiating a bowel and bladder training program E) Discussing long-term treatment plans with the family

B) Assessing for respiratory complications C) Monitoring and maintaining blood pressure

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? A) Analysis B) Assessment C) Nursing interventions D) Proposed nursing care

B) Assessment

A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? A) 3+ protein in the urine B) Blood urea nitrogen >25 mg/dL C) Blood pH >7.45 D) Urine output, 2500 mL/day

B) Blood urea nitrogen >25 mg/dL - Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level (B) indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria (A), an expected finding. Metabolic acidosis is the potential complication, not alkalosis (C). During the diuretic phase of acute renal failure, there can be a normal output volume (D) (approximately 2000 mL/day), which can result from IV fluid hydration.

A nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selected by the client indicates to the nurse that dietary teaching about thiazide diuretics was effective? A) Apples B) Broccoli C) Cherries D) Cauliflower

B) Broccoli - Thiazide diuretics get rid of potassium, so the patient should select a food high in potassium such as broccoli.

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

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

The nurse is teaching a client with cancer about opioid management for intractable pain and tolerance related side effects. The nurse should prepare the client for which side effect that is most likely to persist during long-term use of opioids? A) Sedation. B) Constipation. C) Urinary retention. D) Respiratory depression.

B) Constipation. - The client should be prepared to implement measures for constipation (B) which is the most likely persistent side effect related to opioid use. Tolerance to opiate narcotics is common, and the client may experience less sedation (A) and respiratory depression (D) as analgesic use continues. Opioids increase the tone in the urinary bladder sphincter, which causes retention (C) but may subside.

An exploratory laparotomy is performed on a client with melena, and gastric cancer is discovered. A partial gastrectomy is performed, and a jejunostomy tube is surgically implanted. A NG tube to suction is in place. What should the nurse expect regarding the client's NG tube drainage during the first 24 hours after surgery? A) Green and viscid B) Contain some blood and clots C) Contain large amounts of frank blood D) Similar to coffee grounds in color and consistency

B) Contain some blood and clots

The nurse enters a client's room to complete discharge preparations and finds the client in tears. The client states that someone from the business office insisted that a payment for the hospital bill be made before the client could leave. After providing comfort to the client, what is the best nursing action? A) Call the family to ask about the payment. B) Continue the client's discharge process. C) Resume the discharge when payment occurs. D) Notify the healthcare provider of the situation.

B) Continue the client's discharge process. - Detaining someone against one's wishes, such as physically or emotionally preventing a client from leaving a healthcare facility, is false imprisonment, which is an intentional tort. To prevent infringement of the clients' rights, the best action for the nurse is to continue the client's discharge preparations (B). Although (A, C, and D) may be options made by the client, the nurse should convey that the client is free to be discharged as prescribed.

A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first? A) Insert N/G tube for gastric lavage. B) Determine the child's pulse and respirations. C) Assess the child's level of consciousness. D) Administer an IV D5/0.25 NS as prescribed.

B) Determine the child's pulse and respirations. - The most important principle in dealing with a poisoning is to treat the child first, not the poison. Initiate immediate life support measures with assessment of vital signs (B), in particular, respirations. Inserting an airway or initiating mechanical ventilation may be necessary. Assessment and identification of the poison should occur prior to (A). (C and D) should occur after assessing the airway.

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

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

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

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

A client with a diagnosis of personality disorder with antisocial behavior is hospitalized. The client is openly discussing interpersonal difficulties with family members and the boss at work with whom money has been stolen. The client presently is facing criminal charges. Which behavior indicates that the client is meeting treatment goals? A) Expression of feelings of resentment toward the employer B) Discussion of plans for each of the possible outcomes of a trial C) Expression of resignation about difficult spousal and children relationships D) Discussion of the decision to file a grievance against the employer after discharge from the hospital

B) Discussion of plans for each of the possible outcomes of a trial

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? A) Rapid, thready pulse B) Distended jugular veins C) Elevated hematocrit level D) Increase serum sodium level

B) Distended jugular veins

A client with congestive heart failure (CHF) is being discharged with a new prescription for the angiotensin-converting enzyme (ACE) inhibitor captopril (Capoten). The nurse's discharge instruction should include reporting which problem to the healthcare provider? A) Weight loss. B) Dizziness. C) Muscle cramps. D) Dry mucous membranes.

B) Dizziness. - Angiotensin-converting enzyme (ACE) inhibitors are used in CHF to reduce afterload by reversing vasoconstriction common in heart failure. This vasodilation can cause hypotension and resultant dizziness (B). (A) is desired if fluid overload is present, and may occur as the result of effective combination drug therapy such as diuretics with ACE inhibitors. (C) often indicates hypokalemia in the client receiving diuretics. Excessive diuretic administration may result in fluid volume deficit, manifested by symptoms such as (D).

The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question? A) If the child's tongue darkens, discontinue the Pepto Bismol immediately. B) Do not give if the child has chickenpox, the flu, or any other viral illness. C) Avoid the use of Pepto Bismol until the child is at least 16 years old. D) Pepto Bismol may cause a rebound hyperacidity, worsening the "tummy ache."

B) Do not give if the child has chickenpox, the flu, or any other viral illness. - Pepto Bismol contains aspirin and there is the potential of Reye's syndrome (B). (A) is a common effect of Pepto Bismol and does not warrant discontinuation. Pepto Bismol can be used by children (C). Pepto Bismol does not cause rebound hyperacidity (D), which is a complication of antacids containing calcium.

A nurse is educating a client with a colostomy of the ascending colon about using a colostomy appliance. Which instructions should the nurse provide to help prevent leakage of stool from the appliance? A) Irrigate the colostomy to establish an expected pattern of elimination B) Empty the appliance when it is approximately half full C) Use an antiseptic to clean the peristomal skin before applying the appliance D) Select an appliance with a pouch opening of at least 5 cm or larger than the stoma

B) Empty the appliance when it is approximately half full

A client is admitted with anorexia, weight loss, abdominal distension, and abnormal stools. A diagnosis of malabsorption syndrome is made. What nursing action should the nurse implement to best meet this client's needs? A) Allow the client to eat food preferences B) Encourage the consumption of high-protein foods C) Institute IV therapy to improve the client's hydration D) Maintain NPO status because food precipitates diarrhea

B) Encourage the consumption of high-protein foods

Which dosing schedule should the nurse teach the client to observe for a controlled-release oxycodone prescription? A) As needed. B) Every 12 hours. C) Every 24 hours. D) Every 4 to 6 hours.

B) Every 12 hours. - A controlled-release oxycodone provides long-acting analgesia to relieve moderate to severe pain, so a dosing schedule of every 12 hours (B) provides the best around-the-clock pain management. Controlled-release oxycodone is not prescribed for breakthrough pain on a PRN or as needed schedule (A). (C) is inadequate for continuous pain management. Using a schedule of every 4 to 6 hours (D) may jeopardize patient safety due to cumulative effects.

A nurse is planning a community health program about screening for cancer. Which information recommended by the American Cancer Society (ACS) should the nurse include? A) Mammography should be performed annually after age 35 years for women B) Fecal occult blood testing should be performed yearly beginning at age 50 years C) Breast self-examination should be performed monthly beginning at age 30 years D) Digital rectal exams and PSA testing should be done yearly after age 40 for men

B) Fecal occult blood testing should be performed yearly beginning at age 50 years

A nurse is caring for a client who is receiving serum albumin. What therapeutic effect does the nurse anticipate? A) Improved clotting of blood B) Formation of RBC C) Activation of WBC D) Maintenance of oncotic pressure

B) Formation of RBC

The nurse is preparing to administer dalteparin (Fragmin) subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose? A) Tachypnea B) Guaiac-positive stool C) Multiple small abdominal bruises D) Dependent pitting edema

B) Guaiac-positive stool - Fragmin is an anticoagulant used to prevent deep vein thrombosis (DVT) in the at-risk client. If the client develops overt signs of bleeding, such as guaiac-positive stool (B) while receiving an anticoagulant, the medication should be held and coagulation studies completed. (A) is not an indication to hold the medication unless accompanied by signs of bleeding. (C) is an expected result. (D) is related to fluid volume, rather than anticoagulant therapy.

A 15-year-old adolescent tells the school nurse, "I have persistent pain during my periods." What should the nurse encourage her to do? A) Continue daily activities B) Have a gynecologic exam C) Eat a nutritious diet containing iron D) Practice relaxation of the abdominal muscles

B) Have a gynecologic exam

An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficile. While planning care, which nursing goal should the nurse establish as the priority? A) Fluid and electrolyte balance is maintained. B) Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. C) Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. D) Normal bowel patterns are reestablished.

B) Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. - A priority goal for the client with infectious diarrhea caused by Clostridium difficile is infection control precautions and the prevention of health care-associated infection (HAI) transmission (B). (A and C) are goals dependent on the return of the client's normal bowel pattern (D).

During her sixth month of pregnancy, a woman visits the prenatal clinic for the first time. As part of the initial assessment, a CBC and a urinalysis are performed. Which laboratory finding should alert the nurse that further assessment is required? A) WBC count of 90000/mm B) Hemoglobin level of 10 g/dL C) Urine specific gravity of 1.020 D) Glucose level of 1+ in the urine

B) Hemoglobin level of 10 g/dL - This hemoglobin level is abnormally low. The WBC count and urine specific gravity are normal values. A glucose level of 1+ in the urine is normal during pregnancy.

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

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

A male client with degenerative arthritis of the knees and hips takes an over-the-counter (OTC) nonsteroidal antiinflammatory drug (NSAID) for pain. During a routine clinic visit, the client tells the nurse, "For the past month I've been having a lot of trouble sleeping. I can't seem to fall asleep, and when I finally do get to sleep, I find that I wake up a number of times during the night." Which information should the nurse obtain first? A) Does the client snore or experience sleep apnea? B) How intense does the client rate his pain on a scale of 1 to 10? C) What type of medications does the client take before bedtime? D) Are there any white noise or lights on during the night?

B) How intense does the client rate his pain on a scale of 1 to 10? - A client with degenerative arthritis may have sleep disturbances related to chronic pain, so the client's pain intensity (B) should be determined. Other factors that may affect the client's sleep patterns (A, C, and D) should be considered after assessing the client's arthritic pain and how it is managed.

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

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

A client is admitted to the hospital with a diagnosis of chronic kidney failure. For signs of what electrolyte imbalance should the nurse monitor in this client? A) Hypokalemia B) Hypocalcemia C) Hypernatremia D) Hyperglycemia

B) Hypocalcemia

A client has an anaphylactic reaction after receiving IV penicillin. What does the nurse conclude is the cause of this reaction? A) An acquired atopic sensitization occurred B) There was passive immunity to the penicillin allergies C) Antibodies to penicillin developed after a previous exposure D) Potent antibodies were produced when the infusion was instituted

C) Antibodies to penicillin developed after a previous exposure

During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What condition does the nurse suspect and what suggestion is made to correct it? A) Hypercalcemia and tell her to avoid eating hard cheese B) Hypocalcemia and tell her to increase her intake of milk C) Hyperkalemia and tell her to consult with her HCP D) Hypokalemia and tell her to increase her intake of green, leafy vegetables

B) Hypocalcemia and tell her to increase her intake of milk - Low calcium causes leg cramps.

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

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

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? A) Exploring the client's emotional conflict B) Identifying personal feelings toward this client D) Planning to discuss this with the client's family D) Developing a rapport with the client's healthcare provider

B) Identifying personal feelings toward this client - Nurses must identify their own feelings and prejudices because these may affect the ability to provide objective, nonjudgmental nursing care. Exploring a client's emotional well-being can be accomplished only after the nurse works through one's own feelings. The focus should be on the client, not the family. Health team members should work together for the benefit of all clients, not just this client.

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? A) Decreased blood supply B) Impaired neural functioning C) Perforation of the bowel wall D) Obstruction of the bowel lumen

B) Impaired neural functioning

Based on the client's reported pain level, the nurse administers 8 mg of the prescribed morphine. The medication is available in a 10 mg syringe. Wasting of the remaining 2 mg of morphine should be done by the nurse and a witness. Who should be the witness? A) Nursing supervisor B) LPN C) Client's health care provider D) Designated nursing assistant

B) LPN - The wasting of controlled substances should be witnessed by two licensed personnel according to federal regulations; this can be done by an RN or a LPN.

A client is receiving an IV infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. What nutritional problem notifies the nurse to notify the HCP? A) Excessive carbohydrate intake B) Lack of protein supplementation C) Insufficient intake of water-soluable vitamins D) Increased concentration of electrolytes in cells

B) Lack of protein supplementation

The nurse educator is teaching the nursing staff about a new computerized documentation system that is recently implemented. What information is the best indication that the education is effective? A) A decrease in number of calls to the technology department. B) Less time for nursing staff to complete the daily charting. C) An increase in staff acceptance of computerized charting. D) An improvement from pretest scores of the training session.

B) Less time for nursing staff to complete the daily charting. - Being able to use the system to accomplish charting more efficiently and in less time (B) compared to previous documentation techniques indicates the staff has learned how to use the system effectively. (A) may be related to technology functionality and is not related to effective user learning. Acceptance (C) does not indicate that the staff understand or can use the system correctly. (D) measures cognition but not application.

An older adult with dementia has recently started to make mistakes regarding the time, place, and person. Which action of the nurse would be appropriate in this situation? A) Minimize environmental stress to reduce confusion B) Let the client continue to think in his or her own way C) Prompt the client to recognize the correct date and time D) Ask the client to recall the past to understand the present situation

B) Let the client continue to think in his or her own way - Mistaking the date and time are possible signs of dementia. In this situation, the client would benefit from validation therapy, which involves the adult continuing to think in his or her own way. Minimizing environmental stress can help to reduce confusion, but this is not the appropriate action for the given client's situation. Recognizing the inner needs and feelings of the client is more important than reinforcing the confused older adult's misperceptions. Reminiscence is a therapeutic approach that involves recalling the past to resolve present conflicts.

A nurse is obtaining a history and performing a physical assessment of a client who has cancer of the tongue. Which clinical findings should the nurse expect to identify? Select all that apply. A) Halitosis B) Leukoplakia C) Bleeding gums D) Substernal pain E) Alterations in taste F) Enlarged cervical lymph nodes

B) Leukoplakia E) Alterations in taste F) Enlarged cervical lymph nodes

In today's health care delivery system, a nurse as a teacher is confronted with multiple stressors. What is the major stressor that detracts from the effectiveness of the teaching effort? A) Extent of informed consumerism B) Limited time to engage in teaching C) Variety of cultural beliefs that exist D) Deficient motivation in adult learners

B) Limited time to engage in teaching

The nurse recognizes which behavior(s) in a client as warning sign(s) of an impending suicide attempt? (Select all that apply.) A) Reports feelings of sadness B) Mood changes from depressed to happy C) Begins giving away possessions D) Becomes compliant with medication regimen E) Independently joins a support group

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

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

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

When receiving hemodialysis, the complication of the removal of too much sodium may occur. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply. A) Chovek sign B) Muscle cramps C) Extreme fatigue D) Cardiac dysrhythmias E) Increased temperature

B) Muscle cramps C) Extreme fatigue

A 19-year-old male client who has sustained a severe head injury is intubated and placed on assisted mechanical ventilation. To facilitate optimal ventilation and prevent the client from "fighting" the ventilator, the health care provider administers pancuronium bromide (Pavulon) IV, with adjunctive opioid analgesia. What medication should the nurse maintain at the client's bedside? A) Dantrolene sodium (Dantrium) B) Neostigmine bromide (Prostigmin) C) Succinylcholine bromide (Anectine) D) Epinephrine (Adrenalin)

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

A client who had a suprapubic prostatectomy returns from the PACU and accidentally pulls out the urethral catheter. What should the nurse do first? A) Reinsert a new catheter B) Notify the HCP C) Check for bleeding by irrigating the suprapubic catheter D) Take no immediate action if the suprapbuic tube is draining

B) Notify the HCP

A nurse is caring for a male client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply. A) Polyuria B) Obese trunk C) Hypotension D) Sleep disturbance E) Thin arms and legs

B) Obese trunk D) Sleep disturbance E) Thin arms and legs

The apical heart rate of an infant receiving digoxin (Lanoxin) for congestive heart failure is 80 beats/min. Which intervention should the nurse implement first? A) Administer the next dose of digoxin as scheduled. B) Obtain a serum digoxin level. C) Administer a PRN dose of atropine sulfate. D) Assess for S3 and S4 heart sounds.

B) Obtain a serum digoxin level. - Sinus bradycardia (rate < 90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level is the highest priority (B). Further doses of digoxin should be withheld until the serum level is obtained (A). (C) is not indicated unless the client exhibits symptoms of diminished cardiac output. (D) provides information about cardiac function but is of less priority than (B).

A nurse determines that a postpartum client is gravida 1 and para 1. Her blood type is B negative, and her baby's blood type is O positive. What should the nurse include in the plan of care? A) Type and crossmatch blood B) Obtain an order for RhoGAM C) Determine the father's blood type D) Observe for signs of ABO incompatibility

B) Obtain an order for RhoGAM

The nurse is providing comfort and palliative care for a terminally ill client who is experiencing nausea and vomiting. Which action is best for the nurse to take to promote the client's comfort? A) Increase fluid intake. B) Offer high-protein foods. C) Provide a high-residue diet. D) Give prompt mouth care.

B) Offer high-protein foods. - Measures to manage nausea and vomiting include the use of antiemetics and avoiding foods and liquids that increase stomach acidity, such as coffee, milk, and citrus acid juices. For some clients, an empty stomach exacerbates the nausea, so offering frequent, small amounts of foods that appeal to the client, such as dry cracker or bland, high protein foods (B), help maintain nutritional status. Although (A and C) may help prevent constipation or diarrhea, the best action is to meet the client's basic needs for hydration and nutrition. Although (D) is a comfort measure that minimizes nausea, the presence of protein in the stomach may be more effective.

A client is being admitted for total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation has been completed? Select all that apply. A) After reporting severe pain B) On admission to the hospital C) Upon entering the OR D) Before transfer to a rehabilitation unit E) At the time of scheduling for the surgical procedure

B) On admission to the hospital D) Before transfer to a rehabilitation unit

A nurse is caring for a client with myxedema who has undergone abdominal surgery. What should the nurse consider when administering opioids to this client? A) Tolerance to the drugs develops readily B) One third to one half the usual dose should be prescribed C) Opioids may interfere with the secretion of thyroid hormones D) Sedation will have a paradoxical effect, causing hyperactivity

B) One third to one half the usual dose should be prescribed - Patients with myxedema have an increased sensitivity to opioids and need less of a drug.

A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? A) The dosage is kept at a minimum B) Only a small part of the body is eradicated C) The client's physical condition is not a risk factor D) Nutritional environment of the affected cells is a risk factor

B) Only a small part of the body is eradicated

A nurse is assessing a client with a diagnosis of hypoglycemia. What clinical manifestations support this diagnosis? Select all that apply. A) Thirst B) Palpitations C) Diaphoresis D) Slurred speech E) Hyperventilation

B) Palpitations C) Diaphoresis D) Slurred speech

Which physiologic mechanism explains a drug's increased metabolism that is triggered by a disease process? A) Selectivity response B) Pharmacokinetics C) Pharmacodynamics D) Pharmacotherapeutics

B) Pharmacokinetics - Pharmacokinetics (B) describes the physiologic process of a drug's movement throughout the body and how the drug's interaction is affected by an underlying disease. Selectivity (A), or a selective drug, is defined as a drug that elicits only the response for which it is given. Pharmacodynamics (C) is the impact of drugs on the body. Pharmacotherapeutics (D) is defined as the use of drugs to diagnose, prevent, or treat disease or prevent pregnancy.

A newborn is admitted to the NICU with a myelomeningocele. What is the priority nursing intervention during the first 24 hours? A) Using only disposable diapers B) Place the infant prone or in a side-lying position C) Wash the infant's genital area with an anti infective

B) Place the infant prone or in a side-lying position - Placing the infant prone or in a side-lying position decreases pressure on the sac.

The nurse is planning care for school-aged children at a community care center. Which activity is best for the children? A) Building model airplanes. B) Playing follow-the-leader. C) Stringing large and small beads. D) Playing with Playdough and clay.

B) Playing follow-the-leader. - School-aged children strive for independence and productivity (Erikson's Industry vs. Inferiority) and enjoy individual and group activities related to real-life situations, such as playing follow-the-leader (B). (A) is an individual activity that could contribute to feelings of inferiority and inadequacy if the task is too complex. Although school-aged children enjoy crafts, (C and D) are more appropriate for pre-school children.

A nurse is caring for a postoperative client who has diabetes. WHich is the MOST common cause of DKA that the nurse needs to consider when caring for this client? A) Emotional stress B) Presence of infection C) Increased insulin dose D) Inadequate food intake

B) Presence of infection

A nurse is caring for a male client who is scheduled for dilation of the urethra. Which structure surrounding the male urethra should the nurse include in the teaching when explaining the procedure? A) Epididymis B) Prostate gland C) Seminal vesicle D) Bulbourethral gland

B) Prostate gland

The neonatologist requests a mother to provide breast milk for her 32-week gestational premature newborn. The nurse provides instructions about pumping, storing, and transporting the breast milk. Which additional information should the nurse include to ensure the mother understands the request? A) To promote maternal production with neonatal demand, pump only the volume the newborn takes. B) Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients. C) Pump every 2 to 3 hours, including during the night, to increase breast milk volume. D) A glass of wine prior to pumping reduces anxiety and increases breast milk production.

B) Providing breast milk ensures the premature newborn can easily digest and absorb the nutrients. - Breast milk, rather than formula, provides antibodies and nutrition that is easily digested and readily absorbed by an immature newborn (B). Breast milk can be frozen and used if the mother is unable to provide breast milk every day, so (A) is not necessary. The mother does not have to pump through the night (C). Alcohol is excreted in breast milk and is not safe for the newborn (D).

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A) Assign an unlicensed assistive personnel to transport the client via a wheelchair. B) Remind the client to walk carefully down the stairs until reaching a lower floor. C) Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D) Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

B) Remind the client to walk carefully down the stairs until reaching a lower floor. - During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully (B). Ambulatory clients do not require the assistance of a wheelchair to be evacuated (A). Elevators (C) should not be used during a fire and fire doors should be kept closed (D) to help contain the fire.

A client who begins an exercise program asks the nurse about carbohydrate loading. What concepts should the nurse include in teaching the client ways to increase glycogen store in muscles? A) Moderate exercise and low fat intake. B) Rest and increased carbohydrate intake. C) Intense exercise and decreased carbohydrate intake. D) Intense exercise and high intake of complex carbohydrates.

B) Rest and increased carbohydrate intake. - Carbohydrate loading is the process of changing foods eaten and adjusting exercise intensity to increase glycogen stores in the muscle. To achieve maximum muscle glycogen stores, a high carbohydrate diet should be consumed as part of a regular exercise program (60%-70% of total kilocalories from carbohydrate that tapers off to allow muscles to rest (B). (A, C, and D) do not balance the client's exercise intensity with an intake of high complex carbohydrates needed to provide maximum glycogen stores to maintain muscular conditioning.

A nurse is caring for a client who has a radioactive implant for cancer of the cervix. What is the priority nursing action? A) Store urine in lead-lined containers B) Restrict visitors to a 10 minute stay C) Wear a lead-lined apron when giving care D) Avoid giving injections in the gluteal muscle

B) Restrict visitors to a 10 minute stay

A person who is hospitalized for alcoholism becomes boisterous and belligerent and verbally threatens the nurse. What is the most appropriate response by the nurse? A) Place the client in restraints B) Sedate and place the client in a controlled environment C) Encourage the client to play Ping Pong with another client D) Set firm limits on the client's behavior and enforce adherence to them

B) Sedate and place the client in a controlled environment

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

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

A client at 16 weeks' gestation calls the nurse at the prenatal clinic and states that her partner just told her he has genital herpes. What should the nurse include when teaching the client about sexual activity? A) Condoms must be used when having intercourse B) Sexual abstinence should be practiced during the last six weeks C) It will be necessary to refrain from sexual contact during pregnancy D) Meticulous cleaning of the vaginal area after intercourse is essential

B) Sexual abstinence should be practiced during the last six weeks - This will help prevent transmission to the baby.

A client with the diagnosis of cancer of the stomach expresses aversion to meals and eats only small amounts. What should the nurse provide? A) Nourishment between meals B) Small portions more frequently C) Supplementary vitamins to stimulate the client's appetite D) Only foods the client likes in small portions at mealtimes

B) Small portions more frequently

A nurse is caring for a client who is scheduled for a gastric bypass to treat morbid obesity. Which diet should the nurse teach the client to maintain because it will help minimize clinical manifestations of dumping syndrome? A) Low-residue, bland diet B) Small, frequent feeding schedule C) Fluid intake less than half a quart D) Low-protein, high-carbohydrate diet

B) Small, frequent feeding schedule

A client asks a nurse about the most common problem associated with the use of an intrauterine device (IUD)? A) Perforation of the uterus B) Spontaneous device expulsion C) Discomfort associated with coitus D) Development of vaginal infections

B) Spontaneous device expulsion

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

B) Start an IV infusion of NS - The patient in DKA experiences severe dehydration and must be rehydrated before insulin is administered (B). The other actions will follow rehydration (A, C, and D).

While supervising a smallpox vaccination program, a nurse manager observes a nurse cleansing the arm of a client with an alcohol swab before giving the vaccination. What should the nurse manager's first reaction be? A) Continue observing the vaccination. B) Stop the nurse from giving the vaccination C) Give the nurse a povidone-iodine (Betadine) swab to use instead. D) Notify the members of the team about the need to use antiseptic swabs.

B) Stop the nurse from giving the vaccination - Alcohol deactivates the smallpox vaccine. Cleansing of the arm should not be done before the immunization is given unless the arm is dirty; if dirty, only water should be used to cleanse the site. Observation is insufficient; the nurse manager must intervene to ensure that the vaccine is given using the correct technique. Povidone-iodine will deactivate the smallpox vaccine. The site should be dry before administering the vaccine.

A nurse is caring for a client with CBI. Which is the most important nursing action? A) Monitoring USG to determine hydration B) Subtracting irrigant from output to determine the urine volume C) Recording UO every hour to determine kidney function D) Obtaining a 24 hour urine specimen to determine urine concentration

B) Subtracting irrigant from output to determine the urine volume

A nurse is teaching a client with diabetes about the treatment of hypoglycemia. The nurse knows that teaching was effective if the client picks which foods to treat a hypoglycemic attack? A) Fruit juice and a lollipop. B) Sugar and a slice of bread. C) Chocolate candy and a banana. D) Peanut butter crackers and a glass of milk.

B) Sugar and a slice of bread. - The suggested treatment of hypoglycemia in a conscious client is a simple sugar (such as two packets of sugar), followed by a complex carbohydrate (such as a slice of bread), and finally a protein (such as milk); the simple sugar elevates the blood glucose level rapidly; the complex carbohydrates and protein produce a more sustained response. Fruit juice and a lollipop are fast-acting sugars, and neither of them will provide a sustained response. The fat content of chocolate candy decreases the rate of absorption of glucose. Neither peanut butter crackers nor a glass of milk is a fast-acting sugar; peanut butter crackers and milk can be used to maintain the glucose level after it is raised.

After many years of coping with colitis, a client makes the decision to have a colectomy as advised by the HCP. Which is most likely the significant factor that impacted the client's decision? A) It is temporary until the colon heals B) Surgical treatment cures UC C) UC can progress to Crohn's disease D) Without surgery, eating table foods is contraindicated

B) Surgical treatment cures UC

The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first? A) Inspect the dressing over the puncture site and under the client for bleeding. B) Take the vital signs to determine the client's response for a potential blood loss. C) Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D) Assess the client's pain level to determine the need for analgesic medication.

B) Take the vital signs to determine the client's response for a potential blood loss. - After bone marrow aspiration, pressure is applied at the aspiration site, which is critical for a client with pancytopenia because of a decrease in the platelet count. The client's baseline vital signs should be obtained first to determine changes indicating bleeding caused by the procedure (B). Although (A, C, and D) should be implemented after the procedure, the first action is to obtain a baseline assessment.

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

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

A toddler screams and cries nosily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 - 45 minutes. Legally, how should this behavior be interpreted? A) Limits had to be set to control the child's crying B) The child had a right to remain in the room with the other children C) The child had to be removed because the other children needed to be considered D) Segregation of the child for more than half an hour was too long a period of time

B) The child had a right to remain in the room with the other children

The nurse is reviewing the use of the patient-controlled analgesia (PCA) pump with a client in the immediate postoperative period. The client will receive morphine 1 mg IV per hour basal rate with 1 mg IV every 15 minutes per PCA to total 5 mg IV maximally per hour. What assessment has the highest priority before initiating the PCA pump? A) The expiration date on the morphine syringe in the pump. B) The rate and depth of the client's respirations. C) The type of anesthesia used during the surgical procedure. D) The client's subjective and objective signs of pain.

B) The rate and depth of the client's respirations. - A life-threatening side effect of intravenous administration of morphine sulfate, an opiate narcotic, is respiratory depression (B). The PCA pump should be stopped and the healthcare provider notified if the client's respiratory rate falls below 12 breaths per minute, and the nurse should anticipate adjustments in the client's dosage before the PCA pump is restarted. (A, C, and D) provide helpful information, but are not as high a priority as the assessment described in (B).

A nurse is responding to the needs of victims at a collapsed building. WHat principle guides the nurse's priorities during this disaster? A) Hemorrhage necessitates immediate care to save the most lives B) Those requiring minimal care are treated first so they can help others C) Victims with head injuries are treated first because they are the most complex D) Children receive the higher priority because they have the greatest life expectancy

B) Those requiring minimal care are treated first so they can help others

A client with a family history of goiter is experiencing changes in voice and breathing. Which diagnostic study does the nurse consider to be beneficial in confirming a diagnosis? A) Thyroglobulin B) Thyroid antibodies C) Thyroxine (free T4), total D) Thyroid-stimulating hormone (TSH)

B) Thyroid antibodies - Changes in voice and breathing can be seen in Hashimoto's thyroiditis if the thyroid gland enlarges rapidly and constricts the trachea and laryngeal nerves. Clients with a family history of goiter may have this condition. A thyroid antibody test is used diagnose Hashimoto's thyroiditis by differentiating thyroid dysfunction from thyroiditis. Thyroglobulin is used to detect thyroid cancer. Thyroxine (free T4), total and TSH are used to evaluate thyroid function.

The nurse is developing the plan of care for an older client who is immobile and at risk for pressure ulcers. Which contributing factor should the nurse include in the nursing diagnosis, "Risk for altered skin integrity?" A) Poor nutrition. B) Tissue ischemia. C) Prolonged illness or disease. D) Nitrogen build-up in the underlying tissues.

B) Tissue ischemia. - Prolonged, intense pressure affects cellular metabolism by impeding capillary blood flow to tissue over weight-bearing bony prominences, resulting in tissue ischemia (B), skin breakdown, and tissue death. Although key factors contributing to pressure ulcers include poor nutrition (A), prolonged illness or disease (C), and build-up of metabolic nitrogen in underlying tissues (D), tissue ischemia is the primary factor in pressure ulcer development.

A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease? A) Pulse rate B) Tissue turgor C) Specific gravity D) Body temperature

B) Tissue turgor

A nurse is caring for a client who has had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery? A) Femoral pulse B) Toes for mobility C) Condition of the pin D) Range of motion of the knee

B) Toes for mobility

The nurse assigning care for a 5-year-old child with otitis media is concerned about the child's increasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift? A) An RN should be assigned to take temperatures frequently. B) Tympanic and oral temperatures are equally accurate. C) The PN should take rectal temperatures on this child. D) The pediatrician should decide how to assess the temperature.

B) Tympanic and oral temperatures are equally accurate. - A tympanic membrane sensor approximates core temperatures because the hypothalamus and eardrum are perfused by the same circulation. Tympanic readings obtained using proper technique correlated moderately to strongly with oral temperatures in recent research studies (B). The sensor is unaffected by cerumen or the presence of suppurative or unsuppurative otitis media. An RN is not required to take the child's temperature, but must assess readings received from assistive personnel (A). Although rectal readings are highly accurate (C), such an invasive procedure is unnecessary. (D) is not required.

A person sustains deep-partial thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention, but the client refuses. THe nurse advises the person to go to a HCP if: A) Blisters appear B) Urinary output decreases C) Edema and redness occur D) Low-grade fever develops

B) Urinary output decreases - A decrease in urinary output in a patient with burns indicates hypovolemia and must be treated immediately. Blisters, and edema and redness are expected. A low-grade fever is not as concerning as a decreased urinary output.

An older adult with a history of small cell lung carcinoma reports muscle cramping, thirst, and fatigue. The primary healthcare provider diagnoses the client with a pituitary disorder and is treating the client accordingly. Which is an effective outcome of the treatment? A) Urine output of 10 L/day B) Urine specific gravity less than 1.025 C) Urine osmolarity of 80 mOsm/kg (80 mmol/kg) D) Serum osmolarity of 600 mOsm/kg (600 mmol/kg)

B) Urine specific gravity less than 1.025 - Because the specific gravity is less than 1.025 after treatment, the outcome is considered positive. In syndrome of inappropriate antidiuretic hormone (SIADH), the specific gravity is greater than 1.025. Small cell lung cancer is a risk factor of SIADH. Muscle cramping, thirst, and fatigue are clinical manifestations of SIADH. A serum osmolarity of 600 mOsm/kg indicates central diabetes insipidus. A urine output 10 L/day and a urine osmolarity of 80 mOsm/kg indicate diabetes insipidus.

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

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

A client has a fractured mandible that is immobilized by wires. For which life-threatening postoperative problem should the nurse monitor this client? A) Infection B) Vomiting C) Osteomyelitis D) Bronchospasm

B) Vomiting

A male client has a prescription for disulfiram (Antabuse). Which adverse reaction should the nurse caution the client about while taking the medication? A) Euphoria. B) Vomiting. C) Hypertension. D) Hypoventilation.

B) Vomiting. - A disulfiram reaction includes nausea and severe vomiting (B), if alcohol is ingested while taking disulfiram (Antabuse). (A, C, and D) are not typically associated with the combined use of disulfiram and alcohol.

Which symptoms are serious adverse effects of beta-adrenergic blockers such as propranolol (Inderal)? A) Headache, hypertension, and blurred vision. B) Wheezing, hypotension, and AV block. C) Vomiting, dilated pupils, and papilledema. D) Tinnitus, muscle weakness, and tachypnea.

B) Wheezing, hypotension, and AV block. - (B) represents the most serious adverse effects of beta-blocking agents. AV block is generally associated with bradycardia and results in potentially life-threatening decreases in cardiac output. Additionally, wheezing secondary to bronchospasm and hypotension represent life-threatening respiratory and cardiac disorders. (A, C, and D) are not associated with beta-blockers.

A client who has acromegaly and insulin-dependent diabetes undergoes a hypophysectomy. The nurse identifies further teaching about the hypophysectomy is necessary when the client states, "I know I will.. A) be sterile for the rest of my life." B) require larger doses of insulin than I did preoperatively." C) have to take cortisone or a similar drug for the rest of my life." D) have to take thyroxine or a similar medication for the rest of my life"

B) require larger doses of insulin than I did preoperatively." - The hypophysis (pituitary gland) does not directly regulate insulin release. This is controlled by serum glucose levels. Because somatotropin release will stop after the hypophysectomy, any elevation of blood glucose level caused by somatotropin will also stop.

While awaiting the biopsy report before removal of a tumor, the client reports being afraid of a diagnosis of cancer. How should the nurse respond? A) "Worrying is not going to help the situation." B) "Let's wait until we hear what the biopsy report says." C) "It is very upsetting to have to wait for a biopsy report." D) "Operations are not performed unless there are no other options."

C) "It is very upsetting to have to wait for a biopsy report."

A client asks the nurse if glipizide (Glucotrol) is an oral insulin. Which response should the nurse provide? A) "Yes, it is an oral insulin and has the same actions and properties as intermediate insulin." B) "Yes, it is an oral insulin and is distributed, metabolized, and excreted in the same manner as insulin." C) "No, it is not an oral insulin and can be used only when some beta cell function is present." D) "No, it is not an oral insulin, but it is effective for those who are resistant to injectable insulins."

C) "No, it is not an oral insulin and can be used only when some beta cell function is present." - An effective oral form of insulin has not yet been developed (C) because when insulin is taken orally, it is destroyed by digestive enzymes. Glipizide (Glucotrol) is an oral hypoglycemic agent that enhances pancreatic production of insulin. (A, B, and D) do not provide accurate information.

A family of a client with myasthenia gravis asks the nurse whether the client will be an invalid. What is the nurse's best response? A) "Medications will mask the signs of the disease." B) "With continuous treatment, the progression of the disease can usually be controlled." C) "There will be periods when bed rest will be necessary and times when regular activity will be possible." D) "The progression generally is slow, so people with myasthenia will spend their younger life with few problems."

C) "There will be periods when bed rest will be necessary and times when regular activity will be possible."

A couple indicate that they do not want any more children. The woman is scheduled for a laparoscopic bilateral tubal ligation. What should the nurse include in the preoperative teaching? A) "Menstruation will stop after the surgery." B) "Birth control will be needed until your follow-up appointment." C) "You will be admitted as an outpatient for same-day surgery."

C) "You will be admitted as an outpatient for same-day surgery."

In the immediate postoperative period after a gastrectomy, the client's nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage? A) 1 - 2 hours B) 3 - 4 hours C) 10 - 12 hours D) 24 - 48 hours

C) 10 - 12 hours

Which pediatric client requires immediate intervention by the nurse? A) A 2-year-old with a twenty-four hour urinary output of 500 ml. B) A 3-year-old with several episodes of nocturnal enuresis. C) A 4-year-old with an easily palpable bladder and frequency. D) A 5-year-old with diuresis following furosemide (Lasix) administration

C) A 4-year-old with an easily palpable bladder and frequency. - Frequency and bladder distention (C) are indications of urinary retention, which requires immediate intervention by the nurse. (A) is the normal output for a child of this age. (B) describes bed-wetting, not uncommon in a child of this age, although if the problem persists in a child older than 5 years of age, further assessment and intervention is warranted. (D) is an expected response to the medication, which requires routine monitoring, but does not indicate a need for immediate intervention.

A client is comatose upon arrival to the emergency department after falling from a roof. The client flexes with painful stimuli, and the nurse determines the client's Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's airway? A) Tracheostomy tube insertion. B) An endotracheal tube. C) A nasopharyngeal tube. D) An oral airway.

C) A nasopharyngeal tube. - If head and neck injuries are suspected, a client with a GCS of 6 who demonstrates motor flexion in response to painful stimuli requires airway maintenance without risk of compromise to spinal cord function. Nasal intubation using a nasopharyngeal tube (C) is the airway of choice for a client with suspected spinal cord injury because less cervical spine manipulation is needed during insertion, as compared with endotracheal intubation (B). A tracheostomy (A) is an option if long-term artificial airway maintenance is needed. Although (D) maintains an open airway by keeping the tongue out of the way, neck hyperextension and spinal manipulation pose a risk for spinal cord damage.

The family of an older adult who is aphasic reports to the nurse manager that the primary care nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding? A) Procedure for a client's benefit do not require a signed consent B) Clients who are aphasic are incapable of signing informed consent C) A separate signed informed consent for routine treatments is necessary D) A specific intervention without a client's signed consent is an invasion of rights

C) A separate signed informed consent for routine treatments is necessary - This is considered a routine procedure to meet basic physiologic needs and is covered by a consent signed at the time of admission.

Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling). Which of these is evidence of a stress ulcer? A) Unexplained shock B) Melena for several days C) A sudden massive hemorrhage D) A gradual drop in the hematocrit value

C) A sudden massive hemorrhage - Stress ulcers are asymptomatic until they produce massive hematemesis and rectal bleeding. Shock is the outcome of massive hemorrhage; it is not unexplained because the sudden gastrointestinal bleeding will be identified. Sudden massive bleeding occurs, not the slow oozing that causes melena. A gradual drop in the hematocrit value indicates slow blood loss.

Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate? A) A trial of adrenocorticotrophic hormone injections. B) Frequent stimulation of the cremasteric reflex. C) A trial of human chorionic gonadotrophic hormone. D) Frequent warm baths to gently dilate the scrotal area.

C) A trial of human chorionic gonadotrophic hormone. - A trial of HCG (human chorionic gonadotrophic hormone) (C) may aid in testicular descent, but does not replace surgical repair for true undescended testes. Undescended testes (cryptorchidism) may be found in the inguinal canal due to exaggerated cremasteric reflex. (A) is not indicated. Stimulation of the cremasteric reflex causes the testes to ascend rather than descend in the scrotum (B). (D) may relax the cremasteric muscle, but may not cause the testes to descend.

A nurse is caring for a client admitted to the hospital for DKA. Which clinical findings related to this event should the nurse document in the client's clinical record? Select all that apply. A) Sweating B) Retinopathy C) Acetone breath D) Increased arterial bicarbonate level E) Decreased arterial CO2 level

C) Acetone breath E) Decreased arterial CO2 level

A client with an inflamed sciatic nerve is to have a conventional TENS device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate? A) Maintain the settings programmed by the HCP B) Turn the machine on several times a day for 10 - 20 min C) Adjust the dial on the unit until the client states that pain is relieved D) Apply the color-coded electrodes to the client where they are most comfortable

C) Adjust the dial on the unit until the client states that pain is relieved

A client is scheduled to receive phenytoin 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? A) Sprinkle the powder from the capsule into a cup of water B) Insert a rectal suppository containing 100 mg of phenytoin C) Administer 4 mL of phenytoin suspension containing 125 mg/5 mL D) Obtain a change in the administration route to allow an IM injection

C) Administer 4 mL of phenytoin suspension containing 125 mg/5 mL

A client is taking hydromorphone (Dilaudid) PO q4h at home. Following surgery, Dilaudid IV q4h PRN and butorphanol tartrate (Stadol) IV q4h PRN are prescribed for pain. The client received a dose of the Dilaudid IV four hours ago, and is again requesting pain medication. What intervention should the nurse implement? A) Alternate the two medications q4h PRN for pain. B) Alternate the two medications q2h PRN for pain. C) Administer only the Dilaudid q4h PRN for pain. D) Administer only the Stadol q4h PRN for pain.

C) Administer only the Dilaudid q4h PRN for pain. - Dilaudid is an opioid agonist. Stadol is an opioid agonist-antagonist. Use of an agonist-antagonist for the client who has been receiving opioid agonists may result in abrupt withdrawal symptoms, and should be avoided (C). (A, B, and D) do not reflect good nursing practice.

A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take? A) Dispense a tetanus antitoxin. B) Prepare human tetanus immune globulin. C) Administer tetanus toxoid booster. D) Delay the tetanus toxoid booster until due.

C) Administer tetanus toxoid booster. - After the completion of the initial tetanus immunization schedule, the recommended booster for an adolescent or adult is every ten years or less if a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds from missiles, burns, or frostbite. The adolescent's injury is considered a contaminated wound requiring prophylactic therapy, so the tetanus toxoid booster should be administered (C). (A, B, and D) are not indicated.

A client's dose of isosorbide dinitrate (Imdur) is increased from 40 mg to 60 mg PO daily. When the client reports the onset of a headache prior to the next scheduled dose, which action should the nurse implement? A) Hold the next scheduled dose of Imdur 60 mg and administer a PRN dose of acetaminophen (Tylenol). B) Administer the 40 mg of Imdur and then contact the healthcare provider. C) Administer the 60 mg dose of Imdur and a PRN dose of acetaminophen (Tylenol). D) Do not administer the next dose of Imdur or any acetaminophen until notifying the healthcare provider.

C) Administer the 60 mg dose of Imdur and a PRN dose of acetaminophen (Tylenol). - Imdur is a nitrate which causes vasodilation. This vasodilation can result in headaches, which can generally be controlled with acetaminophen (C) until the client develops a tolerance to this adverse effect. (A and B) may result in the onset of angina if a therapeutic level of Imdur is not maintained. Lying down (D) is less likely to reduce the headache than is a mild analgesic.

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

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

A client with ARDS is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? A) Regulate the PEPP according to the rate and depth of the client's respirations B) Deflate the cuff on the endotracheal tube for a few minutes every one to two hours C) Assess the need for suctioning when the high pressure alarm is activated D) Adjust the temperature of fluid in the humidification chamber, depending on the volume of gas delivered

C) Assess the need for suctioning when the high pressure alarm is activated

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

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

A HCP orders a GI endoscopy with a capsule endoscopic device. What should the nurse instruct the client to do? A) Check the recorder every hour B) Avoid eating food and fluid during the test C) Avoid stooping and bending during the test D) Swallow the capsule as soon as it is placed in the mouth

C) Avoid stooping and bending during the test

A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? Select all that apply. A) Polyuria B) Jaundice C) Azotemia D) HTN E) Polycythemia

C) Azotemia E) Polycythemia

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

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

A client who is about to have a blood transfusion asks the nurse, "Which type of hepatitis is most frequently transmitted by transfusions?" The nurse should response, "Although the risk is minimal, the type of hepatitis associated with blood transfusions is hepatitis: A) A B) B C) C D) D

C) C

When performing a newborn assessment after a vaginal birth, a nurse observes a swelling on one side of the top of the head. What clinical manifestation did the nurse identify? A) Caput succedaneum that will spread across the scalp and then resolve B) Fontanelle that bulges when the infant cries and then will close in eighteen months C) Cephalohematoma that does not cross the suture line and will resolves in several weeks D) Molding that results from the skull taking the shape of the vagina and will disappear in several days

C) Cephalohematoma that does not cross the suture line and will resolves in several weeks - This is a description of a cephalohematoma because it is only on one side of the head and does not cross the suture line.

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

C) Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. B) Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). A) Gently insert the catheter without suction using sterile technique. D) Apply suction intermittently while withdrawing the catheter. - Equipment should be set up and adjusted prior to beginning the procedure (C). Hyperoxygenation using an MRB should be completed prior to inserting the catheter (B). After preoxygenation, the catheter can be inserted (A) and suction can be applied intermittently (D).

During a colostomy irrigation, a client reports feeling abdominal cramps. What should the nurse do in response to the client's statement? A) Discontinue the irrigation B) Lower the container of fluid C) Clamp the catheter for a few minutes D) Advance the catheter approximately an inch

C) Clamp the catheter for a few minutes

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

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

A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes and the other has type 2 diabetes. The nurse determines that the main difference between newly diagnosed type 1 and type 2 diabetes is that in type 1 diabetes: A) Onset of the disease is slow B) Excessive weight is a contributing factor C) Complications are not present at the time of diagnosis D) Treatment involves diet, exercise and oral medications

C) Complications are not present at the time of diagnosis - Clinical presentation of type 1 diabetes is characterized by ACUTE (ABRUPT) onset, and therefore there is no time to develop the long-term complications that are common with long-standing disease.

A nurse is caring for a client after radioactive iodine is administered for Graves disease. What information about the client's condition after this therapy should the nurse consider when providing care? A) Not radioactive and can be handled as any other individual B) Highly radioactive and should be isolated as much as possible C) Mildly radioactive but should be treated with routine safety precautions D) Not radioactive but may still transmit some dangerous radiations and must be treated with precautions.

C) Mildly radioactive but should be treated with routine safety precautions

A postoperative client has been receiving a continuous IV infusion of meperidine (Demerol) 35 mg/hr for four days. The client has a PRN prescription for Demerol 100 mg PO q3h. The nurse notes that the client has become increasingly restless, irritable and confused, stating that there are bugs all over the walls. What action should the nurse take first? A) Administer a PRN dose of the PO meperidine (Demerol). B) Administer naloxone (Narcan) IV per PRN protocol. C) Decrease the IV infusion rate of the meperidine (Demerol) per protocol. D) Notify the healthcare provider of the client's confusion and hallucinations.

C) Decrease the IV infusion rate of the meperidine (Demerol) per protocol. - The client is exhibiting symptoms of Demerol toxicity, which is consistent with the large dose of Demerol received over four days. (C) is the most effective action to immediately decrease the amount of serum Demerol. (A) will increase the toxic level of medication in the bloodstream. Naloxone (B) is an opioid antagonist that is used during an opioid overdose, but it is not beneficial during Demerol toxicity and can precipitate seizures. The healthcare provider should be notified (D), but that is not the initial action the nurse should take; first the amount of drug infusing should be decreased.

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

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

Which drug can cause diabetes insipidus? A) Cabergoline B) Metyrapone C) Demeclocycline D) Aminoglutethimide

C) Demeclocycline - Prolonged administration of demeclocycline may cause diabetes insipidus, as this drug decreases the production of antidiuretic hormone by the kidneys. Cabergoline inhibits the release of growth hormone and prolactin by stimulating dopamine receptors in the brain. Metyrapone and aminoglutethimide decrease cortisol production.

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

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

Two hours after a subtotal gastrectomy, the nurse identifies that the drainage from the client's NG tube is bright red. What should the nurse do first? A) Notify the HCP B) Clamp the NG tube for one hour C) Determine that this is an expected finding D) Irrigate the NG tube with iced saline

C) Determine that this is an expected finding

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

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

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. A) Tetany B) Seizures C) Diarrhea D) Weakness E) Dysrhythmias

C) Diarrhea D) Weakness E) Dysrhythmias

A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" What information should the nurse include in response to this question? A) Malignant growth B) Pocked of undigested food particles C) Dilated space of necrotic tissue and blood D) Sack filled with fluid and pancreatic enzymes

C) Dilated space of necrotic tissue and blood

A nurse is teaching a client with a permanent colostomy about self-care in preparation for discharge from the hospital. Which intervention should the nurse discuss with the client? A) Limiting activity B) Wearing special clothing C) Dilating the stoma periodically D) Maintaining a low-residue diet

C) Dilating the stoma periodically

A nurse is caring for a client with ascites. What does the nurse consider to be the cause of the ascites? A) Portal hypertension B) Kidney malfunction C) Diminished plasma protein level D) Decreased production of potassium

C) Diminished plasma protein level

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

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

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation on the operative site. For which most critical reaction should the nurse assess the client? A) Dry skin B) Skin reactions C) Mucosal edema D) Bone marrow suppression

C) Mucosal edema - Mucosal edema can lead to airway obstruction, therefore it is the most critical reaction to assess for.

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

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

The nurse is suctioning the tracheostomy for a child who is experiencing rhonchi and unable to expel mucus. Which action should the nurse implement to provide effective pulmonary toileting? A) Encourage child to cough to raise the secretions before suctioning. B) Allow child to rest after every five times the suction catheter is passed. C) Each pass of the suction catheter should take no longer than five seconds. D) Select a catheter 3/4 the size of the diameter of the tracheostomy tube.

C) Each pass of the suction catheter should take no longer than five seconds. - To ensure the child's O2 saturation returns to normal, suctioning of the tracheostomy should last no more than five seconds per aspiration (C) and rest periods provided after each aspiration, not (B). (A) is not effective. To facilitate ease of insertion and prevent tracheal wall abrasion, the suction catheter should be half the diameter of the tracheostomy tube, not (D).

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

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

Which intervention(s) should the nurse use when interacting with a client with Alzheimer's disease? (Select all that apply). A) Adhere to strict time limits for activities. Incorrect B) Give all instructions at the start of the activity. C) Encourage verbal and nonverbal communication. Correct D) Speak to the client in a loud and clear voice. E) Maintain a calm demeanor during all interactions. Correct

C) Encourage verbal and nonverbal communication. E) Maintain a calm demeanor during all interactions. - Alzheimer's causes the client to experience cognitive deficits and memory impairment, so frequent communication (C) and a calm affect (E) should be maintained with the client. (A, B, and D) increases the client's frustration.

A nurse is caring for a child with a very low platelet count related to chemotherapy. The nurse should monitor this child's urine for the presence of which consistent? A) Protein B) Glucose C) Erythrocytes D) Lymphocytes

C) Erythrocytes - Patients with low platelet counts are at an increased risk for bleeding and will have erythrocytes (RBC) in the urine.

A nurse is collecting information about a client who has type 1 diabetes and who is being admitted because of diabetic ketoacidosis coma. Which factors can predispose a client to this condition? Select all that apply. A) Taking too much insulin B) Getting too much exercise C) Excessive emotional stress D) Running a fever with the flu E) Eating fewer calories than prescribed

C) Excessive emotional stress D) Running a fever with the flu -

A client with cancer of the cervix has an intracavitary radioactive sealed implant in place. What precaution should the nurse take to protect against excessive exposure to radiation? A) Dispose of body fluids in special marked containers B) Cohort two clients who have implanted radiation therapy C) Exit the room walking backward while wearing an apron D) Limit visitors to individuals who are 13 years and older

C) Exit the room walking backward while wearing an apron

While changing a newborn's diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How should the nurse respond to this concern? A) Assess for other signs of bleeding B) Obtain an order for vaginal cultures C) Explain that this is an expected finding D) Apply a urine specimen bag to the perineum

C) Explain that this is an expected finding

Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.) A) Direct the client to sign a liability release form. B) Restrict the client's ability to leave the unit. C) Explain the benefits of remaining in the hospital. D) Instruct the client to take medications as prescribed. E) Provide the client with names of local support groups. F) Notify the health care provider of the client's intention.

C) Explain the benefits of remaining in the hospital. D) Instruct the client to take medications as prescribed. F) Notify the health care provider of the client's intention. - Correct responses are (C, D, and F). To maintain safety and to provide information, the nurse should explain the potential benefits of continuing treatment in the hospital (C) and the need to take prescribed medications (D). This client, who is very likely self-destructive, should remain on the unit and the health care provider should be notified (F). Signing a release form (A) before leaving the hospital does not contribute to safety. The nurse may ask the client not to leave the hospital (B), but pressuring clients is unethical behavior. (E) may be helpful at a later time in this client's treatment program.

What clinical indicator is important for the nurse to assess after a client undergoes a submucosal resection for a deviated septum? A) Occipital headache B) Periorbital edema C) Exportation of blood D) Changes in vocalization

C) Exportation of blood

A nurse provides dietary teaching about a low-sodium diet for a client with HTN. Which nutrient selected by the client indicates an understanding about foods that are low in natural sodium? A) Milk B) Meat C) Fruits D) Vegetables

C) Fruits

A nurse is evaluating a client who has been receiving medical intervention for the diagnosis of Crohn disease. What expected outcome is most important for this client? A) Does skin care B) Takes oral fluids C) Gains a half pound per week D) Experiences less abdominal cramping

C) Gains a half pound per week

A nurse is caring for a newly admitted client with a diagnosis of Cushing syndrome. Why should the nurse monitor this client for clinical indicators of diabetes mellitus? A) Cortical hormones stimulate rapid weight loss. B) Tissue catabolism results in a negative nitrogen balance. C) Glucocorticoids accelerate the process of gluconeogenesis. D) Excessive adrenocorticotropic hormone (ACTH) secretion damages pancreatic tissue.

C) Glucocorticoids accelerate the process of gluconeogenesis. - Excess glucocorticoids cause hyperglycemia, and signs of diabetes mellitus may develop ACTH, which causes sodium retention and subsequent weight gain. Although muscle wasting is associated with excessive corticoid production, this will not cause diabetes mellitus. ACTH affects the adrenal cortex, not the pancreas.

The nurse is preparing to administer the disease-modifying antirheumatic drug (DMARD) methotrexate (Rheumatrex) to a client diagnosed with rheumatoid arthritis. Which intervention is most important to implement prior to administering this medication? A) Assess the client's liver function test results. B) Monitor the client's intake and output. C) Have another nurse check the prescription. D) Assess the client's oral mucosa.

C) Have another nurse check the prescription. - Double-checking the prescription (C) is an important intervention because death can occur from an overdose. This medication is administered weekly and in low doses for rheumatoid arthritis and should not be confused with administration of the drug as a chemotherapeutic agent. (A and B) are appropriate interventions for those who are receiving this drug, but they are not the most important interventions. Stomatitis (D) is an expected side effect of this medication.

A medication that is classified as a beta-1 agonist is most commonly prescribed for a client with which condition? A) Glaucoma. B) Hypertension. C) Heart failure. D) Asthma.

C) Heart failure. - Beta-1 agonists improve cardiac output by increasing the heart rate and blood pressure and are indicated in heart failure (C), shock, atrioventricular block dysrhythmias, and cardiac arrest. Glaucoma (A) is managed using adrenergic agents and beta-adrenergic blocking agents. Beta-1 blocking agents are used in the management of hypertension (B). Medications that stimulate beta-2 receptors in the bronchi are effective for bronchoconstriction in respiratory disorders, such as asthma (D).

A client is admitted to the ED with a contaminated wound. The client is a poor historian, and the nurse realizes that it is impossible to determine whether the client is immunized against tetanus. Which medication does the nurse expect the HCP to prescribe because it will provide passive immunity for several weeks with minimal danger of an allergic reaction? A) Tetanus toxoid B) Equine tetanus antitoxin C) Human tetanus antitoxin D) DTaP vaccine

C) Human tetanus antitoxin

Which nursing intervention is most important when caring for a client receiving the antimetabolite cytosine arabinoside (Arc-C) for chemotherapy? A) Hydrate the client with IV fluids before and after infusion. B) Assess the client for numbness and tingling of extremities. C) Inspect the client's oral mucosa for ulcerations. D) Monitor the client's urine pH for increased acidity.

C) Inspect the client's oral mucosa for ulcerations. - Cytosine arabinoside (Arc-C) affects the rapidly growing cells of the body, therefore stomatitis and mucosal ulcerations are key signs of antimetabolite toxicity (C). (A, B, and D) are not typical interventions associated with the administration of antimetabolites.

A thin older adult client is diagnosed with osteoporosis. What should the nurse include in the discharge plan for this client? A) Encouragement of gradual weight gain B) Monitoring for decreased urine calcium C) Instructions relative to diet and exercise D) Safety factors when using opioids and NSAIDS

C) Instructions relative to diet and exercise

The nurse is caring for a client with diabetes mellitus. What is the primary fluid shift that occurs with this condition? A) Intravascular to interstitial because of glycosuria B) Interstitial to extracellular because of hypoproteinemia C) Intracellular to intravascular because of hyperosmolarity D) Intercellular to intravascular because of increased hydrostatic pressure

C) Intracellular to intravascular because of hyperosmolarity - The osmotic effect of hyperglycemia pulls fluid from the intracellular and interstitial compartments, resulting in dehydration. Hyperglycemia pulls fluid from the interstitial to the intravascular compartment, eventually spilling into the urine. Interstitial fluid is part of the extracellular compartment; the osmotic pull of glucose exceeds other osmotic forces. An increase in hydrostatic pressure results in an intravascular to interstitial shift.

Why is it important for a nurse to support the parents' decision to abort a fetus with a birth defect even if the nurse is morally against abortion? A) Supporting them will eliminate feelings of guilt B) The parents are legally responsible for the decision C) It is essential for maintenance of the family equilibrium D) The nurse's support will relieve the pressure caused by this decision

C) It is essential for maintenance of the family equilibrium

A client has a urinary retention catheter in place after surgery. What should the nurse do when planning the client's safety needs in relation to this device? A) Empty the bag every 6 hour s B) Maintain the tension on the tubing C) Keep the system closed at all times D) Attach the bag to the side rail of the bed

C) Keep the system closed at all times - Urinary catheter systems should be kept closed at all times. The bag should be emptied more frequently than every 6 hours. Tension should be relieved not maintained. The bag should not be attached to the side rail of the bed because if the side rail is moved the catheter may detach.

A client has severe diarrhea, and the HCP prescribes IV fluids, sodium bicarbonate, and an antidiarrheal medication. Which most frequently ordered antidiarrheal drug does the nurse expect the HCP to prescribe? A) Bisacodyl B) Psyllium C) Loperamide D) Docusate sodium

C) Loperamide

An antacid (Maalox) is prescribed for a client with peptic ulcer disease. The nurse knows that the purpose of this medication is to: A) Decrease production of gastric secretions. B) Produce an adherent barrier over the ulcer. C) Maintain a gastric pH of 3.5 or above. D) Decrease gastric motor activity.

C) Maintain a gastric pH of 3.5 or above. - The objective of antacids is to neutralize gastric acids and keep pH of 3.5 or above (C) which is necessary for pepsinogen inactivity. (A) is the purpose of H2 receptor antagonists (cimetidine, ranitidine). (B) is the purpose of sucralfate (Carafate). (D) is the purpose of anticholinergic drugs which are often used in conjunction with antacids to allow the antacid to remain in the stomach longer.

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

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

A client with metastatic cancer who has been receiving fentanyl (Duragesic) for several weeks reports to the nurse that the medication is not effectively controlling the pain. Which intervention should the nurse initiate? A) Instruct the client about the indications of opioid dependence. B) Monitor the client for symptoms of opioid withdrawal. C) Notify the health care provider of the need to increase the dose. D) Administer naloxone (Narcan) per PRN protocol for reversal.

C) Notify the health care provider of the need to increase the dose. - Clients can develop a tolerance to the analgesic effect of opioids and may require an increased dose (C) for effective long-term pain relief. The client is not exhibiting indications of dependence (A), withdrawal (B), or toxicity (D).

A client with hemiplegia is staring blankly at the wall and reports feeling like half a person. What is the initial nursing action? A) Use techniques to distract the client B) Include the client in decision making C) Offer to spend more time with the client D) Help the client to problem-solve personal issues

C) Offer to spend more time with the client

A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate? A) Behind the client B) In front of the client C) On the client's left side D) On the client's right side

C) On the client's left side - When the nurse is assisting the client to ambulate, she should stand on the client's stronger, unaffected side.

Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma? A) Inspection of the skin B) Breath sound auscultation C) Pain scale measurement D) Mobility limitations

C) Pain scale measurement - Multiple myeloma is a tumor that causes bone marrow changes, which most commonly manifest as pain, so measurement of the client's pain is the highest priority (C). (A, B, and D) are part of the complete assessment but do not have the priority of (C) for this client.

A client who had an I+D of an oral abscess is to be discharged. For which clinical finding, if it should occur, should the nurse instruct the client to notify the HCP? A) Foul odor to the breath B) Pain associated with swallowing C) Pain with swelling after one week D) Tenderness in the mouth when chewing

C) Pain with swelling after one week - Pain and swelling should subside before one week. Continued pain and swelling may indicate infection.

A client has myxedema, which results from a deficiency of thyroid hormone synthesis in adults. The nurse knows that which medication should be contraindicated for this client? A) Liothyronine (Cytomel) to replace iodine. B) Furosemide (Lasix) for relief of fluid retention. C) Pentobarbital sodium (Nembutal Sodium) for sleep. D) Nitroglycerin (Nitrostat) for angina pain.

C) Pentobarbital sodium (Nembutal Sodium) for sleep. - Persons with myxedema are dangerously hypersensitive to narcotics, barbiturates (C), and anesthetics. They do tolerate liothyronine (Cytomel) (A) and usually receive iodine replacement therapy. These clients are also susceptible to heart problems such as angina for which nitroglycerin (Nitrostat) (D) would be indicated, and congestive heart failure for which furosemide (Lasix) (B) would be indicated.

An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome? A) Stop the flow of unoxygenated blood into systemic circulation. B) Increase the flow of unoxygenated blood to the lungs. C) Prevent the return of oxygenated blood to the lungs. D) Reduce peripheral tissue hypoxia and nailbed clubbing.

C) Prevent the return of oxygenated blood to the lungs. - Closure of VSDs stops oxygenated blood from being shunted from the left ventricle to the right ventricle (C). VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation (A and B). (D) is common with Tetrology of Fallot, which is a cyanotic defect.

In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first? A) Food planning and selection. Incorrect B) Administering insulin injections. C) Process of glucose testing. D) Drawing up the correct insulin dose.

C) Process of glucose testing. - Developmentally, a 5-year-old has the cognitive and psychomotor skills to use a glucometer (C) and to read the number (it is especially helpful if the nurse presents this activity as a game). (A, B, and D) require more advanced cognitive and psychomotor skills and have greater potential for errors.

A client with a history of gambling has legal difficulties for embezzling money and is required to obtain counseling. During an intake interview, the client says, "I never would have done this if I had been paid what I am worth." What factor will create the greatest difficulty when assisting this client to develop insight? A) Feelings of boredom and emptiness B) Grandiosity related to personal abilities C) Projection of reasons for difficulties onto others D) Anger toward those who are in authority positions

C) Projection of reasons for difficulties onto others

Which hormones are secreted by the client's hypothalamus? Select all that apply. A) Growth hormone B) Follicle-stimulating hormone C) Prolactin-inhibiting hormone D) Corticotropin-releasing hormone E) Melanocyte-stimulating hormone

C) Prolactin-inhibiting hormone D) Corticotropin-releasing hormone - The hormones that are secreted by the hypothalamus include prolactin-inhibiting hormone and corticotropin-releasing hormone. Growth hormone, follicle-stimulating hormone, and melanocyte-stimulating hormone are hormones secreted by the anterior pituitary gland.

A nurse is caring for a client with an undescended testicle. The nurse teaches the client that the main reason why the testicles are suspended in the scrotum is to: A) Protect the sperm from the acidity of urine B) Facilitate the passage of sperm through the urethra C) Protect the sperm from high abdominal temperatures D) Facilitate their maturation during embryonic development

C) Protect the sperm from high abdominal temperatures

A client is admitted to a medical unit with a diagnosis of Addison disease. The client is emaciated and reports muscular weakness and fatigue. Which disturbed body process does the nurse determine is the root cause of the client's clinical manifestations? A) Fluid balance B) Electrolyte levels C) Protein anabolism D) Masculinizing hormones

C) Protein anabolism - Glucocorticoids help maintain blood glucose and liver and muscle glycogen content. A deficiency of glucocorticoids causes hypoglycemia, resulting in the breakdown of protein and fats as energy sources.

A client at the women's health clinic tells the nurse she has endometriosis. What factors associated with endometriosis does the nurse anticipate the client will report? Select all that apply. A) Insomnia B) Ecchymoses C) Rectal pressure D) Abdominal pain E) Skipped periods F) Pelvic infections

C) Rectal pressure D) Abdominal pain

A health care provider prescribes a diuretic for a client with hypertension. What should the nurse include the teaching when explaining how diuretics reduce blood pressure? A) Facilitates vasodilation B) Promotes smooth muscle relaxation C) Reduces the circulating blood volume D) Blocks the sympathetic nervous system

C) Reduces the circulating blood volume

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic? A) Increased physical activity B) Absence of further outbursts C) Relaxation of tensed muscles D) Denial of the need for further discussion

C) Relaxation of tensed muscles - Relaxation of muscles and facial expression are examples of nonverbal behavior; nonverbal behavior is an excellent index of feelings because it is less likely to be consciously controlled. Increased activity may be an expression of anger or hostility. Clients may suppress verbal outbursts despite feelings and become withdrawn. Refusing to talk may be a sign that the client is just not ready to discuss feelings.

Which nursing action is protected from legal action? A) Providing health teaching regarding family planning B) Offering first aid at the scene of an automobile collision C) Reporting incidence of suspected child abuse to the appropriate authorities D) Administering resuscitative measures to an unconscious child pulled out of a swimming pool

C) Reporting incidence of suspected child abuse to the appropriate authorities -

A client is receiving an opioid analgesic every 2 hours for intractable pain. Which pathophysiological consequence should the nurse identify if the client receives the medication at regular intervals? A) Metabolic acidosis. B) Metabolic alkalosis. C) Respiratory acidosis. D) Respiratory alkalosis.

C) Respiratory acidosis. - Respiratory acidosis (C) results from retention of CO2 secondary to hypoventilation due to respiratory depression, which is an adverse effect of opiates. Metabolic acidosis (A) is caused by chronic renal failure, loss of bicarbonates during diarrhea, and metabolic disorders that result in overproduction of lactic acid or ketoacids. Metabolic alkalosis (B) is caused by excessive loss of gastric acid and administration of alkalinizing salts. Respiratory alkalosis (D) is precipitated by hyperventilation.

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

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

Which nursing diagnosis is important to include in the plan of care for a client receiving the angiotensin-2 receptor antagonist irbesartan (Avapro)? A) Fluid volume deficit. B) Risk for infection. C) Risk for injury. D) Impaired sleep patterns.

C) Risk for injury. - Avapro is an antihypertensive agent, which acts by blocking vasoconstrictor effects at various receptor sites. This can cause hypotension and dizziness, placing the client at high risk for injury (C). Avapro does not act as a diuretic (A), impact the immune system (B), or alter sleep patterns (D).

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

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

A preschool-age child has been restricted to bed rest since admission to the hospital. As a response to the improvement, the child becomes interested in playing. Based on the child's developmental level and activity restriction, what should the nurse provide? A) Television viewing time B) Squeaky stuffed animals C) Small farm animals and a little barn D) Simple three-or four-piece wooden puzzles

C) Small farm animals and a little barn

What gross motor skills should the nurse expect a developmentally appropriate 3-year-old child to perform? Select all that apply. A) Skipping on alternate feet B) Riding alone on a small bicycle C) Standing on one foot for a few seconds D) Alternating feet when walking up the stairs E) Jumping rope by lifting both feet simultaneously

C) Standing on one foot for a few seconds D) Alternating feet when walking up the stairs

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

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

A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen? A) The oxygen had not been ordered and therefore should not have been administered B) The symptoms were too vague for the nurse to determine a need for administering oxygen C) The nurse's observations were sufficient, and the oxygen should have been administered D) The HCP should have been called for an order before the nurse administered the oxygen

C) The nurse's observations were sufficient, and the oxygen should have been administered - The Nurse Practice Act states that nurses diagnose and treat human responses to actual or potential health problems. Administration of oxygen is an emergency situation and is within the scope of nursing practice.

A nurse is teaching a client how to self-administer a medicated douche. In which direction should the nurse instruct the client to direct the douche nozzle? A) To the left B) To the right C) Toward the sacrum D) Toward the umbilicus

C) Toward the sacrum

Which food selected by a client with osteoporosis indicates that the nurse's dietary teaching was effective? A) Red meat B) Soft drinks C) Turnip greens D) Enriched grains

C) Turnip greens - Turnip greens are high in calcium.

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

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

A nurse is caring for a client after surgical creation of a conduit diversion. What is the major disadvantage of a conduit diversion that the nurse should consider when caring for this client? A) Peristalsis is greatly decreased B) Stool continuously oozes from it C) Urine continuously drains from it D) Absorption of nutrients is diminished

C) Urine continuously drains from it

Two clients with polydipsia and polyuria arrived at the hospital. Both were having similar symptoms but were diagnosed with different types of diabetes insipidus. Which assessment finding helped to differentiate the diagnosis? A) Urine output B) Specific gravity C) Urine osmolarity D) Serum osmolarity

C) Urine osmolarity - Polydipsia and polyuria are signs of diabetes insipidus. When a water deprivation test is performed, urine osmolarity is increased dramatically from 100 to 600 mOsm (mmol)/kg in clients with central diabetes insipidus. But in nephrogenic diabetes insipidus, the urine osmolarity may not be greater than 300 mOsm (mmol)/kg. The urine output is 2 L to 20 L/day in all types of diabetes insipidus. The specific gravity is less than 1.005 in all types of diabetes insipidus and the serum osmolarity is also greater than 295 mOsm (mmol)/kg in all types of diabetes insipidus.

The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A) Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B) Apply ice packs to edematous or tender joints to reduce pain and swelling. C) Warm the child with an electric blanket prior to getting the child out of bed. D) Immobilize swollen joints during acute exacerbations until function returns.

C) Warm the child with an electric blanket prior to getting the child out of bed. - Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child (C) in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. (A) on an empty stomach is likely to cause gastric discomfort. Warm (not cold) packs or baths are used to minimize joint inflammation and stiffness (B). (D) is contraindicated, because joints should be exercised, not immobilized.

A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide? A) Remove all blackheads and follow with an alcohol scrub. B) Use medicated cosmetics only to help hide the blemishes. C) Wash the hair and skin frequently with soap and hot water. D) Encourage her to see a dermatologist as soon as possible.

C) Wash the hair and skin frequently with soap and hot water. - Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and helps prevent and treat acne. Oily skin is especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not) should be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at a later time, if healthcare recommendations are not successful.

The nurse is assessing a client who is receiving risperidone (Risperdal). The nurse should monitor the client for which common side effect that is most likely to occur during therapy? A) Dystonia. B) Akathisia. C) Weight gain. D) Photosensitivity.

C) Weight gain. - Risperidone (Risperdal, Consta) is an atypical antipsychotic agent with a lower potential for extrapyramidal effects, but cause common side effects, such as weight gain (C), insomnia, hypotension, and headache. Atypical antipsychotics are less likely to induce extrapyramidal side effects (EPS) (movement disorders), such as pseudoparkinsonism and tardive dyskinesia, where as (A, B, and D) are more likely to occur during therapy with conventional phenothiazine antipsychotics.

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

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

After a hysterosalpingo-oophorectomy, a client wants to know whether it would be wise for her to take hormones right away to prevent symptoms of menopause. WHat is the nurse's most appropriate response? A) "It is best to wait because you may not have any symptoms." B) "It is comforting to know that hormones are available if you should ever need them." C) "You have to wait until symptoms are severe; otherwise, hormones will have no effect." D) "Discuss this with your HCP, because it is important to know your concerns."

D) "Discuss this with your HCP, because it is important to know your concerns."

A client with type 2 diabetes, who is taking an oral hypoglycemic agent, is to have a serum glucose test early in the morning. The client asks the nurse, "What do I have to do to prepare for this test?" Which statement by the nurse reflects accurate information? A) "Eat your usual breakfast." B) "Have clear liquids for breakfast." C) "Take your medication before the test." D) "Do not ingest anything before the test."

D) "Do not ingest anything before the test." - Fasting before the test is indicated for accurate and reliable results; food before the test will increase serum glucose levels through metabolism of the nutrients. Food should not be ingested before the test; food will increase the serum glucose level, negating accuracy of the test. Instructing the client to have clear liquids for breakfast is inappropriate; some clear fluids contain simple carbohydrates, which will increase the serum glucose level. Medications are withheld before the test because of their influence on the serum glucose level.

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

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

A parent whose newborn infant son has a cleft lip and palate asks the nurse, "How should I feed my baby because he has difficulty sucking?" What information should the nurse provide concerning a safe feeding technique for the infant? A) "Since he tires easily, it is best to have him lying in bed while he is being fed." B) "He should be held in a horizontal position and fed slowly to avoid aspiration." C) "Try using a soft nipple with an enlarged opening so he can get milk through a chewing motion." D) "Give him brief rest periods and frequent burpings during feedings so that he can get rid of swallowed air."

D) "Give him brief rest periods and frequent burpings during feedings so that he can get rid of swallowed air." - Infants with cleft lips and palates tend to swallow a lot of air, so frequent rest periods and burping are the best teaching for this client.

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

D) "I seem to be having difficulty thinking clearly." - A common side effect of Pepcid is confusion (D). (A, B, and C) are not side effects of this medication.

When teaching a class about parenting, the nurse asks the participants what they do when their toddlers have a temper tantrum. Which statement demonstrates one parent's understanding of the origin of temper tantrums? A) "After a temper tantrum, I discipline my child by restricting a favorite food or candy." B) "When a temper tantrum begins, I isolate and ignore my child until the behavior improves." C) "During a temper tantrums, I partially give in to my child before the tantrum becomes excessive." D) "I try to prevent a temper tantrum by allowing my child to chose between two reasonable alternatives."

D) "I try to prevent a temper tantrum by allowing my child to chose between two reasonable alternatives."

A nurse is caring for a client who is cachexic. What information about the function of adipose tissue in fat metabolism is necessary to better address the needs of this client? A) Releases glucose for energy B) Regulates cholesterol production C) Uses lipoproteins for fat transport D) Stores triglycerides for energy reserves

D) Stores triglycerides for energy reserves

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

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

A client is diagnosed with uterine fibroids, and the HCP advises a hysterectomy. The client expresses concern about having a hysterectomy at age 45 because she has heard from friends that she will undergo severe symptoms of menopause after surgery. What is the nurse's most appropriate response? A) "You are correct, but there are medicines you can take that will ease the symptoms." B) "This sometimes occurs in women of your age, but you needn't worry about it at this time." C) "Perhaps you should talk to your surgeon because I am not allowed to discuss this with you." D) "Some women may experience symptoms of menopause if their ovaries are removed with their uterus."

D) "Some women may experience symptoms of menopause if their ovaries are removed with their uterus."

A nurse is teaching a client about a restricted diet. What is the nurse's best initial comment? A) "What type of foods do you usually eat?" B) "You should follow this diet exactly as written." C) "You must limit the intake of foods on this special list." D) "What do you know about this diet that was ordered for you?"

D) "What do you know about this diet that was ordered for you?"

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

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

A nurse is monitoring a client's fasting plasma glucose. At which FPG level should the nurse identify that the client has prediabetes? A) 70 mg/dL B) 100 mg/dL C) 130 mg/dL D) 160 mg/dL

D) 160 mg/dL

A 15-year-old sexually active girl diagnosed with pelvic inflammatory disease (PID) is admitted to the hospital with a temperature of 101.6° F and a purulent vaginal discharge. She has no insurance and tells the nurse she enjoys small children. Which room should the nurse assign this client? A) A semi-private room with a 4-year-old girl who is currently receiving chemotherapy. B) A semi-private room with an older adolescent girl who had surgery yesterday. Incorrect C) A room close to the nurse's station. D) A private room.

D) A private room. - Despite the fact that the client has no insurance and enjoys small children, she is infected and should be placed in a private room (D). This client is infected, which is a priority consideration, so (A and B) would not be the best room assignment for this client because they would put the roommates at serious, unnecessary risk. This client is not acutely ill and does not need to be assigned to a room next to the nurse's station (C).

The charge nurse is assigning a room for a newly-admitted client, diagnosed with acute Pneumocystis carinii pneumonia, secondary to acquired immunodeficiency syndrome (AIDS). Which room would be best to assign to this client? A) A private room fully equipped with an outside air ventilation system. B) A semi-private room shared with an bed-ridden elder who would enjoy the company. C) A semi-private room with a bed available nearest to the bathroom. D) A semi-private room that does not have a client in the other bed at this time.

D) A semi-private room that does not have a client in the other bed at this time. - A semi-private room without a roommate (D) is the best assignment because the room can be easily blocked to create a private room should the client require isolation measures due to the pneumonia (the AIDS diagnosis alone does not affect the type of room assignment). A client with pneumonia should not be exposed to an outside air ventilation system (A). The client should not be assigned to a room with a client who is at risk for pneumonia (B). Mobility is not a factor for this client, therefore (C) is not indicated.

What clinical finding indicates to the nurse that the client may have hypokalemia? A) Edema B) Muscle spasms C) Kussmaul breathing D) Abdominal distension

D) Abdominal distension

The nurse is caring for a client who is diagnosed with hyperpituitarism due to a prolactin-secreting tumor. Which clinical manifestation can help confirm the diagnosis? A) Hypertrophy of skin B) Enlargement of liver C) Hypertrophy of the heart D) Absence of menstruation

D) Absence of menstruation - A prolactin-secreting tumor is a common type of pituitary adenoma that results from excessive secretion of prolactin. Therefore, ultimately, there are associated clinical symptoms, such as absence of galactorrhea and menstruation and infertility. Excessive production of growth hormone is manifested by clinical symptoms, such as skin hypertrophy and enlargement of organs (e.g., liver and heart).

Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? A) Anger B) Denial C) Depression D) Acceptance

D) Acceptance - In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.

What are the cardiovascular manifestations observed in a client with adrenal insufficiency? A) Fatigue B) Salt craving C) Weight loss D) Hyponatremia

D) Hyponatremia - Hyponatremia is a decrease in serum sodium levels, which is the cardiovascular manifestation of adrenal insufficiency. Fatigue is a neuromuscular manifestation observed in clients with adrenal insufficiency, while salt cravings and weight loss are the abdominal manifestations observed in clients with adrenal insufficiency.

The nurse is preparing to administer a secondary infusion of a dobutamine solution to a client. The nurse notes that the solution is brown in color. Which action should the nurse implement? A) Verify the prescribed dose with the health care provider. B) Discard the solution and reorder from the pharmacy. C) Dilute the solution with more normal saline until it becomes lighter in color. D) Administer the drug if the solution's reconstitution time is less than 24 hours.

D) Administer the drug if the solution's reconstitution time is less than 24 hours. - The color of the dobutamine solution is normal (D), and it should administered within 24 hours after reconstitution, so the time of reconstitution should be verified before administering the solution of medication. (A) is not indicated. (B) is not necessary. Additional dilution of a drug in solution is stated in the manufacturer's reconstitution instructions, but (C) is not needed.

A nurse is teaching a group of women about the side effects of different types of contraceptives. What is the most frequent side effect associated with the use of an intrauterine device (IUD)? A) A tubal pregnancy B) A rupture of the uterus C) An expulsion of the device D) An excessive menstrual flow

D) An excessive menstrual flow

A client with acute kidney failure becomes confused and irritable. Which does the nurse determine is the most likely cause of this behavior? A) Hyperkalemia B) Hypernatremia C) A limited fluid intake D) An increased BUN

D) An increased BUN

What should the nurse do when caring for a client with an ileostomy? A) Teach the client to eat foods high in residue B) Explain that drainage can be controlled with daily irrigations C) Expect the stoma to start draining on the third postoperative day D) Anticipate that any emotional stress can increase intestinal peristalsis

D) Anticipate that any emotional stress can increase intestinal peristalsis

A child with acute poststreptococcal glomerulonephritis requests a snack. Which is the most therapeutic selection of food the nurse can provide? A) Peanuts B) Pretzels C) Bananas D) Applesauce

D) Applesauce - Applesauce is the most nutritious selection. Bananas are high in potassium and are contraindicated in patients with glomerulonephritis.

A client with advanced cirrhosis and hepatic encephalopathy is manifesting mounting ascites and 4+ pitting edema of the feet and legs. The nurse identifies fluid leaking from his skin when he is turned. Which intervention is most important for the nurse to include in the client's plan of care? A) Turn the client every 4 hours. B) Restrict dietary protein intake. C) Perform passive range of motion 4 times per day. D) Apply a pressure-relieving mattress under the client.

D) Apply a pressure-relieving mattress under the client. - The client's risk for impaired skin integrity requires meticulous skin care because the edematous tissues are showing indications of breakdown. A pressure-relieving mattress (D) should be used to reduce the risk of skin tearing with manual turning. Although (A and C) are valuable in preventing complications of immobility, the client's skin integrity is threatened by fluid retention and requires measures to prevent breakdown. Dietary protein (B) may be indicated with hepatic encephalopathy, but the client's skin integrity is threatened by pitting edema and ascites and should be addressed.

A nurse in the surgical ICU is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client? A) Vitamin A B) Cyanocobalamin C) Phytonadione D) Ascorbic Acid

D) Ascorbic Acid - Ascorbic Acid is also known as Vitamin C and aids in collagen production.

A mother brings her 18-month-old child to the community health center because the child has had "bad diarrhea" for the last 3 days. She states, "I bought some of this liquid at the pharmacy and gave my daughter a half-ounce." The nurse sees that the bottle contains loperamide (Imodium AD). Which intervention is most important for the nurse to implement initially? A) Tell the mother never to give this drug to her toddler. B) Ask if any other siblings have experienced diarrhea. C) Take the child's oral and tympanic temperatures. D) Ask the mother when the child last voided.

D) Ask the mother when the child last voided. - Determining when the child last voided (D) is most important because urine output is decreased with dehydration and an 18-month-old with a 3-day history of diarrhea could be severely dehydrated. Although the manufacturer states that loperamide (Imodium AD) should not be given to a child younger than 2 years except under the direction of a health care provider (A), this information is not the best answer for this question. In addition, loperamide (Imodium AD) causes an anticholinergic effect of urinary retention. Data obtained in (B and C) are not as high a priority as (D) in this situation.

A client undergoes cardiac catheterization via femoral artery because of a history of bilateral mastectomies. What is the most important nursing action after the procedure? A) Provide a bed cradle B) Check for a pulse deficit C) Elevate the head of the bed D) Assess the groin for bleeding

D) Assess the groin for bleeding - Hematoma and hemorrhage are common complications after cardiac catheterization.

The health care provider prescribes ipratropium (Atrovent) for a client. An allergic reaction to which other medication would cause the nurse to question the prescription for Atrovent? A) Albuterol (Proventil) B) Theophylline (Theo-24) C) Metaproterenol (Alupent) D) Atropine sulfate (Atropine)

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

A HCP prescribes tolterodine for a client with an overactive bladder. What is most important for the nurse to teach the client to do? A) Maintain a strict record of fluid intake and urinary output B) Chew the extended release capsule thoroughly before swallowing C) Report episodes of diarrhea or any increase in respiratory secretions D) Avoid activities requiring alertness until the response to the medication is known

D) Avoid activities requiring alertness until the response to the medication is known - Tolterodine is a urinary antispasmodic and may cause dizziness.

Using Piaget's theory of cognitive development, what should the nurse expect a 6-month-old infant to demonstrate? A) Early traces of memory B) Beginning sense of time C) Repetitious reflex responses D) Beginning of object permanence

D) Beginning of object permanence

Which information is most accurate for the nurse to use when calculating safe drug dosages for a child? A) Age. B) Height. C) Weight. D) Body surface area.

D) Body surface area. - The most accurate method of calculating pediatric doses is based on a child's body surface area (BSA) (D). Drug calculations are not consistently precise when made on the basis of a child s age (A) since children vary widely in size and maturity for chronologic age. Although the calculation of a child's BSA utilizes a child's height and weight, (B and C) alone do not correlate with the distribution or metabolism of a drug due to the variance in each child's growth and development

The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? A) Ask the UAP to check for the advanced directive while the nurse completes the assessment. B) Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C) Check the medical record for the advanced directive and then complete the client assessment. D) Call for the charge nurse to check the advanced directive while continuing to assess the client.

D) Call for the charge nurse to check the advanced directive while continuing to assess the client. - Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse and cannot be delegated to the UAP. (C) is contraindicated.

A client's laboratory values demonstrate an increased serum calcium level, and further diagnostic tests reveal hyperparathyroidism. What clinical manifestations might the nurse identify when assessing this client? Select all that apply. A) Muscle tremors B) Abdominal cramps C) Increased peristalsis D) Cardiac dysrhythmias E) Hypoactive bowel sounds

D) Cardiac dysrhythmias E) Hypoactive bowel sounds - When the serum calcium level is increased, initially it causes tachycardia; as it progresses, it depresses electrical conduction in the heart, causing bradycardia. Hypercalcemia causes decreased peristalsis identified by constipation and hypoactive or absent bowel sounds. Muscle tremors occur with hypocalcemia, not hypercalcemia. Abdominal cramps occur with hypocalcemia, not hypercalcemia. Increased intestinal peristalsis occurs with hypocalcemia, not hypercalcemia.

A client with a high cholesterol level says to the nurse, "Why can't the doctor just give me a medication to eliminate all of the cholesterol in my body so it isn't a problem? Which factor related to why cholesterol is important in the human body should the nurse include in a response to the client's question? A) Blood clotting B) Bone formation C) Muscle contraction D) Cellular metabolism

D) Cellular metabolism

Which nursing action can best prevent infection from a urinary retention catheter? A) Cleansing the perineum B) Encouraging adequate fluids C) Irrigating the catheter once daily D) Cleansing around the meatus routinely

D) Cleansing around the meatus routinely

A client's problem with ineffective control of type 1 diabetes is pinpointed as a sudden decrease in blood glucose level followed by rebound hyperglycemia. What should the nurse do when this event occurs? A) Give the client 8 oz (240 mL) of orange juice. B) Seek a prescription to increase the insulin dose at bedtime. C) Encourage the client to eat smaller, more frequent meals. D) Collaborate with the primary healthcare provider to alter the insulin prescription

D) Collaborate with the primary healthcare provider to alter the insulin prescription - The client is experiencing the Somogyi effect. It is a paradoxical situation in which sudden decreases in blood glucose are followed by rebound hyperglycemia. The body responds to the hypoglycemia by secreting glucagon, epinephrine, growth hormone, and cortisol to counteract the low blood sugar; this results in an excessive increase in the blood glucose level. It most often occurs in response to hypoglycemia when asleep. The primary healthcare provider may choose to decrease the insulin dose and then reassess the client. Giving the client 8 oz (240 mL) of orange juice will further increase the serum glucose level and is contraindicated. Increasing the insulin dose at bedtime will further worsen the problem. Encouraging the client to eat smaller, more frequent meals will not address the hypoglycemia and rebound hyperglycemia that occurs when sleeping. However, a bedtime snack may help minimize this event.

A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan? A) Invite other children home to share meals. B) Accept that he will eat when he is hungry. C) Reward the child with a nap after eating. D) Consistently follow a set mealtime routine.

D) Consistently follow a set mealtime routine. - A 2-year-old child is comforted by consistency (D). (A) is contraindicated because two-year-olds may participate in parallel activities with other children but are too young to feel comfort and support by the presence of other children when anxious or afraid. (B) may or may not be true and does not address the child's fears. The child with reflux should remain upright at least two hours after eating (C) to reduce symptoms.

A client who has trouble swallowing pills intermittently has been prescribed venlafaxine (Effexor XR) for depression. The medication comes in capsule form. What should the nurse include in the discharge teaching plan for this client? A) Capsule contents can be sprinkled on pudding or applesauce. B) Chew the medication thoroughly to enhance absorption. C) Take the medication with a large glass of water or juice. D) Contact the health care provider for another form of medication.

D) Contact the health care provider for another form of medication. - Venlafaxine (Effexor XR) is administered PO in capsule form. Capsules that are extended-release (XR) or continuous-release (CR) contain delayed-release, enteric-coated granules to prevent decomposition of the drug in the acidic pH of the stomach. The client should notify the health care provider about the inability to swallow the capsule (D). This medication should not be chewed or opened so that the delayed-release, enteric-coated granules can remain intact (A and B). Water or juice (C) will not affect the medication.

A nurse at the fertility clinic is counseling a couple about the tests that will be needed to determine the cause of their infertility. Which test should the nurse describe that will evaluate the woman's organs of reproduction? A) Biopsy B) Cystogram C) Culdoscopy D) Hysterosalpingogram

D) Hysterosalpingogram

The health care provider has prescribed a low-molecular-weight heparin, enoxaparin (Lovenox) prefilled syringe, 30 mg/0.3 mL IV every 12 hours, for a client following hip replacement. Prior to administering the first dose, which intervention is most important for the nurse to implement? A) Assess the client's IV site for signs of inflammation. B) Evaluate the client's degree of mobility. C) Instruct the client regarding medication side effects. D) Contact the health care provider to clarify the prescription.

D) Contact the health care provider to clarify the prescription. - Lovenox is a low-molecular-weight heparin that can only be administered subcutaneously, so the nurse should contact the health care provider to clarify the route of administration (D). (A and B) are important nursing interventions but not necessary to the administration of this medication. The client should be instructed about medication side effects (C), but this is of lower priority than obtaining a correct prescription.

The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam hydrochloride (Versed). In assessing the client, the nurse determines that the client has slurred speech with diplopia. Based on this finding, what action should the nurse take? A) Open the airway with a chin lift-head tilt maneuver. B) Obtain a fingerstick glucose reading. C) Administer flumazenil (Romazicon). D) Continue to monitor the client

D) Continue to monitor the client - The desired level III in conscious sedation includes slurred speech, glazed eyes, and marked diplopia. Because this is the desired outcome of the medication regimen, no action is needed but continuing to monitor the client (D). The airway is open if the client is able to talk (A). There are no signs of hypoglycemia (B). No reversal is necessary for the benzodiazepine (Versed) without signs of oversedation, such as respiratory depression (C).

A client who had an organ transplant is receiving cyclosporine. For what should the nurse monitor to identify a serious adverse effect of cyclosporine? A) Skin for hirsutism B) Stools for constipation C) Heart rhythm for dysrhythmias D) Creatinine level for an increase

D) Creatinine level for an increase - Cyclosporine causes nephrotoxicity.

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

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

During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report? A) The occurrence of any episodes of sleep apnea B) The child's blood pressure, pulse, and respirations C) Length of rapid eye movement (REM) sleep that the child is experiencing D) Description of the family's home environment

D) Description of the family's home environment - School-age children often resist bedtime. The nurse should begin by assessing the environment of the home (D) to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. (A) often causes daytime fatigue rather than resistance to going to sleep. (B) is unlikely to provide useful data. The nurse cannot determine (C).

During the first prenatal visit of a woman who is at 23 weeks' gestation, the nurse discovers that the client has a history of pica. What is the most appropriate nursing action? A) Seek a physiologic referral B) Explain the danger this poses to the fetus C) Obtain a prescription for an iron supplement D) Determine whether the diet is nutritionally adequate

D) Determine whether the diet is nutritionally adequate - Patients who have a history of pica typically have a nutritionally INADEQUATE diet, so the nurse should assess the patient's regular diet.

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

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

A client has a transverse loop colostomy. What should the nurse do when inserting a catheter for the colostomy irrigation? A) Use an oil-based lubricant B) Instruct the client to gently bear down C) Apply gentle but continuous pressure D) Direct it toward the client's right side

D) Direct it toward the client's right side

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A) Use the normal saline solution once more and then discard. B) Obtain a new sterile syringe to draw up the labeled saline solution. C) Use the saline solution and then relabel the bottle with the current date. D) Discard the saline solution and obtain a new unopened bottle.

D) Discard the saline solution and obtain a new unopened bottle. - Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded (D). (A, B, and C) describe incorrect procedures.

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

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

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

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

A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? A) Airway obstruction B) Inadequate nutrition C) Prolonged gastric suction D) Excessive mechanical ventilation

D) Excessive mechanical ventilation - The patient is exhibiting symptoms of respiratory alkalosis, which is commonly caused by mechanical ventilation.

During a group therapy session, a client with hypomania threatens to strike another client. What intervention is best for the nurse to implement? A) Summon assistance of several other staff. B) Send the other clients out of the group setting. C) Tell the client to leave the group to gain control of the behavior. D) Firmly inform the client that acting out anger is not acceptable.

D) Firmly inform the client that acting out anger is not acceptable. - A client with hypomania may demonstrate a varying degree of feelings, rapid thoughts, speech patterns, and impulsive acts. The client should be informed firmly that threats or behavior to act out feelings of anger is not acceptable (D). Staff assistance should be summoned (A) only if the client becomes aggressive and out of control. If a client persists with threats or aggressive behavior, changing the client's environment should be implemented before (B). Although personal time away from the group (C) may allow the client time out, the client should be confronted to recognize that the behavior is unacceptable.

During a home visit to a client, the nurse identifies tremors of the client's hands. When discussing this assessment, the client reports being nervous, having difficulty sleeping, and feeling as if the collars of shirts are getting tight. Of the additional assessment findings, which one should the nurse report to the practitioner? A) Increased appetite B) Recent weight loss C) Feelings of warmth D) Fluttering in the chest

D) Fluttering in the chest - Many of these problems are associated with hyperthyroidism; palpitations may indicate cardiovascular changes requiring prompt intervention. The increased metabolism associated with hyperthyroidism can lead to heart failure. Although an increased appetite becomes a compensatory mechanism for the increased metabolism associated with hyperthyroidism, it is not life threatening. Although unexplained weight loss can result from catabolism associated with hyperthyroidism, it is not life threatening. Although a feeling of warmth caused by the increased metabolism associated with hyperthyroidism is uncomfortable, it is not life threatening.

The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. What action should the nurse take? A) Institute the ordered blood transfusion because the client's surgical depends on volume replacement B) Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion C) Phone the HCP for an administrative order to give the transfusion under these circumstances D) Give the spouse a treatment refusal form to sign and notify the HCP that a court order can now be sought

D) Give the spouse a treatment refusal form to sign and notify the HCP that a court order can now be sought - The client is unconcious. Although the spouse can give consent, there is no legal power to refuse treatment for the client unless previously authorized to do so by the power of attorney or a health care proxy ; the court can make a decision for the client.

A nurse is teaching an athletic teenager about nutrients that provide the quickest source of energy. Which food selected from the menu indicates to the nurse that the adolescent understands the teaching? A) Glass of milk B) Slice of bread C) Chocolate candy bar D) Glass of orange juice

D) Glass of orange juice

A nurse is transferring a client with a diagnosis of pheochromocytoma from a bed to a chair. What is the MOST important nursing intervention associated with this procedure for this client? A) Supporting the client on the weak side B) Ensuring that the chair is close to the client's bed C) Placing sturdy shoes with rubber soles on the client's feet D) Having the client sit on the side of the bed for a few minutes before the transfer

D) Having the client sit on the side of the bed for a few minutes before the transfer - Having the client sit on the side of the bed for several minutes allows time for the blood pressure to adjust to the vertical position; this avoids dizziness and the potential for fainting or falling.

Dobutamine (Dobutrex) is an emergency drug most commonly prescribed for a client with which condition? A) Shock. B) Asthma. C) Hypotension. D) Heart failure.

D) Heart failure. - Dobutamine is a beta-1 adrenergic agonist that is indicated for short term use in cardiac decompensation or heart failure (D) related to reduced cardiac contractility due to organic heart disease or cardiac surgical procedures. Alpha and beta adrenergic agonists, such as epinephrine and dopamine, are sympathomimetics used in the treatment of shock (A). Other selective beta-2 adrenergic agonists, such as terbutaline and isoproterenol, are indicated in the treatment of asthma (B). Although dobutamine improves cardiac output, it is not used to treat hypotension (C).

A client with a tentative diagnosis of Cushing syndrome has an increased cortisol level. What response should the nurse assess this client for? A) Hypovolemia B) Hyperkalemia C) Hypoglycemia D) Hypernatremia

D) Hypernatremia - A client with Cushing syndrome secretes excess amounts of cortisol, a corticosteroid that acts to retain sodium and water, resulting in hypernatremia and edema. Hypervolemia, not hypovolemia, is caused by fluid retention. Hypokalemia, not hyperkalemia, occurs because potassium is lost when there is sodium retention. Hyperglycemia, not hypoglycemia, results from cortisol-induced glucose intolerance.

A nurse is caring for a client who had a hypophysectomy. For which complications specific to this surgery should the nurse assess the client for early clinical manifestations? A) Urinary retention B) Respiratory distress C) Bleeding at the suture line D) Increased ICP

D) Increased ICP - Because the pituitary gland is located in the brain, edema after surgery may result in increased ICP. Early signs include decreased visual acuity, papilledema, and unilateral pupillary dilatation.

A HCP prescribes simvastatin 20 mg daily for elevated cholesterol and triglyceride levels for a middle-age female. Which is most important for the nurse to teach the client to do when initially taking this medication? A) Take the medication with breakfast B) Have liver function tests twice a year C) Wear sunscreen to prevent photosensitivity reactions D) Inform the HCP if becoming pregnant is desired

D) Inform the HCP if becoming pregnant is desired - Simvastatin use is contraindicated during pregnancy.

Which intervention is most important for the nurse to include in the plan of care for a client with ankylosing spondylitis? A) Limit the client's daily fat intake to 30%. B) Increase the client's fluid intake to 3000 ml daily. C) Place pillows under the client when lying supine. D) Initiate a smoking cessation program.

D) Initiate a smoking cessation program. - As the spine progressively stiffens, the client with ankylosing spondylitis should be encouraged to stop smoking (D) to decrease the risk for pulmonary complications related to reduced chest expansion and movement. Although recommended health promotion practices (A and B) should be encouraged, the risk of complications with ankylosing spondylitis is increased if the client continues to smoke. Using pillows under the client when lying supine may promote comfort, but should be evaluated to prevent flexion that increases the client's risk for flexion or fixation deformity (D).

A nurse is assessing two clients. One client has UC and the other client has Crohn disease. Which is more likely to be identified in the client with UC? A) Inclusion of transmural involvement of the small bowel wall B) Correlation with increased malignancy because of malabsorption syndrome C) Pathology beginning proximally with intermittent plaques found along the colon D) Involvement starting distally with rectal bleeding that spreads continually up the colon

D) Involvement starting distally with rectal bleeding that spreads continually up the colon

What does the nurse expect to be the priority concern of a 28-year-old woman who has to undergo a laparoscopic bilateral salpingo-oophrectomy? A) Acute pain B) Risk for hemorrhage C) Fear of chronic illness D) Loss of childbearing potential

D) Loss of childbearing potential

A client is scheduled for ligation of hemorrhoids. Which diet does the nurse expect to be ordered in preparation for this surgery? A) Bland B) Clear liquid C) High-protein D) Low-residue

D) Low-residue

What must the nurse emphasize to a family when preparing a child with persistent asthma for discharge? A) A cold, dry environment is desirable B) Limits should not be placed on the child's behavior C) The health problem is gone when symptoms subside D) Medications must be continued even when asymptomatic

D) Medications must be continued even when asymptomatic

A nurse administers the prescribed regular insulin (Novolin R) to a client in DKA. In addition, the nurse anticipates that the IV solution prescribed will contain potassium to replenish potassium ions in the extracellular fluid that are being: A) Rapidly lost from the body by copious diaphoresis present during coma B) Carried with glucose to the kidneys to be excreted in the urine in increased amounts C) Quickly used up during the rapid series of catabolic reactions stimulated by insulin and glucose D) Moved into the intracellular fluid compartment because of the generalized anabolism induced by insulin and glucose

D) Moved into the intracellular fluid compartment because of the generalized anabolism induced by insulin and glucose - Insulin stimulates cellular uptake of glucose and also stimulates the sodium/potassium pump, leading to the influx of potassium into cells. The resulting hypokalemia is offset by parenteral administration of potassium.

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

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

A pregnant adolescent at 10 weeks' gestation visits the prenatal clinic for the first time. The nutrition interview indicates that her dietary intake consists mainly of soft drinks, candy, French fries, and potato chips. Why does the nurse consider this diet inadequate? A) Caloric content will result in too great a weight gain B) Ingredients in soft drinks and candy can be teratogenic during pregnancy C) Salt in this diet will contribute to the development of gestational hypertension D) Nutritional composition of the diet places her at risk for a low-birth weight infant

D) Nutritional composition of the diet places her at risk for a low-birth weight infant

When planning care for a child with autism, the nurse understands that given a choice, the child with autism usually enjoys playing: A) On a jungle gym B) With a cuddly toy C) With a small yellow block D) On a playground merry-go-round

D) ON a playground merry-go-round

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A) Encourage the client to use a nicotine patch. B) Reassure the client that it is almost time for another break. C) Have the client leave the unit with another staff. D) Review the schedule of outdoor breaks with the client.

D) Review the schedule of outdoor breaks with the client. - The best nursing action is to review the schedule of outdoor breaks (D) and provide concrete information about the schedule. (A) is contraindicated if the client wants to continue smoking. (B) is insufficient to encourage a trusting relationship with the client. (C) is preferential for this client only and is inconsistent with unit rules.

Which action should the nurse implement to assess for jugular vein distention (JVD) in a client with heart failure (HF)? A) Ask the client to perform the Valsalva maneuver while lying in a supine position. B) Palpate the jugular veins, comparing the volume and pressure of one with those of the other. C) Measure in centimeters the distance that the jugular veins are distended outward from the neck. D) Observe the vertical distention of the veins as the client is gradually elevated to an upright position.

D) Observe the vertical distention of the veins as the client is gradually elevated to an upright position. - An indicator of elevated right atrial pressure in HF is jugular distention of greater than 3 cm vertical distance between the intersection of the angle of Louis and the level of the jugular distention, which occurs when the client is gradually elevated to an upright position (D). (A, B, and C) do not provide the best evaluation of JVD in a client with HF.

During the postpartum period a nurse identifies a client's rubella titer is negative. What action should the nurse plan to take? A) Check for allergies to penicillin B) Alert the staff in the newborn nursery C) Assure the client that she has active immunity D) Obtain a prescription for an immunization before discharge

D) Obtain a prescription for an immunization before discharge

A client had a mastectomy asks about ERP-positive. The nurse explains that tumors cells are evaluated for estrogen receptor protein to determine the: A) Need for supplemental oxygen B) Feasibility of breast reconstruction C) Degree of metastasis has occurred D) Potential response to hormone therapy

D) Potential response to hormone therapy

An older adult with dementia is admitted to a nursing home. The client is confused, agitated, and at times unaware of the presence of others. What is the best nursing approach to help this client adapt to the unit? A) Initiate a program of planned interaction B) Explain the nature and routines of the unit C) Explore in depth the reasons for admission D) Provide for the continuous presence of staff members

D) Provide for the continuous presence of staff members

A nurse administers an IM injection of vitamin K to a newborn. What is the purpose of the injection? A) Maintains the intestinal flora count B) Promotes proliferation of intestinal flora C) Stimulates vitamin K production in the baby D) Provides protection until intestinal flora is established

D) Provides protection until intestinal flora is established

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

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

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? A) Alkalosis B) Renal failure C) Hypervolemia D) Pulmonary edema

D) Pulmonary edema

A HCP orders intermittent NG tube feeding to supplement a client's oral nutritional intake. Which hazard associated with NG tube feeding will be reduced if the nurse administers this feeding over 60 minutes? A) Distension B) Flatulence C) Indigestion D) Regurgitation

D) Regurgitation

A mother asks the nurse to explain how using time-out to discipline her 2-year-old child is an effective method. Which rationale should the nurse provide? A) Offers positive reinforcement. B) Provides a consequence to behavior. C) Extinguishes the behavior by ignoring it. D) Removes a reinforcer that a child is receiving.

D) Removes a reinforcer that a child is receiving. - Time-out is a disciplinary approach that removes a reinforcer, such as the satisfaction or attention the child receives from a behavior or activity (D). When placed in an unstimulating and isolated place, the child becomes bored and consequently agrees to behave in order to reenter the family group. Positive reinforcement (A) uses rewards that encourages a child to behave in another specified way, which reduces the unacceptable behavior. Time-out avoids physical punishment, which is a negative reinforcement (B) that may reinforce behavior because it brings attention. Although no reasoning or scolding is given with time-out, ignoring behavior allows the child to continue the behavior until it is eventually extinguished or minimized.

A client who is experiencing an acute attack of gouty arthritis is prescribed colchicine (Colcrys) USP, 1 mg PO daily. Which information is most important for the nurse to provide the client? A) Take the medication with meals. B) Limit fluid intake until the attack subsides. C) Stop the medication when the pain resolves. D) Report any vomiting to the clinic.

D) Report any vomiting to the clinic. - The client should be instructed to report signs of colchicine toxicity, such as nausea, diarrhea, vomiting (D), and/or abdominal pain, to the health care provider. Food inhibits the absorption of colchicine when ingested concurrently (A). Limited fluid intake (B) decreases the excretion of the uric acid crystals, which contributes to painful attacks. Typically, a client should remain on a daily dose of colchicine to decrease the number and severity of acute attacks, so stopping the medication after the pain resolves (C) is not indicated.

A nurse is giving discharge instructions to a client who had an aspiration abortion by suction curettage. What should the client be told? A) Avoid showering for 2 days B) Tampons may be used after 1 day C) Sexual intercourse should be delayed for 3 weeks D) Report bleeding that requires pad changes every 2 hours

D) Report bleeding that requires pad changes every 2 hours

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? A) Accept the client's crying B) Encourage unrestricted family visitors C) Explain details of the care being given D) Stay nearby without initiating conversation

D) Stay nearby without initiating conversation

A nurse is teaching a class about hepatitis, specifically hepatitis A. Which food should the nurse explain will most likely remain contaminated with hepatitis A virus after being cooked? A) Canned tuna B) Broiled shrimp C) Baked haddock D) Steamed lobster

D) Steamed lobster

A client is experiencing chronic constipation and the nurse discusses how to include more bulk in the diet. The nurse concludes that learning has occurred when the client states, "Bulk in the diet promotes defecation by: A) Irritating the bowel wall B) Stimulating the intestinal mucosa chemically C) Acting on the microorganisms in the large intestine D) Stretching intestinal smooth muscle, which causes it to contract

D) Stretching intestinal smooth muscle, which causes it to contract

A client is admitted with diarrhea, anorexia, weight loss, and abdominal cramps. What clinical manifestations of an electrolyte deficit should the nurse report immediately? Select all that apply. A) Diplopia B) Skin rash C) Leg cramps D) Tachycardia E) Muscle weakness

D) Tachycardia E) Muscle weakness

The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A) Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B) Sit quietly in the client's room until the client leaves the bathroom. C) Allow the client to cry alone and leave the client in the bathroom. D) Talk to the client and attempt to find out why the client is crying.

D) Talk to the client and attempt to find out why the client is crying. - The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed (D). (A) is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully (B). Although (C) may be correct, the nurse should determine if the client's safety is compromised and offer assistance, even if it is refused.

The nurse expects a clinical finding of cyanosis in an infant with which condition(s)? (Select all that apply.) A) Ventircular septal defect (VSD) B) Patent ductus arteriosis (PDA) C) Coarction of the aorta D) Tetrology of Fallot E) Transposition of the great vessels

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

When administering an intramuscular (IM) injection to an adult client using the ventrogluteal site, which landmarks should the nurse identify to locate the area for injection? A) The greater trochanter and the knee. B) The acromion process and the dorsal surface of the upper arm. C) The greater trochanter and the posterior iliac spine. D) The anterosuperior iliac spine and the greater trochanter.

D) The anterosuperior iliac spine and the greater trochanter. - The heel of the hand is placed on the greater trochanter and the fingers spread to palpate the anterosuperior iliac spine, which are the landmarks used to give an injection in the ventrogluteal site (D). (A) locates the vastus lateralis, (B) locates the deltoid, and (C) locates the gluteus maximus, which is no longer recommended as an IM site.

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how it provides passive immunity? A) It increases production of short-lived antibodies B) It accelerates antigen-antibody union at the hepatic sites C) The lymphatic system is stimulated to produce antibodies D) The antigen is neutralized by the antibodies it supplies

D) The antigen is neutralized by the antibodies it supplies

A client with esophageal cancer is to receive TPN. A right subclavian catheter is inserted. What is the primary reason why the HCP ordered a central line? A) It prevents the development of infection B) There is less chance of this infusion infiltrating C) It is more convenient so clients can use their hands D) The large amount of blood helps to dilate the concentrated solution

D) The large amount of blood helps to dilate the concentrated solution

The registered nurse teaches a nursing student about the implementation process of nursing. Which example does the registered nurse use while describing indirect care interventions using his or her knowledge? A) The nurse counseling a client at the time of grief B) The nurse administering an intravenous infusion to a client C) The nurse teaching the client about an appropriate nutrition plan D) The management of the client's environment to prevent infections

D) The management of the client's environment to prevent infections - Nursing interventions are based on clinical judgment and knowledge and performed by the nurse for enhancing the client's outcomes. Indirect care interventions are treatments which are performed away from the client but will benefit the client. Managing the client's environment to prevent infection control is an indirect care intervention. Direct care interventions are performed through interactions with the clients. Direct care interventions may include counselling the client at the time of grief, administering an intravenous infusion to the client, and teaching the client about an appropriate nutrition plan.

An older adult is hospitalized for weight loss and dehydration because of nutritional deficits. What should the nurse consider when caring for this client? A) Financial resources usually are unrelated to nutritional status B) An older adult's daily fluid intake must be markedly increase C) The client's diet should be high in carbohydrates and low in proteins D) The nutritional needs of an older adult are unchanged except for a decreased need for calories

D) The nutritional needs of an older adult are unchanged except for a decreased need for calories

A newborn is Rh positive, and the mother is Rh negative. The infant is to receive an exchange transfusion. The nurse explains to the parents that their baby will receive RH-negative blood because: A) It is the same as the mother's blood B) It is neutral and will not react with the baby's blood C) The possibility of a transfusion reaction is eliminated D) The red blood cells will not be destroyed by maternal anti-Rh antibodies

D) The red blood cells will not be destroyed by maternal anti-Rh antibodies

What is important for a nurse to discuss with a client who had a vasectomy? A) Recanalization of the vas deferens is impossible B) Unprotected coitus is safe within 1 week to 10 days C) Some impotency is to be expected for several weeks D) There must be 15 ejaculations to clear the tract of sperm

D) There must be 15 ejaculations to clear the tract of sperm

The nurse is assessing a client using the Snellen chart and determines that the client's visual acuity is the same as in a previous examination, which was recorded as 20/100. When the client asks the meaning of this, which information should the nurse provide? A) This visual acuity result is five times worse that of a normal finding. B) This line should be seen clearly when the client wears corrective lenses. C) A client with normal vision can read at 100 feet what this client reads at 20 feet. D) This client can see at 100 feet what a client with normal vision can see at 20 feet.

D) This client can see at 100 feet what a client with normal vision can see at 20 feet. - The interpretation of the client's visual acuity is compared to the Snellen scale of 20/20, which indicates that the letter size on the Snellen chart is seen clearly and read by a client with normal vision at 20 feet. A finding of 20/100 means that this client can read at 20 feet what a person with normal vision can read at 100 feet (C). (A, B, and D) are inaccurate.

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

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

A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the HCP? A) Passage of pink-tinged sputum B) Pink drainage on the dressing C) Intake of 1750 mL in 24 hours D) Urine output of 20 - 30 ml/hr

D) Urine output of 20 - 30 ml/hr

The nurse is planning care for a child with Trisomy 21 who is admitted with recurrent upper respiratory infections and chronic constipation. Which intervention should the nurse include in the plan of care? A) Provide a high caloric diet that meets the child's mental age. B) Delay solid food introduction until the child's tongue thrust subsides. C) Maintain regular meal times to minimize frequency of constipation. D) Use a bedside cool-mist vaporizer during naps and night time.

D) Use a bedside cool-mist vaporizer during naps and night time. - A child with Trisomy 21, Down syndrome, typically has an under-developed nasal bone that compromises respiratory expansion and causes a chronic problem of inadequate drainage of nasal mucus. This persistent nasal congestion forces the child to mouth-breathe, which dries the oropharyngeal membranes and increases the susceptibility to upper respiratory tract and ear infections. Using a cool-mist vaporizer (D) moistens the nasal mucous membranes, liquefies, and drains nasal secretions to reduce this medium for infection. Caloric intake is based on the child's development, height, and weight, not mental age (A). The risk for constipation is related to a decreased muscle tone, not serving times (C). Parents may need instruction about introducing solid foods, but (B) is not indicated.

In reviewing the medical record, the nurse notes that a client's last eye examination revealed an intraocular pressure (IOP) of 28 mmHg. What information should the nurse ask the client? A) Length of time the client has been wearing prescription lenses. B) Recent experience of seeing light flashes or floaters. C) Complaints of any blind spots in the client's field of vision. D) Use of prescribed eye drops since last exam by ophthalmologist.

D) Use of prescribed eye drops since last exam by ophthalmologist. - Normal intraocular pressures range between 10 and 21 mmHg, so the client's use of any prescribed eye drops should be determined to evaluate the client's intraocular pressure (D). Although (A, B, and C) should be determined to screen for other ophthalmic disorders, the use of an ophthalmic prescription for glaucoma focuses the evaluation of the client's IOP status.

A client who has been taking levodopa PO TID to control the symptoms of Parkinson's disease has a new prescription for sustained release levodopa/carbidopa (Sinemet 25/100) PO BID. The client took his levodopa at 0800. Which instruction should the nurse include in the teaching plan for this client? A) Take the first dose of Sinemet today, as soon as your prescription is filled. B) Since you already took your levodopa, wait until tomorrow to take the Sinemet. C) Take both drugs for the first week, then switch to taking only the Sinemet. D) You can begin taking the Sinemet this evening, but do not take any more levodopa.

D) You can begin taking the Sinemet this evening, but do not take any more levodopa. - Carbidopa significantly reduces the need for levodopa in clients with Parkinson's disease, so the new prescription should not be started until eight hours after the previous dose of levodopa (D), but can be started the same day (B). (A and C) may result in toxicity.

A HCP orders an upper GI series and a barium enema. The client asks, "Why do I have to have barium for these tests?" The nurse's best response is "Barium: A) gives off visible light, illuminating the alimentary tract" B) provides fluorescence, thereby lighting up the alimentary tract" C) dyes the structures of the alimentary tract, making them more visible" D) gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."

D) gives more contrast to the soft tissue of the alimentary tract, allowing absorption of x-rays."