Final HESI EXIT

1) CORRECT - Implementation: outcome not desired; muscle spasm should decrease with traction; if muscle spasm pain increases, the amount of traction weight should be assessed 2) Implementation: outcome desired; vertical movement is allowed as long as line of pull is maintained 3) Implementation: outcome desired; balanced suspension traction not affected by movement of bed; not affected by client movement unless line of pull affected 4) Implementation: outcome desired; can move up and down only, moving side-to-side changes line of pull of traction

A 12-year-old diagnosed boy with a fractured right femur is placed in balanced suspension traction with a Thomas splint and Pearson attachment. The nurse is MOST concerned by which client statement? 1. "I will experience more muscle spasms and pain while my leg is in traction." 2. "I can lift my body up while I grab the overhead trapeze and bend my left leg." 3. "The health care provider told me it is okay to move the head of my bed up and down by myself." 4. "I need to put the phone where I can reach for it without moving onto my side."

1) Implementation: outcome not desired; incubation period is 14-21 days, not communicable at this time; if woman develops rubella infection during the first trimester, abortion may be considered 2) CORRECT-Implementation: outcome desired; communicability is approximately 7 days before to 5 days following onset of rash; client needs to be evaluated 3) Implementation: outcome: not desired; vaccination contraindicated for pregnant women; increased risk of fetal complications 4) Implementation: outcome not desired; needs to be seen by the healthcare provider

A 25-year-old multigravida client, 22 weeks gestation, calls to inform the clinic nurse that she was exposed to rubella 2 days ago. Which statement, if made by the nurse, is MOST appropriate? 1. "You need to see the health care provider today, but come in after hours." 2. "Come in this afternoon for your regularly scheduled appointment." 3. "You will receive the rubella vaccine during your regularly scheduled appointment." 4. "Please cancel today's appointment and reschedule for next month."

1) Implementation: outcome not desired; not used during transition; not effective and may interfere with mother's cooperation; may cause respiratory depression in infant 2) Implementation: outcome desired but not priority; priority action is to assist client to get control 3) CORRECT-Implementation: outcome desired and priority; slow breathing, reorient; model appropriate behaviors; this will assist client to get control and reduce muscle tension 4) Implementation: outcome desired but not priority; meet physical needs first

A 25-year-old woman is admitted to the labor unit for delivery of her first child. Her husband is coaching her during labor. During the transitional phase of labor, the client begins to scream and grab the side rails with each contraction. Which action, if taken by the nurse, is MOST effective? 1. Offer the client pain medication before her next contraction. 2. Assist the client to a side-lying position with her knees flexed and a pillow between her legs. 3. Establish eye contact with the client and breathe with her. 4. Suggest to the client that she watch television between contractions.

1) Assessment: outcome not priority; immunization deferred in presence of acute respiratory disease or other acute infection 2) CORRECT-Assessment: outcome priority; allergy to eggs is a contraindication to receiving flu vaccine 3) Assessment: outcome not priority; immunization deferred only if client has active infection 4) Assessment: outcome not priority; medication allergy not pertinent

A 60-year-old client comes to the outclient clinic to receive the influenza vaccine. Which of the following questions, if asked by the nurse, is BEST? 1. "Have you had the flu in the past month?" 2. "Do you have any food allergies?" 3. "Has anyone in your family been sick?" 4. "Are you allergic to any medication?"

1) Implementation: outcome not desired and not priority; documentation of suspected abuse should contain facts and be nonjudgmental 2) Assessment: outcome not priority; priority action is to report potential abuse to nurse manager 3) Implementation: outcome not desired; close-ended statement; confrontational 4) CORRECT-Implementation: outcome desired; follows chain of command; potential abuse situation

A 7-year-old boy is brought to the emergency room by his mother following a fall from his bicycle. X-ray reveals healed fractures of the ribs. The child's mother states, "My son is such a careless child; he's always having accidents or fights with his brother." Which response by the nurse would be MOST appropriate? 1. "When I document information about these injuries, it will be on your son's hospital record forever." 2. "How would you describe your son's relationship with his brothers and sisters?" 3. "What I see suggests that someone has been abusing your son." 4. "I will need to talk to the nurse manager about this situation before you leave."

1) Assessment: outcome desired but not priority; question stem tells you that assessment has been done; changes in pulse, color, sensation should be reported immediately to the healthcare provider 2) CORRECT - Implementation: outcome priority and desired; diminished pulses indicates change in circulation 3) Assessment: outcome desired but not priority; should report changes in circulation 4) Assessment: outcome not desired; symptoms suggest changes in circulation to extremity; more important to report change in distal circulation

A child in a new plaster walking cast has dusky, swollen toes. Which action by the nurse is MOST appropriate? 1. Get Doppler studies to check the pulse. 2. Notify the healthcare provider. 3. Determine if the cast is dry. 4. Check the client's vital signs.

1) Assessment: outcome desired but not priority; cyanosis is a late sign of respiratory distress; central cyanosis will occur later than peripheral cyanosis 2) Assessment: outcome not desired; priority is to assess respiratory status; blood pressure may change due to decreased arterial oxygen levels; priority is to correct underlying problem 3) CORRECT - Assessment: outcome priority; will give early and clearest indication of respiratory status, will hear changes with narrowed airways, fluid in alveoli or pneumothorax 4) Assessment: outcome desired but not priority; late indication of respiratory distress; intercostal muscles are accessory muscles

A child sustains a crushing chest injury in a car accident. In the emergency room, an endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the child in respiratory distress. It is MOST important for the nurse to take which action prior to the angiogram? 1. Observe the color of the client's fingernail beds. 2. Assess the client's blood pressure in both arms. 3. Listen to the client's breath sounds. 4. Assess for intercostal retractions.

1) Assessment: outcome not priority; seen with electrolyte imbalance, not rejection 2) CORRECT-Assessment: outcome priority and expected with kidney rejection; tenderness over kidney is sign of rejection 3) Assessment: outcome not expected; oliguria is seen with rejection due to failing kidney 4) Assessment: outcome not expected; edema and weight gain are seen with rejection

A client had a right kidney transplant 1 week ago. Which symptom, if experienced by the client, indicates to the nurse that the client is experiencing rejection? 1. The client complains of generalized muscle weakness. 2. The client complains of diffuse pain over the right abdomen. 3. The client gets up twice each night to void. 4. The client has lost 3 pounds.

1) Assessment: outcome not priority; right heart failure and weight gain seen with chronic bronchitis; priority is to assess oxygenation 2) Assessment: outcome not priority; dysrhythmias occur due to right heart failure; priority is oxygenation 3) CORRECT-Assessment: outcome desired; priority is to establish oxygenation status 4) Assessment: outcome not priority; common reason for worsening status is respiratory infection; more important to establish respiratory status first

A client is admitted to the hospital with a diagnosis of chronic bronchitis. Which action should the nurse take FIRST? 1. Weigh the client. 2. Place cardiac telemetry leads. 3. Place pulse oximetry on finger. 4. Obtain a sputum specimen

1) Assessment: outcome not priority; symptoms of hypokalemia 2) CORRECT-Assessment: outcome priority; elevated Na+ and elevated BUN, other values are normal; elevated Na+ and BUN seen with dehydration 3) Assessment: outcome not priority; symptoms of fluid volume overload 4) Assessment: outcome not priority; symptoms of hyponatremia; hypernatremia seen with dehydration

A client is brought to the clinic by the spouse. The client's lab results are Na+ 156 mEq/L, Cl- 100 mEq/L, K+ 4.0 mEq/L, BUN 86 mg/dL, glucose 100 mg/dL. Which is the MOST appropriate action for the nurse to take? 1. Assess for muscle weakness and dysrhythmias. 2. Assess for confusion and tachycardia. 3. Check for peripheral edema and lung crackles. 4. Determine if muscular twitching and muscle weakness are present.

(1.) CORRECT-Glucocorticoids decrease bone density; calcium and vitamin D supplements or biphosphonates will decrease risk (2.) Glucocorticoids depress the immune response, but not the white cell count (3.) Glucorticoids cause hyperglycemia and glyxosuria (4.) CORRECT-Glucocorticoids cause hypokalemia and hypernatremia (5.) Glucocorticoids increase the risk of cataracts and glaucoma (6.) CORRECT-Glucocorticoids cause sodium and water retention

A client is prescribed prednisone and asks about possible adverse effects. The nurse teaches the client about which common adverse effects of prednisone? Select all that apply 1. (1.) Osteoporosis. 2. (2.) Decreased white count. 3. (3.) Low blood sugar. 4. (4.) Low serum potassium. 5. (5.) Retinal detachment. 6. (6.) Fluid retention

Your Response: Correct Response: 8800 units 50 units heparin/1 mL 50 units x 22 = 1100 units per hour 1100 units x 8 = 8800 units heparin

A client receives an IV heparin infusion at 22 mL/hr through an infusion pump. The IV bag contains 25,000 units of heparin in 500 mL of 5% dextrose in water. How many units of heparin is the client receiving during an 8-hour shift? Calculate and record the answer in the box.

1) Implementation: outcome not desired; mask is placed on client to prevent transmission of airborne pathogen 2) CORRECT-Implementation: outcome desired and priority; client must wear a standard isolation mask if out of room 3) Implementation: outcome not desired; no reason to postpone, place mask on client 4) Implementation: outcome desired but not priority; mask worn to prevent transmission of airborne pathogen

A client with suspected active tuberculosis is scheduled for a chest x-ray. Which action, if taken by the nurse, is MOST appropriate? 1. Instruct the staff transporting the client to wear a gown and mask. 2. Place a face mask on the client. 3. Request that the x-ray be postponed. 4. Give the client an emesis basin and tissues.

1) Implementation: outcome not desired; cleansing may be done according to facility policy; shaving may not be recommended due to possible abrasions and increased risk of infection 2) CORRECT - Assessment: outcome desired and priority; pulse location may be marked according to facility policy; important to get baseline assessment of color, motion, temperature and sensitivity of extremities as well as strength and equality of pulses 3) Implementation: outcome not desired; NPO 8 hours prior to test; dye may cause possible nausea; fluid intake should be increased after procedure to clear dye and reduce risk of renal toxicity 4) Implementation: outcome desired but not highest priority; not at greatly increased risk for atelectasis

A femoral angiogram is scheduled for a client. It is MOST important for the nurse to take which action prior to the angiogram? 1. Clean and shave the catheter insertion-site area. 2. Locate and note the presence of peripheral pulses. 3. Encourage the client to increase oral fluid intake. 4. Teach coughing and deep-breathing exercises.

1) Implementation: outcome not desired; foods high in purines cause hyperuricemia 2) Implementation: outcome not desired; activity does not precipitate a gout attack 3) Implementation: outcome not desired; excessive drinking precipitates gout 4) CORRECT-Implementation: outcome desired; hyperuricemia may result from prolonged fasting; increases production of ketones, which inhibit normal excretion of uric acid

A man comes into the outclient rheumatology clinic for follow-up care after an episode of acute gouty arthritis. The nurse would be MOST concerned if the client made which of the following statements? 1. "I don't eat shrimp and scallops anymore." 2. "I play softball twice a week without any problem." 3. "I don't go to bars on Friday nights anymore." 4. "I have been drinking SlimFast for breakfast and lunch each day."

1) CORRECT-Assessment: outcome priority; catheter may be blocked or client may be having bladder spasms 2) Assessment: outcome not priority; need to check patency of tubing first 3) Assessment: outcome not priority; more important to look for obstruction in tubing 4) Implementation: outcome not desired; decrease in traction against bladder neck could cause bleeding; is a healthcare provider order and should not be changed

A man is returned to his room in stable condition after a transurethral prostatectomy (TURP). He has continuous bladder irrigation through a 3-way urinary drainage catheter with a 30-mL balloon tip. Tension has been applied to the catheter. The client reports that he feels pressure in his bladder and rectum, and feels as though he has to urinate. Which action should the nurse take FIRST? 1. Check the patency of the catheter. 2. Assess residual urine volume using bladder ultrasonography. 3. Assess the amount of drainage in the urinary drainage bag. 4. Decrease the tension on the catheter.

1) CORRECT - Implementation: outcome desired; sperm count decreased after the vasectomy; some sperm may remain in the vas deferens 2) Implementation: outcome not desired; sperm stored in vas deferens may be ejaculated for several weeks after the vasectomy 3) Implementation: outcome not desired; not effective enough 4) Implementation: outcome not desired; considered successful after 2 negative sperm counts

A man scheduled for a vasectomy tells the nurse that he and his wife are involved in a monogamous relationship. Which statement by the nurse is BEST? 1. "You will need to wear a condom when having sexual intercourse for 6 weeks following the vasectomy." 2. "No other form of birth control is necessary for you or your wife at this time." 3. "You do not need to wear a condom when having sexual intercourse for the next few weeks, but your wife should use spermicidal jelly." 4. "Always wear a condom when having sexual intercourse because not all vasectomies are successful."

1) Assessment: outcome not priority; don't ask "why" questions on the NCLEX-RN®; "why" questions are considered to be confrontational 2) Implementation: outcome not desired; confirms client presence; breaches confidentiality; report to nursing supervisor 3) CORRECT- Follows the chain of command within the facility. 4) Verified the client's admission, violates client's confidentiality.

A news reporter and camera person arrive on the nursing unit to videotape an interview of a client. When the nurse refuses their request, the reporter references his First Amendment rights. Which statement, if made by the nurse, is MOST appropriate? 1. "Why do you want to talk with the client?" 2. "I'll ask the client if he is ready to speak with you." 3. "I will need to call the nurse manager about your request." 4. "Does the client know that you are coming?"

1) CORRECT-Implementation: outcome desired; stable client with predictable outcome; serial casting used to correct congenital club foot 2) Implementation: outcome unstable client; needs assessment and evaluation; possible teaching interventions needed 3) Implementation: outcome not desired; unstable client; require frequent assessment and evaluation 4) Implementation: outcome not desired; unstable client; required assessment, evaluation, teaching and judgment

A nurse from the surgical floor is reassigned to the pediatric unit. Which of the following client assignment is MOST appropriate for this nurse? 1. A 5-month-old infant after a cast application on the left extremity due to club foot. 2. A 4-year-old boy with right abdominal swelling and a decreased appetite. 3. A 6-year-old boy admitted with cystic fibrosis and a temperature of 101.5 F (38.68 C). 4. A 10-year-old girl with newly diagnosed type 1 diabetes.

1) See last; most stable client 2) See second; unstable client; cardiovascular; requires further assessment and antihypertensive medication 3) CORRECT-See first; unstable client; upper airway injury possibly due to inhalation injury 4) See third; vital signs consistent with dehydration, rapid respiration is Kussmaul's and expected

A nurse is performing triage in the emergency department. Which of the following clients should the nurse see FIRST? 1. A client with an open fracture of the left femur. BP 110/60, P 86, R 20, T 99.2° F (37.3° C). 2. A client complaining of a "crushing" headache. BP 160/ 100, P 76, R 18, T 98.4° F (36.9° C). 3. A client with burns on the face, chest, and hands. BP 120/80, P 100, R 24, T 98.8° F (37° C). 4. A client with type 1 diabetes. Blood sugar 480 mg/dL. BP 100/60, P 100, R 26, T 99.4° F (37.4° C).

1) CORRECT - Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased and concentrated 2) Assessment: outcome not priority; indicates that blood is hemoconcentrated 3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours 4) Assessment: outcome not priority; normal BP is 120/80

A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status? 1. Urinary output of 1,500 mL in 24 hours. 2. Serum hematocrit 52%. 3. Oral fluid intake of 900 mL in 24 hours. 4. Blood pressure of 100/82.

1) Implementation: outcome not desired; no increase in venous return 2) Implementation: outcome not desired; will decrease venous return 3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on inferior vena cava reduced 4) Implementation: outcome not desired; elevation of legs will increase venous return, but fetal pressure on vena cava will prevent blood return to heart

A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate? 1. Place the client flat on her back. 2. Elevate the head of the bed 30 degrees. 3. Place the client on her left side with her legs flexed. 4. Place the client supine with the foot of the bed elevated.

1) Implementation: outcome not desired; if Apgar less than 8 and infant is in respiratory distress nasopharyngeal suctioning may be indicated. 2) CORRECT-Implementation: outcome desired; Apgar score of 8 to 10 is considered to be good 3) Implementation: outcome not desired; done if respirations absent or inadequate 4) Implementation: outcome not desired; resuscitative measure, used to stimulate infant

A woman delivers a 6-lb and 2-oz infant. The Apgar scores at 1 and 5 minutes are 8 and 9, respectively. Which action is MOST appropriate for the nurse to take? 1. Perform nasopharyngeal suctioning. 2. Document the Apgar score. 3. Administer O2 per mask. 4. Rub the infant's back.

1) CORRECT-Implementation: outcome desired and priority; stimulation helps with orientation; allows for frequent assessment 2) Implementation: outcome not desired; meets safety needs but lacks environmental stimulation 3) Implementation: outcome not desired; client should be frequently assessed and needs stimulation 4) Implementation: outcome not desired; does provide environmental stimulation but client should be frequently assessed

A woman with a diagnosis of Alzheimer's disease is admitted to the hospital for treatment of an upper respiratory tract infection. On admission, she is incontinent of urine. When assigning the client to a room on the nursing unit, which location would be BEST? 1. A semi-private room near the nurse's station. 2. A private room near the nurse's station. 3. A private room away from the nurse's station. 4. A semi-private room away from the nurse's station.

1) Assessment: outcome not priority but may be appropriate; pinpoint pupils are a sign of heroin overdose 2) CORRECT - Assessment: outcome priority; shallow respirations seen; impaired alveolar gas exchange and possible respiratory arrest 3) Assessment: outcome not priority; most important to assess airway and breathing 4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria may be seen; not priority

A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate? 1. Assess pupil size and reactivity. 2. Assess oxygen saturation levels. 3. Palpate dorsalis pedis pulses. 4. Ask the client if he knows today's date.

1) Assessment: outcome not priority; assessment of client must be done by nurse; question is not necessary 2) CORRECT-Implementation: outcome desired; contains full description of situation, error committed, condition of client, remedial steps taken; medication error form must be completed for all variances 3) Implementation: outcome not desired; it is a nursing responsibility; health care provider should be informed 4) Implementation: outcome not desired; always complete form for any medication error

An LPN/LVN informs the nurse that aspirin 325 mg was given to a client even though 80 mg aspirin had been ordered once daily. The LPN/LVN asks the nurse if it is necessary to complete a medication-error form since "no harm was done." Which statement, if made by the nurse, is BEST? 1. "What do you mean, "no harm was done"? 2. "A medication-error form must be completed whenever the wrong preparation of a medication is given." 3. "I will call the health care provider and ask what should be done to deal with this error." 4. "It is not necessary to complete an incident report with over-the-counter medications."

1) Implementation: outcome desired; required monthly to prevent pernicious anemia 2) Implementation: outcome desired; small, frequent feeding prevents dumping syndrome 3) Implementation: outcome desired; prevents dumping syndrome 4) CORRECT-Implementation: outcome not desired; drinking fluids with meals causes stomach content to empty too rapidly into the jejunum

An elderly woman is being seen by the home care nurse following a partial gastrectomy for cancer. Which statement, if made by the client, requires further teaching? 1. "The healthcare provider told me to come in once a month for vitamin B12 injections." 2. "I eat frequently throughout the day." 3. "I do not eat concentrated sweets." 4. "I drink several glasses of iced tea with my meals."

1) Implementation: outcome not desired; cephalosporins have cross-allergies with penicillins 2) Implementation: outcome not desired; NSAIDs should be used cautiously with aspirin allergies 3) Implementation: outcome not desired; both medications should be withheld due to allergies 4) CORRECT - Implementation: outcome desired; both medications should be withheld; risk of hypersensitivity reaction

During the admission interview, the client reports a red, itchy raised rash on the chest and lip swelling after use of aspirin and penicillin. The admission orders include bed rest, soft diet as tolerated, naproxen (Naprosyn), and cefaclor (Ceclor). Which is the BEST description of expected breath sounds heard during auscultation? 1. Administer the Ceclor as ordered; do not administer the naproxen. 2. Administer the naproxen as ordered; do not administer the Ceclor. 3. Administer both the Ceclor and naproxen as ordered; document the client's response. 4. Do not administer the Ceclor or naproxen; notify the healthcare provider.

1) Assessment: outcome a concern but not priority; can cause tachycardia 2) CORRECT-Assessment: outcome not expected and priority; extrapyramidal reactions usually dose-related; controlled by dose-reduction or antiparkinsonian medications (benztropine) 3) Assessment: outcome a concern but not priority; possible maculopapular rash 4) Assessment: outcome a concern but not priority; intolerance to light not seen; blurred vision not commonly seen

Haloperidol (Haldol) 5 mg IM every 4 hours PRN is prescribed for a client. Which observation requires an IMMEDIATE intervention by the nurse? 1. Patient reports dizziness; heart rate 58 beats per minute. 2. Patient has tongue protrusion and muscle rigidity. 3. Patient has a facial rash and periorbital edema. 4. Patient reports sensitivity to light and blurred vision.

1) CORRECT- Implementation: outcome desired; PTT lower limit of normal 20 - 25 seconds, upper limit of normal 32 to 39 seconds, therapeutic range 1.5 to 2 times normal, 5 seconds is within therapeutic range 2) Implementation: outcome medication should be given; PTT is in therapeutic range 3) Implementation: outcome not desired; unnecessary 4) Implementation: outcome not desired; unnecessary

Heparin 5,000 units subcutaneously is ordered every 12 hours for a client. The result of the client's most recent PTT is 55 seconds. Which action by the nurse is MOST appropriate? 1. Document the result and administer the heparin. 2. Withhold the heparin. 3. Notify the healthcare provider. 4. Have the test repeated.

1) Assessment: outcome desired; risk of infection at pin sites; client should be taught signs of inflammation and infection 2) Implementation: outcome desired; showers increase risk of infection at pin sites 3) CORRECT - Implementation: outcome not desired and may be a problem; client is not able to turn with halo device; increases the risk of injury to self and others 4) Implementation: outcome desired; difficulty manipulating cup or glass due to immobilized neck

The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the nurse? 1. "My wife looks at the pin sites every day." 2. "I like to bathe in the tub." 3. "I drove to the library yesterday." 4. "I drink with a straw."

1) Implementation: outcome not desired; medication should be given; if nurse questions the order, the health care provider should be contacted 2) Implementation: outcome not desired; unnecessary; 1 milligram of digoxin is a digitalizing dose; digitalizing dose is necessary to reach therapeutic blood levels 3) Implementation: outcome not desired; nurse can never change prescribed dose 4) CORRECT-Implementation: outcome desired; loading dose to achieve therapeutic blood levels; if loading dose not given, therapeutic levels are not reached for 6 days

The client is admitted to the hospital with chest pain when taking deep breaths and peripheral edema. The health care provider's order for the client reads; "Digoxin 0.25 mg orally now. Repeat digoxin 0.25 mg orally in 12 hours." Which action, if taken by the nurse, is MOST appropriate? 1. Do not administer the second dose of digoxin. 2. Call the health care provider to clarify the order. 3. Administer half the prescribed second dose of digoxin. 4. Administer the first and second dose of digoxin as ordered.

1) Assessment: outcome not priority but may be appropriate; can be asked as part of assessment 2) Assessment: outcome not priority but may be appropriate; should be assessed for further teaching 3) CORRECT - Assessment: outcome priority; action of nicotine is vasoconstriction; increases heart rate and myocardial oxygen consumption; increased risk of angina and myocardial infarction 4) Assessment: outcome may be appropriate but not priority; gum is place between cheek and gums; may stain dental work

The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask? 1. "Have you tried other methods to stop smoking?" 2. "How long have you been smoking?" 3. "Have you ever had chest pain?" 4. "Do you have a partial dental bridge?"

1) Implementation: outcome not desired; last resort unless safety is an issue 2) Implementation: outcome desired but not priority; safety is a priority 3) CORRECT - Implementation: outcome desired; nurse should delegate and give specific instructions to LPN/LVN 4) Implementation: outcome not desired; administered to assist the client to refrain from drinking first dose administered at least 12 hours after the last alcohol consumed

The client with with a 5-year history of alcohol abuse is treated in the emergency room for acute alcohol intoxication. The client is agitated and verbally abusive. Admission orders include chlordiazepoxide (Librium) 50 mg IM or PO every 4-6 hours for agitation. Which action by the nurse is MOST appropriate? 1. Place the client in chest restraints. 2. Assist the client to the bathroom every 2 hours. 3. Assign a licensed practical nurse to stay with the client. 4. Administer disulfram (Antabuse) 500 mg every 12 hours.

1) Follow-up required, but not priority; see second 2) Will require assessment and teaching, but no immediate care indicated; see third 3) CORRECT-Rapid weight gain indicates fluid retention, which could exacerbate CHF; see first 4) Stable client; pain control will be addressed but not first; see last

The home health nurse is planning client visits for the day. Which of the following clients should the nurse see FIRST? 1. A 70-year-old diabetic with fasting blood glucose readings of 240-260 mg/dL for 1 week. 2. A 65-year-old discharged from the hospital 2 days ago following coronary artery bypass graft surgery (CABG). 3. A 55-year-old with congestive heart failure who gained 3 lbs in the last 24 hours. 4. A 40-year-old with metastatic breast cancer complaining of pain unrelieved by pain medication.

1) Implementation: outcome not desired; need to assess first 2) Assessment: outcome not priority; "yes/no" question; doesn't help determine the problem 3) CORRECT - Assessment: outcome priority; nurse needs to determine what the problem is before implementing; recent history of falling is most important contributor to increased risk of falls 4) Assessment: outcome not priority; "yes/no" question is non-therapeutic; need to assess; may be a contributing factor

The home care nurse cares for a client who is diagnosed with hypertension and mild depression. The client's daughter states that her mother has been falling frequently. WWhich response by the nurse is BEST? 1. "Let's get your mother a walker." 2. "Do you think it's time to put your mother in a nursing home?" 3. "When does your mother fall?" 4. "Does your mother seem to be more confused lately?"

1) Implementation: outcome not desired; Lasix is a potassium-wasting diuretic, hypokalemia may precipitate digitalis toxicity 2) Implementation: outcome not desired; high in sodium, would increase fluid retention 3) Implementation: outcome not desired; high in calcium, no indication to increase calcium in the diet; dairy products are high in sodium 4) CORRECT-Implementation: outcome desired; good source of potassium, decreased potassium can predispose to digitalis toxicity

The home care nurse instructs the daughter of a client diagnosed with congestive heart failure. The daughter states her father is taking digoxin (Lanoxin) 0.25 mg and the healthcare provider just prescribed furosemide (Lasix) 40 mg. Which statement, if made by the daughter to the nurse, indicates teaching is successful? 1. "I'm glad that Dad doesn't have to change his diet." 2. "Dad is going to have to eat more cottage cheese and add some more salt to his diet." 3. "Dad must increase his intake of cheese and yogurt." 4. "I should encourage Dad to eat more fresh fruits and vegetables."

1) CORRECT-Implementation: outcome desired; intervention not possible without consent of the senior if person is legally competent; further assessment needed to determine cause of bruises 2) Implementation: outcome not desired; legally competent senior can choose where to live and with whom 3) Implementation: outcome not desired; appropriate if senior is legally incompetent and in immediate danger 4) Implementation: outcome not desired; must have consent of client

The home care nurse is visiting an alert, oriented woman living with her daughter. The client is malnourished and has multiple bruises on her body, and the situation is reported to the appropriate authority. After counseling the client and daughter, the nurse notes the situation has not improved. The client decides to remain with her daughter. Which action, if taken by the nurse, is MOST appropriate? 1. Respect the client's decision to stay in her daughter's home. 2. Insist the client move in with her other child. 3. Begin guardianship procedures. 4. Place live-in help in the home.

1) CORRECT-Assessment: outcome desired and priority; confusion can be caused by drug toxicity and polypharmacy; decreased renal function may increase risk 2) Assessment: outcome desired but not priority; hypoglycemia may be a factor 3) Assessment: outcome desired but not priority; is a good open-ended question 4) Assessment: outcome desired but not priority; not most important; urinary tract infections cause acute confusion in elderly

The home care nurse makes an initial visit to an 80-year-old client. The client's daughter states that her mother has a history of colon cancer and has been restless and confused for about a week. It is MOST important for the nurse to obtain an answer to which question? 1. "What medication is your mother taking?" 2. "Is there a family history of diabetes?" 3. "Describe your mother's usual diet." 4. "Does your mother complain of difficulty urinating?"

1) Implementation: outcome desired but not priority; non-therapeutic; closed statement 2) Assessment: outcome not desired; "yes/no" question; non-therapeutic 3) CORRECT-Assessment: outcome desired; teaching opportunity; includes family in teaching 4) Implementation: outcome not desired; "passing the buck"

The home care nurse observes an elderly woman on a low-sodium diet eating a dill pickle that her son gave her with lunch. Which response by the nurse is MOST appropriate? 1. "Giving your mother salty food will only make her condition worse." 2. "Didn't your mother tell you she's on a low-sodium diet?" 3. "Tell me what you know about your mother's diet." 4. "Let's make an appointment for you to meet with a dietician."

1) Assessment: outcome expected, hypotonia; speech may be hard to understand 2) CORRECT-Assessment: outcome not expected; at risk for aspiration due to difficulty swallowing and the accumulation of saliva 3) Assessment: outcome expected, present at rest; may disappear with purposeful movement 4) Assessment: outcome expected, teach postural exercises to minimize this effect

The home care nurse visits a client diagnosed with Parkinson's disease. The nurse is MOST concerned if which of the following is observed? 1. The client has soft, monotonous speech. 2. The client is drooling. 3. The client rolls the left thumb against the fingers. 4. The client ambulates with a stooped posture.

1) CORRECT-Outcome desired; open-ended; client can verbalize concerns 2) Outcome not priority; need to address husband's immediate concerns; is "yes/no" answer 3) Outcome not desired; need to deal with the "here and now" 4) Outcome not desired; non-therapeutic; dismisses concerns

The husband of an elderly client who is incontinent asks the nurse whether his wife will have to wear diapers. Which response, if made by the nurse, is MOST appropriate? 1. "Let's discuss your specific concerns about your wife." 2. "Have you tried any type of incontinence pads in the past?" 3. "Let's wait and see if incontinence pads are necessary." 4. "There are many brands of adult diapers available for you to try."

1) Assessment: outcome desired but not priority; ABCs apply here 2) Assessment: outcome not desired; peripheral cyanosis is a late sign of hypoxemia 3) CORRECT-Assessment: outcome priority; anterior wall MI high risk for heart failure; assess client first and then equipment 4) Assessment: outcome desired but not priority; should be assessed, but ABCs apply here

The nurse cares for a client 4 hours after admission to the hospital for treatment of an anterior wall myocardial infarction. The client suddenly reports difficulty breathing and appears very anxious. Which action should the nurse take FIRST? 1. Evaluate the client's cardiac rhythm. 2. Check for cyanosis of the hands and the toes. 3. Auscultate the client's posterior lung fields. 4. Listen to the apical heart rate.

1) CORRECT-Implementation: outcome desired; prevents hip flexion contracture 2) Implementation: outcome not desired; will increase edema 3) Implementation: outcome not desired; legs should be adducted to prevent flexion contractures 4) Implementation: outcome not desired; done for the first 24 hours; increases venous return; prevents edema; promotes comfort

The nurse cares for a client 72 hours after a right-below-knee amputation. Which is the MOST important action for the nurse to take? 1. Lay the client prone for 25 minutes every 3-4 hours. 2. Dangle the client's residual limb over the side of the bed. 3. Abduct the client's residual limb by placing pillows between the legs. 4. Elevate the client's residual limb on a pillow.

1) Implementation: outcome not desired; increases risk of infection; catheter-related infections are most common hospital-acquired infection 2) Implementation: outcome not desired; increases chance of infection 3) Implementation: outcome appropriate but not priority; does not keep client independent and active 4) CORRECT - Implementation: outcome desired; keeps client active and independent

The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and incontinent of urine. What is the MOST important action for the nurse to take? 1. Insert an indwelling urinary drainage catheter. 2. Perform intermittent catheterization every 4 hours. 3. Offer the bedpan to the client every 2 hours. 4. Assist the client to a bedside commode every 2 hours.

1) Implementation: outcome not desired; high-fat, high-protein, high-residue; high-residue contraindicated 2) Implementation: outcome not desired; low-fat, low-protein, low-residue 3) CORRECT - Implementation: outcome desired; low-fat, high-protein, low-residue, nonirritating, high in calories, minerals 4) Implementation: outcome not desired; high-fat, low-protein, high-residue; may cause diarrhea

The nurse cares for a client diagnosed with Crohn's disease. The nurse instructs the client about diet. Which menu selection indicates to the nurse that teaching is effective? 1. Cheeseburger on a whole-wheat bun, french fries, and an apple. 2. Tomato soup, saltines, and a slice of unfrosted angel food cake. 3. Baked cod, biscuit without butter, fruit roll-up. 4. Macaroni and cheese, coleslaw, 2 macaroon cookies.

1) Assessment: outcome not priority; immediate action to decrease blood pressure is priority; rectal stimulation may increase autonomic dysreflexia 2) Assessment: outcome not priority; immediate need is to reduce blood pressure and prevent hemorrhage 3) CORRECT-Implementation: outcome desired; immediate effect; decrease venous return to heart, decrease stroke volume, and decrease in blood pressure 4) Implementation: outcome not desired as initial action; causes vasodilation; more immediate effect with position change; if cause of autonomic dysreflexia removed, sudden drop in blood pressure could occur

The nurse cares for a client diagnosed with a complete spinal cord injury 12 weeks ago due to compression fractures of the 5th and 6th cervical vertebrae. The client reports a sudden onset of sweating and has a flushed face and chest. Which action should the nurse take FIRST? 1. Perform a digital rectal examination. 2. Check the color and temperature of the extremities. 3. Place the client in high-Fowler's position. 4. Administer hydralazine (Apresoline) 20 mg intravenously.

1) Assessment: outcome not expected; sibilant wheezes, heard with asthma, caused by narrow bronchioles 2) Assessment: outcome not expected; crackles, heard with pneumonia and CHF, caused by fluid in the alveoli 3) CORRECT - Assessment: outcome expected; sonorous wheezes or rhonchi, caused by mucus in the airways; excessive mucous production is primary symptom 4) Assessment: outcome not expected; pericardial friction rub, caused by inflamed pleura or pericarditis

The nurse cares for a client diagnosed with chronic bronchitis and peripheral vascular disease. The nurse expects to assess which of these breath sounds? 1. Continuous, high-pitched musical sounds heard on expiration. 2. Soft, high-pitched interrupted sounds heard on inspiration. 3. Deep, low-pitched rumbling sounds are heard mainly on expiration. 4. Harsh, grating sounds heard best during inspiration.

1) CORRECT - Assessment: outcome desired; clients with depression may have increased or decreased sleep time 2) Assessment: outcome not desired; lack of appetite is a frequent sign of depression 3) Assessment: outcome not desired; lack of concentration is sign of depression 4) Assessment: outcome not desired; is a sign of anxiety

The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement? 1. "I have been sleeping 6 hours at night." 2. "I have lost 2 lbs in the past week." 3. "Lately, I have trouble watching television." 4. "I have much less muscle tension now."

1) CORRECT - Implementation: outcome desired; menstruation may last several days to a week; protein and red cells may alter the results of the urinalysis 2) Implementation: outcome not desired; all urine must be collected for accuracy 3) Implementation: outcome not desired; invasive procedure should be avoided if possible 4) Implementation: outcome not desired; would change the results of the 24-hour urine sample; all urine must be collected for accuracy

The nurse cares for a client during a 24-hour urine specimen collection. Several hours later, the client tells the nurse that she has started to menstruate. Which action by the nurse is MOST appropriate? 1. Inform the health care provider that the client is menstruating. 2. Send the urine collected prior to the onset of the client's menstruation to the lab. 3. Insert an indwelling bladder catheter during the remainder of the collection period. 4. Request a separate urine collection container from the laboratory to be used during the remainder of the urine collection period.

1) Assessment: outcome not desired; check client, not equipment; fetal monitor may give incorrect information 2) Implementation: outcome not desired; position on left side if needed to prevent pressure on vena cava; no information in question indicates fetal hypoxia 3) CORRECT-Assessment: outcome priority; check for possible prolapsed cord; recheck in 10 minutes; fetal assessment is priority during labor 4) Assessment: outcome not priority; provides no information about baby

The nurse cares for a client in active labor. The client's membranes rupture spontaneously at 6 centimeters of dilation. Which action actions should the nurse take FIRST? 1. Check the fetal monitor. 2. Place the client on her right side. 3. Auscultate fetal heart rate. 4. Check the client's heart rate and blood pressure.

1) Implementation: outcome not desired; nurse should not explain the procedure; the health care provider doing the procedure should explain the risks and benefits 2) CORRECT - Assessment: outcome desired; nurse should determine if client understands risks and benefits of the procedure before the client and nurse sign the informed consent form 3) Implementation: outcome not desired; yes/no question non-therapeutic response 4) Implementation: outcome desired but not priority; reading materials do not ensure that client understands risks and benefits of the procedure

The nurse cares for a client scheduled for a femoral popliteal bypass procedure. When the nurse approaches the client with the informed consent form, the client says, "I don't need to talk to anybody about this procedure. I already know everything I need to know about it." Which response by the nurse is BEST? 1. "After I explain the operation to you, both of us will sign the form for legal purposes and it will be placed in your chart." 2. "Tell me what the healthcare provider told you about the risks and benefits of this operation." 3. "Can I answer any questions that you have about the procedure?" 4. "You should read all these materials to be sure that you understand everything about this procedure."

1) Implementation: outcome desired; is isotonic; will replace lost blood volume 2) CORRECT-Implementation: outcome not desired; effect is vasoconstriction with further decrease of blood flow to vital organs; used to treat anaphylactic shock 3) Implementation: outcome desired; measuring urinary output meaures renal perfusion; appropriate activity 4) Implementation: outcome desired; is a crystalloid; will expand plasma volume rapidly; must carefully monitor response

The nurse cares for a client who had a Roux-en-Y gastric bypass procedure 4 hours ago. The client's vital signs are blood pressure 92/68, apical heart rate 112 per minute, and respiratory rate 22 per minute. Which order should the nurse question? 1. 0.9% sodium chloride water infusion at 150 mL/hour. 2. Epinephrine (Adrenalin) 1 mg bolus intravenously. 3. Monitor urinary output hourly for 24 hours. 4. 50 mL 25% albumin (human) 50 mL intravenously.

1) Implementation: outcome not a problem; no interaction 2) Implementation: outcome not a problem; surgery within 3 weeks is potential contraindication 3) Implementation: outcome not a problem; active peptic ulcer disease is potential contraindication; needs further investigation 4) CORRECT-Implementation: outcome a problem; significant traumatic head injury within 3 months is an absolute contraindication for thrombolytic therapy

The nurse cares for a client who is to receive thrombolytic therapy with tissue plasminogen activator (rtPA). The nurse is MOST concerned if the client makes which of the following statements? 1. "I take a multivitamin tablet daily for cold and flu prevention." 2. "I had major abdominal surgery a year ago." 3. "I get some stomach pain when I eat spicy foods." 4. "I hit my head and lost consciousness during a car accident 2 months ago."

1) CORRECT - Implementation: outcome desired; cuff inflation decreases the risk of aspiration; cuff position and pressure should be assessed frequently; swallowing and breathing will cause tracheostomy tube movement 2) Implementation: outcome not desired; accumulated oral secretions above the cuff will drain into the bronchi; increased risk of infection 3) Implementation: outcome not desired; cuff pressure should be less than 20 mm Hg (25 cm H2O); risk of trauma to trachea with higher pressures 4) Implementation: outcome not desired; increases the risk of trauma to lower airways

The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take? 1. Leave the cuff inflated and suction through the tracheostomy. 2. Deflate the cuff and suction through the tracheostomy tube. 3. Inflate the cuff pressure to 40 mm Hg before suctioning. 4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning.

1) Assessment: outcome desired but not priority; client needs insulin coverage now 2) CORRECT - Implementation: outcome desired; sliding scale-receives predetermined amount of insulin according to glucose level; surgery and infection increase insulin needs 3) Implementation: outcome not desired; needs insulin regardless of oral intake due to elevated blood glucose 4) Implementation: outcome not desired; no reason to contact healthcare provider; order is valid and appropriate for situation

The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should be administered. Which of the following is the FIRST action the nurse should take? 1. Check the client records to see if insulin was given prior to surgery. 2. Administer the 6 units of regular insulin subcutaneously. 3. Administer the insulin when oral fluids are tolerated. 4. Contact the healthcare provider.

1) Implementation: outcome desired; client is NPO before the procedure; risk of dye-induced nausea and vomiting; encourage fluid to decrease risk of dye-induced nephrotoxicity after the procedure 2) Implementation: outcome desired; photophobia common after subarachnoid hemorrhage 3) CORRECT-Implementation: outcome not desired and is priority; leg should be extended and in a neutral position after femoral angiogram 4) Assessment: outcome not desired but not priority; urine is concentrated; fluids encouraged to flush dye through kidneys

The nurse cares for a client with suspected subarachnoid hemorrhage who had a bilateral carotid angiogram 2 hours ago. Which finding requires an intervention by the nurse? 1. The client requests a large glass of water. 2. The client lies quietly in bed with a cloth placed over the forehead and eyes. 3. The head of the bed is elevated 30° and the client's legs are bent at the knee. 4. The urine specific gravity is 1.025.

1) Assessment: outcome not desired; blood pressure and heart rate should be assessed prior to ambulation; more important to assess for shortness of breath and activity tolerance 2) Implementation: outcome not desired; avoid soft-soled shoes; remove barriers; orthostatic precautions are priority; no indication in the question that a walker is needed 3) Implementation: outcome not desired; should have wide-based gait to distribute center of gravity; may be unsafe ambulation 4) CORRECT-Implementation: outcome desired and priority; elderly have decreased cerebral perfusion; antihypertensives and medications used to treat heart failure cause vasodilation

The nurse cares for an 80-year-old client taking medication for the treatment of hypertension and heart failure. Which action is MOST important for the nurse to take? 1. Check the client's blood pressure and heart rate immediately after ambulation. 2. Instruct the client to use a walker at all times during ambulation. 3. Encourage the client to walk with the feet as close together as possible. 4. Instruct the client to sit on the edge of the bed for 3 to 5 minutes before arising.

1) Implementation: outcome not desired; "passing the buck;" mental status of roommate unknown 2) Implementation: outcome not desired; client confused 3) Implementation: outcome not desired; "passing the buck"; must check identification 4) CORRECT - Implementation: outcome desired; only way to positively identify client

The nurse cares for an 84-year-old man who appears disheveled, restless and confused. The nurse prepares to administer medication and observes that the client's armband is missing. Which is the MOST appropriate action for the nurse to take? 1. Ask the client's roommate to identify the client. 2. Ask the client to state his name. 3. Ask another nurse to identify the client. 4. Look in the chart at the picture of the client.

1) Implementation: outcome not desired; does not address orientation needs; risk of overstimulation; television should be on intermittently 2) CORRECT - Implementation: outcome desired; provides for safety needs and frequent orientation 3) Implementation: outcome not priority; does not address safety needs or orientation 4) Implementation: outcome desired not priority; addresses safety but not orientation or stimulation needs

The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST important for the nurse to take which action? 1. Leave the television on all day in the client's room. 2. Frequently inform the client of the room and bathroom location. 3. Provide the client with newspapers and magazines. 4. Assign a staff member to check on the client every 15 minutes.

1) Implementation: outcome not desired; judgmental; non-therapeutic communication 2) Assessment: outcome not desired; non-therapeutic; "why" questions make client defensive, feel threatened 3) CORRECT - Implementation: outcome desired; reality orientation; talk with client in non-threatening way about her needs 4) Implementation: outcome not desired; misses opportunity to reality test; distraction used for small children and manic clients

The nurse cares for clients in a mental health center. The nurse observes the client, formerly homeless and malnourished, diagnosed with chronic schizophrenia putting food from lunch into a plastic bag. Which statement by the nurse is MOST appropriate? 1. "We don't allow people to take food from the dining room." 2. "What are you going to do with the food?" 3. "We will be serving snacks and juice at 3 P.M." 4. "Let's go watch a movie with the others."

1) Outcome not priority; indicates that Rh antibodies present; needs further investigation 2) CORRECT - Outcome priority; indicates pre-eclampsia; requires immediate evaluation; is at risk for complications 3) Outcome not priority; colostrum may leak from breast during pregnancy; normal finding 4) Outcome not priority; normal finding; quickening doesn't occur before 18 weeks in primagravidas; 20 weeks in multigravidas

The nurse cares for clients in the antepartum clinic. Which client should the nurse see FIRST? 1. An 18-year-old multigravida client at 28 weeks gestation with a positive indirect Coombs' test. 2. A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema. 3. A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate. 4. A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of fetal movement.

1) Not priority; further assessment required; see second 2) Not priority; may be safety issue; further assessment needed; see last 3) CORRECT-Priority; may have decreased cerebral blood flow or oxygenation; see first 4) Not priority; client is at risk for thrombophlebitis; further assessment and evaluation needed; see third

The nurse cares for clients on an acute-care surgical area. Which client should the nurse see FIRST? 1. The LPN/LVN reports that a client who had a thoracotomy 2 days ago has clots in the chest drainage system. 2. The nursing assistive personnel reports that a client who had a thyroidectomy 24 hours ago refuses to ambulate 30 minutes after receiving hydrocodone (Vicoden). 3. The family of a client who had a small bowel resection 48 hours ago reports the client is more confused than yesterday. 4. A client who had an ileostomy 3 days ago complains of "aching legs."

1) Implementation: outcome not desired; if client holds breath, may increase intracranial pressure 2) Implementation: outcome not desired; need to assess risk for aspiration first before any oral fluids or foods given 3) CORRECT - Assessment: outcome desired and priority; decreased oxygen levels will increase intracranial pressure, client at high risk for aspiration 4) Assessment: outcome desired but not priority; at risk for thrombophlebitis due to immobility

The nurse cares for the client 3 days after a stroke. It is MOST important for the nurse to take which action? 1. Instruct the client to push with the feet while moving client up in bed. 2. Offer the client soft foods on request. 3. Auscultate the client's lungs every 4 hours. 4. Observe the client's legs for warm, reddened, and tender areas every 4 hours.

1) Assessment: outcome desired but not priority; edema not seen with SIADH even though water is retained; needs to be monitored 2) CORRECT - Assessment: outcome desired and priority; normal sodium range is 135-145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically depressed with increased risk of seizures 3) Asssessment: outcome desired but not priority; indicates fluid retention, not as important as hyponatremia; important to watch trends in weight 4) Assessment: outcome not desired; 1.008 indicates that urine is very dilute; with SIADH, urine will have high concentration and specific gravity due to excess ADH secretion

The nurse cares for the client diagnosed with lung cancer. The family states that the client has become confused and that urinary output has decreased during the previous 24 hours. Which finding MOST concerns the nurse? 1. 2+ pitting pretibial edema. 2. Sodium 128 mEq/L. 3. Weight gain of 2 kg in 24 hours. 4. Urine specific gravity 1.008.

1) Assessment: outcome not priority; manic client (bipolar disorder); symptoms include inappropriate dress, excessive talking, lack of inhibition, inability to stop moving, disorientation 2) CORRECT - Assessment: outcome priority; may withdraw from previous relationships or regress to previous behavior levels 3) Assessment: outcome not priority; no data to support relationship 4) Assessment: outcome not priority; secondary to withdrawn behavior; common with other psychiatric problems

The nurse cares for the client diagnosed with schizophrenia. Which question is MOST important for the nurse to ask the client's spouse? 1. "Have you noticed loud talking and excessive restlessness lately?" 2. "Has your spouse seemed withdrawn and less responsive to you during the last few weeks?" 3. "How would you describe your spouse's daily consumption of alcohol?" 4. "Does your spouse appear to have lost weight recently?"

1) Assessment: outcome not desired but not priority; further assessment needed 2) Implementation: outcome not a problem; NPO for 8 hours prior to scan 3) Assessment: outcome not desired but not priority; possible orthostatic hypotension; further assessment needed 4) Correct - Implementation: outcome not desired and priority; metformin should be held for 48 hours prior to tomography with contrast media; risk lactic acidosis with potential renal damage

The nurse cares for the client diagnosed with type 2 diabetes. The client is scheduled for a renal computed tomography scan with contrast media at 10 a.m. The nurse is MOST concerned if the client makes which statement? 1. "My blood sugar was 124 mg/dL this morning." 2. "I drank a glass of water at midnight." 3. "Sometimes I get dizzy when I first get out of bed." 4. "I took my metformin (Glucophage ER) at 6 A.M. this morning."

1) Implementation: outcome not desired; must assess client's readiness to learn first 2) CORRECT - Assessment: outcome desired; ventilate feelings and assess readiness to learn 3) Implementation: outcome not desired; needs to be ready to learn 4) Implementation: outcome not desired; won't assist in adjustment

The nurse cares for the client immediately after an ileostomy procedure. Which is the best INITIAL action for the nurse to take during client teaching? 1. Schedule the teaching demonstrations during family visits. 2. Encourage the client to discuss any concerns and to ask questions. 3. Show a video demonstrating ileostomy care. 4. Perform care for the ileostomy until the client is able to do it herself.

1) Implementation: outcome not desired; lithotomy position; will not decrease pressure on umbilical cord 2) Implementation: outcome not desired; position used to remove weight of fetus from vena cava to prevent maternal hypotension; will not help with prolapsed cord 3) Implementation: outcome not desired; would aggravate prolapsed cord pressure 4) CORRECT - Implementation: outcome desired; Trendelenburg or knee chest position desired to decrease pressure on umbilical cord

The nurse cares for the client in the labor unit. During the transitional phase of labor, the umbilical cord becomes prolapsed. It is MOST important for the nurse to take which action? 1. Place the client on her back with thighs flexed on her abdomen. 2. Place the client on her left side with legs flexed. 3. Place the client supine with the head of the bed elevated 30°. 4. Place the client supine with the foot of the bed elevated.

1) Assessment: outcome not priority; may cough due to irritation of the airway; does not reflect client responsiveness 2) CORRECT - Assessment: outcome priority; client is alert and able to maintain his own airway 3) Assessment: outcome not priority; client needs to be responsive before airway is removed; may be a reflexive action 4) Assessment: outcome not priority; client will be able to swallow before he is responsive

The nurse cares for the client in the recovery room after a knee surgery procedure. The client has an oral airway in place. Which is the BEST indicator that the oral airway can be removed? 1. The client has a forceful cough during repositioning. 2. The client tries to chew on the oral airway.. 3. The client tries to push the airway out with his tongue. 4. The client is able to swallow.

1) Assessment: outcome not priority but may be appropriate; if tubing is obstructed, alarm is activated 2) Assessment: outcome may be appropriate but not priority; more important to determine pain level, description of the pain, region and radiation of the pain, and relieving factors 3) Implementation: outcome not desired; more important to assess severity of pain and pain relief first 4) CORRECT - Assessment: outcome priority; must validate that client is in pain before implementation

The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take? 1. Assess the patency of the PCA IV tubing. 2. Determine the client's understanding of the PCA pump function. 3. Obtain an order to begin a PCA infusion of fentanyl. 4. Ask the client to describe the pain.

1) Implementation: outcome desired; purpose of childbirth class is to eliminate fear of the unknown 2) Implementation: outcome not desired but not priority; focus of class is on fetus and mother; further assessment needed 3) Implementation: outcome desired; anxiety and pain reduction techniques included in class, but mothers are encouraged to use analgesia if needed 4) CORRECT-Implementation: outcome not desired; breathing techniques may decrease anxiety and pain but have no effect on time of labor

The nurse counsels a woman at 36 weeks gestation who has attended childbirth class in preparation for labor and delivery. Which statement by the client requires an intervention by the nurse? 1. "I now know when to expect discomfort during labor and delivery and the things I can do to decrease the discomfort." 2. "My husband is still concerned that he is not sure what to do during the labor process." 3. "Even though I learned pain control techniques, I still may need some pain medication during labor and delivery." 4. "The breathing patterns I learned in class will decrease the amount of time I spend in labor."

1) Implementation: outcome not desired; unnecessary to use catheter 2) This is the procedure for a double void specimen and the question is for a clean catch specimen. 3) CORRECT-Implementation: outcome desired; a culture and sensitivity urinalysis is a sterile specimen 4) Implementation: outcome not desired; need sterile container

The nurse describes to a male client how to collect a clean-catch urine for culture and sensitivity. Which explanation, if made by the nurse, is MOST accurate? 1. "The urinary meatus is cleansed with an antiseptic solution, and then a urinary drainage catheter is inserted to obtain urine." 2. "You will be asked to empty your bladder one half-hour before the test; you will then be asked to void into a container." 3. "Before voiding, the urinary meatus is cleansed with an antiseptic solution; urine is then voided into a sterile container; the container must not touch the penis." 4. "You must void a few drops of urine, and then stop; then void the remaining urine into a clean container which should be immediately covered."

1) Implementation: outcome not desired; only beef is a good source 2) Implementation: outcome not desired; only sausage is good source 3) Implementation: outcome not desired; low in iron 4) CORRECT-Implementation: outcome desired; contains 24-30 mg; vitamin C from potato and salad enhance iron availability

The nurse discusses an appropriate diet with a client diagnosed with iron-deficiency anemia. Which meal, if selected by the client, indicates to the nurse, that teaching is effective? 1. Spaghetti with a sauce of ground beef, cheese, and garlic bread. 2. Baked sausage casserole with rice and sliced tomato. 3. Frankfurter, baked beans, and chopped cabbage salad. 4. Lamb chop, baked potato, and tossed green salad.

1) Implementation: outcome not desired; can't inhale, can't exert enough pressure 2) CORRECT-Implementation: outcome desired; abdominal thrust maneuver appropriate when client not moving air 3) Implementation: outcome not desired; no time to do this 4) Implementation: outcome not desired; could cause increased problems; food could migrate further into respiratory tract

The nurse feeds the client in a chair when the client suddenly begins to choke on food. The client is conscious but unable to speak. Which action is MOST appropriate for the nurse to take? 1. Encourage the client to cough and breathe deeply. 2. Leave the client in the chair and apply vigorous abdominal or chest thrusts from behind. 3. Return the client to the bed and apply vigorous abdominal or chest thrusts while straddling the client's thighs. 4. Apply several vigorous back blows until the food dislodges.

(1.) CORRECT - At risk for diabetic ketoacidosis (2.) CORRECT - Acidic medication (3.) At risk for respiratory acidosis (4.) CORRECT - Kidneys not able to excrete acids or absorb bases (5.) At risk for metabolic alkalosis; lose acids (6.) CORRECT - Lose base in diarrhea

The nurse identifies which client is at risk to develop metabolic acidosis? Select all that apply 1. (1.) A client diagnosed with type 1 diabetes mellitus. 2. (2.) A client diagnosed with salicylate toxicity. 3. (3.) A client diagnosed with bilateral bacterial pneumonia. 4. (4.) A client diagnosed with acute renal failure. 5. (5.) A client diagnosed with continuous nasogastric drainage. 6. (6.) A client diagnosed with severe diarrhea.

1) Implementation: outcome not desired; parents are encouraged to remain with child 2) Implementation: outcome not desired; appropriate only for school-aged and adolescent children 3) Implementation: outcome not desired; not appropriate 4) CORRECT - Implementation: outcome desired; encourage expression of feelings (e.g., anger); fear mutilation; allow child to play with models of equipment

The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST important for the nurse to make which of these statements? 1. "Your parents are going to leave a half hour before the surgery." 2. "You're going to talk with some other children who had this surgery." 3. "If you have this surgery, your parents will buy you a new toy." 4. "Take this doll and show me where the operation will be done."

1) Implementation: outcome desired; would indicate fluid retention 2) Implementation: outcome desired; symptoms of digitalis toxicity, CHF 3) CORRECT - Implementation: outcome not desired; salt substitutes contain potassium; spironolactone is a potassium-sparing diuretic 4) Implementation: outcome desired; some medications may contain sodium and potassium

The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix), spironolactone (Aldactone), and a low-sodium diet. Which statement by the client indicates the need for further instruction? 1. "I should weigh myself every morning and call the health care provider if I gain more than a couple of pounds in a few days." 2. "I should call the health care provider immediately if I start to feel nauseated or have difficulty breathing with normal activities." 3. "I plan to use salt substitutes now that I have to limit my sodium intake." 4. "I should read food and nonprescription medication labels to check the ingredients."

1) Potential for hemorrhage or fatty embolism; eliminate second 2) Potential pneumothorax; see second 3) CORRECT - Real problem; vitals signs indicate significant increase in intracranial pressure; most unstable client 4) Most stable client; eliminate first

The nurse is responsible for triage of injured residents of an apartment building that collapsed during a tornado. Which client should the emergency personnel see FIRST? 1. A 38-year-old client with potential fracture left femur. Blood pressure 110/78, pulse 92/minute, shallow respirations at 16/minute. 2. A 42-year-old client with ecchymotic areas on the left anterior and posterior chest. Blood pressure 142/90, pulse 88/minute, shallow respirations at 20/minute. 3. A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute, irregular respirations at 12/minute. 4. A 64-year-old client complaining of left hand and wrist pain asking, "Where am I?" Blood pressure 128/72, pulse 88/minute, respirations unlabored at 16/minute.

1) CORRECT-Implementation: outcome desired; contact precautions; Clostridium difficile infection may develop after antibiotic treatment 2) Implementation: outcome not desired; unnecessary; should use stool and enteric precautions 3) Implementation: outcome not desired; mask unnecessary; used for airborne infection 4) Implementation: outcome not desired; need to use contact precautions, gown only if soiling likely

The nurse makes a follow-up phone call to the family of an infant receiving treatment for watery diarrhea after 7 days of amoxicillin (Amoxil) therapy. The nurse knows teaching is successful if the family makes which statement? 1. "We wear a fresh pair of clean gloves with each diaper change." 2. "We are not allowing our other children to be in the same room with the baby." 3. The grandmother wears a mask when changing the baby's diaper. 4. The mother wears an apron when changing the baby's diaper.

1) Implementation: outcome not desired; too traumatic to the joints 2) Implementation: outcome not desired; too traumatic to the joints 3) Implementation: outcome not desired; too traumatic to the joints 4) CORRECT-Implementation: outcome desired; good moving and stretching activity; also, throwing or kicking a ball, riding a bicycle, swimming

The nurse monitors the activities of a 9-year-old girl with juvenile rheumatoid arthritis (JA). Which activity is MOST appropriate? 1. The girl is jumping rope. 2. The girl is skipping. 3. The girl jumps off the end of a slide. 4. The girl participates on a swim team.

1) CORRECT-Assessment: outcome desired; order for physical assessment is inspection, palpation, percussion, and auscultation; tactile fremitus is vibration produced when client says "99" 2) Assessment: outcome desired; used to listen for high-pitched sounds such as vesicular breath sounds 3) Assessment: outcome desired; a tight seal increases accuracy 4) Assessment: outcome desired; the order for physical assessment is inspection, palpation, percussion, and auscultation

The nurse observes a student nurse examine a client's chest. Which action requires an intervention by the nurse? 1. The student nurse auscultates heart sounds and then palpates for tactile fremitus. 2. The student nurse uses the diaphragm of the stethoscope to listen to heart sounds. 3. The student nurse places the stethoscope firmly against the skin surface. 4. The student nurse inspects the chest before performing palpation.

1) CORRECT - Implementation: outcome desired; autoimmune disease; not infectious 2) Implementation: outcome not desired; possible skin damage and suppression of bone marrow with decreased white-blood-cell levels; increased risk for infection 3) Implementation: outcome not desired; generalized skin infection of deeper connective tissue; usually caused by Streptococcus or Staphylococcus; increased risk for infection 4) Implementation: outcome not desired; elderly clients receiving long-term antibiotic therapy are at risk for Clostridium difficile infection; highly contagious; increased risk for infection

The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appropriate? 1. A 38-year-old client with a diagnosis of systemic lupus erythematosus. 2. A 45-year-old client receiving daily external radiation therapy treatments for breast cancer. 3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg. 4. A 74-year-old client who has received intravenous antibiotics for 7 days.

1) Assessment: outcome not a problem; 30-60 breaths/min with periods of apnea; normal 2) Assessment: outcome not a problem; 120-160/minute; varies while asleep and awake 3) Assessment: outcome not a problem; startle reflex; normal until 4 months 4) CORRECT - Assessment: outcome not expected and is a problem; Babinski reflex; in newborn, should see dorsiflexion of big toe

The nurse performs an assessment of a newborn boy. The nurse is MOST concerned if which of the by which observation? 1. The respiratory rate is 40 per minute with short periods of apnea. 2. The heart rate is 140 beats per minute with variation during sleeping and waking states. 3. A sudden loud noise causes abduction of the infant's arms and flexion of his elbows. 4. Stroking the outer sole of the infant's foot upward causes his toes to curl downward.

1) CORRECT - Assessment: outcome expected; normal specific gravity of urine, normal hematocrit; specific gravity and hematocrit increase with dehydration 2) Assessment: outcome not expected; increased specific gravity of urine, increased hematocrit; suggests ongoing fluid volume deficit 3) Assessment: outcome not expected; decreased specific gravity of urine, increased hematocrit; does not indicate improvement 4) Assessment: outcome not expected; increased specific gravity of urine, decreased hematocrit; does not indicate improvement

The nurse plans care for a client admitted with fever, vomiting, and diarrhea. Which laboratory value demonstrates an improvement in the client's condition? 1. Specific gravity of urine 1.020 and hematocrit 42%. 2. Specific gravity of urine 1.039 and hematocrit 50%. 3. Specific gravity of urine 1.010 and hematocrit 52%. 4. Specific gravity of urine 1.030 and hematocrit 35%.

1) Assessment: outcome not priority; may cause anemia, but not usually seen 2) CORRECT - Assessment: outcome priority; nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance 3) Assessment: outcome not priority; will be increased in inflammation and rheumatoid arthritis 4) Assessment: outcome not priority; will be increased with any inflammatory process

The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old client. Which is the MOST important action for the nurse to take prior to administration of the medication? 1. Request a daily hemoglobin and hematocrit test. 2. Monitor the serum BUN and creatinine. 3. Request a highly-sensitive C-reactive protein (hs-CRP) test. 4. Monitor the erythrocyte sedimentation rate (ESR).

1) Implementation: outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepressant 2) CORRECT - Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation; combination of vasodilation and diuresis increases risk of orthostatic hypotension 3) Implementation: outcome not a problem; no interaction; gabapentin classified as antiseizure medication; off-label use for neuropathic pain 4) Implementation: outcome not a problem; is a hypnotic; no interaction with ACE inhibitors

The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which medication should the nurse question giving to the client? 1. 20 mg oral escitalopram (Celexa) in the morning. 2. 40 mg oral furosemide (Lasix) in the morning. 3. 300 mg of oral gabapentin (Neurontin) twice daily. 4. 10 mg zolpidem (Ambien) at bedtime.

1) CORRECT - Assessment: outcome priority; must evaluate competency of the UAP; nurse is accountable for UAP's actions during delegation process 2) Assessment: outcome not priority; number of procedures done is not as important as demonstrated competency 3) Assessment: outcome not priority; nurse should be able to delegate procedure if UAP is competent 4) Assessment: outcome not priority; obtaining a capillary glucose sample is within UAP scope of practice

The nurse prepares to assign a client requiring a capillary blood glucose test to a newly hired nursing assistive personnel. Which action should the nurse take FIRST? 1. "Show me how you check a capillary glucose level." 2. "How many of these glucose checks have you done in the past?" 3. "Would you like for me to go with you when you do the glucose test?" 4. "Was this procedure covered during your nursing assistive personnel class?"

(1.) CORRECT - read labels carefully to determine the exact amount of herbs in the preparation (2.) herbal preparations are classified as dietary supplements; adverse reactions may be reported after use (3.) CORRECT - the FDA does not research or regulate herbal preparations because they are classified as dietary supplements (4.) CORRECT - read labels carefully to determine what the herbal preparation contains (5.) label should state that the herbal preparation will "decrease inflammation or support the immune system"; label cannot say that the preparation "protects against cancer"

The nurse presents a class on herbal medications at a community health care seminar. Which statement should be included in the class? Select all that apply 1. (1.) The potency of herbal preparations varies between manufacturers. 2. (2.) The FDA tests and regulates herbal preparations. 3. (3.) Herbal preparations are classified as dietary supplements. 4. (4.) Ma huang contains ephedra and can be dangerous for people with high blood pressure. 5. (5.) Herbal preparations are used in the treatment of immune system dysfunction.

1) Assessment: outcome not priority; psychosocial assessment; eliminate; address physical needs first 2) CORRECT - Assessment: outcome priority; physical needs are highest priority 3) Assessment: outcome desired but not highest priority; address physical needs first 4) Implementation: outcome not highest priority; legal documentation is not the highest priority

The nurse prioritizes the needs of a client who has been raped. Which nursing action is MOST important? 1. Observe the client for withdrawn, tearful behavior. 2. Determine if the client sustained any injuries. 3. Obtain information about events which preceded the rape. 4. Accurately document the client's comments about the rape.

1) Assessment: outcome desired but not priority; methylphenidate has appetite suppressant effects 2) Implementation: outcome not desired; Ritalin should be tapered 3) CORRECT-Assessment: outcome desired and priority; long-acting Ritalin should be given after breakfast to decrease appetite-suppressant effects 4) Assessment: outcome not priority; more important to assess effect of medication on appetite

The nurse receives a phone call from the mother of a 10-year old child taking methylphenidate (Ritalin) daily. The mother reports the child has lost 2 pounds in the last 2 weeks. Which is the MOST appropriate response by the nurse? 1. "How much does your child exercise on a daily basis?" 2. "Stop giving the Ritalin for several days to see if the appetite improves." 3. "At what time do you give your child the Ritalin medication?" 4. "What is your child's bedtime and when does he usually awaken?"

1) Assessment: outcome expected; irregular menstrual periods common during the first year or two after menarche 2) Assessment: outcome expected; age-appropriate and common 3) Assessment: outcome expected; temporary, age-appropriate phenomenon 4) CORRECT-Assessment: outcome not expected; one of the earliest changes of puberty; occurs from age 9-13

The nurse reviews health assessments completed by student nurses. Which assessment warrants further investigation? 1. An 11-year-old female who states that she has had 3 periods in the past 6 months. 2. A 13-year-old male with intermittent voice changes. 3. A 14-year-old male with bilateral breast enlargement. 4. A 15-year-old female with bilateral breast buds.

1) Implementation: outcome not desired; carbamazepine and valproic acid increase risk of birth defects; daily folic acid decreases risk of neural tube defects if taken during pregnancy; folic acid will not increase fertility 2) Implementation: outcome not desired; possible birth defects due to action of the medication; route of administration does not matter 3) CORRECT - Implementation: outcome desired; carbamazepine may be teratogenic; the health care provider should discuss risks and benefits with client 4) Implementation: outcome not desired; grapefruit juice can increase serum levels of carbamazepine as much as 40%

The nurse reviews medications with a 35-year-old female. The client takes 200 mg carbamazepine (Tegretol) orally twice daily. The client asks the nurse about future pregnancies. Which statement by the nurse is MOST appropriate? 1. "If you take 5 mg folic acid daily while trying to conceive, you should be able to get pregnant." 2. "It is recommended that you take carbamazepine suspension instead of the tablets when trying to get pregnant." 3. "You should contact your health care provider and discuss your concerns about pregnancy." 4. "If you avoid drinking grapefruit juice, there should be no problem with conception."

1) Implementation: outcome desired; standard of care for ileostomy 2) Implementation: outcome desired; ileostomy drainage is liquid and very alkaline; great risk of skin irritation 3) CORRECT - Implementation: outcome not desired; osmotic laxative and is contraindicated; avoid enteric-coated or capsule medication, which may not be absorbed through GI tract 4) Implementation: outcome desired; inform healthcare provider and pharmacist about ileostomy

The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further teaching is needed? 1. "The skin around the stoma should be cleaned with warm water and thoroughly dried." 2. "The appliance should fit snugly around the ileostomy opening." 3. "I should take polyethylene glycol (MiraLax) with a large glass of water." 4. "I will continue to take a daily multi-vitamin."

1) Implementation: outcome not desired; skin needs to be toughened if prosthesis is going to be used; no lotions, creams, or powders should be used unless prescribed 2) CORRECT-Implementation: outcome desired; bandages may be loose; expose to air 20 min/day; inspect residual limb for redness, irritation 3) Implementation: outcome not desired; the prone position will decrease the risk of flexion contractures 4) Implementation: outcome not desired; client can sit in straight back chair; time should be restricted to 1 hour or less

The nurse teaches a client who had an above-knee amputation (AKA) 2 days ago about how to care for the residual limb. Which statement, if made by the client, indicates to the nurse that the teaching is effective? 1. "I shall apply cream to the residual limb to soften the skin." 2. "I should rewrap my residual limb with elastic bandages 3 times a day." 3. "I will not be able to sleep on my stomach from now on." 4. "I will no longer be able to sit in straight back chairs at home."

1) Implementation: outcome not desired; false reassurance; need to assess first 2) Implementation: outcome not desired; fosters dependence 3) CORRECT-Implementation: outcome not desired; reflects feelings; allows nurse to assess 4) Implementation: outcome not desired; implies deficiency in the client

The nurse teaches the client how to perform a colostomy irrigation. During the teaching, the client states, "I can't do this." Which response, if made by the nurse, is BEST? 1. "Sure you can do this. You just need to have more practice." 2. "I'll do it for you this time, but you must perform the irrigation the next time." 3. "You seem to be frustrated. What are your specific concerns?" 4. "Most of the other clients learn this without any difficulty. Let's try it again."

1) Outcome not desired; requires frequent assessment of neuromuscular function and monitoring response to therapy 2) Outcome not desired; elderly clients are at risk for clostridium difficile infection due to antibiotic therapy; client would need frequent assessment and evaluation 3) CORRECT - Outcome desired; LPN/LVN can care for stable clients with expected outcomes; nothing in question indicates instability; as cerebral edema resolves, the condition will improve 4) Outcome: not desired; client requires frequent assessment and evaluation; WBC indicates possible infection

The nursing team consists of one RN, one LPN/LVN and two nursing assistive personnel (NAPs). Which assignment is MOST appropriate for the LPN/LVN? 1. A 38-year-old client diagnosed with Guillain-Barré syndrome receiving plasmapheresis therapy. 2. A 72-year-old client admitted yesterday with a 10-day history of oral antibiotic therapy and a 24-hour history of watery diarrhea. 3. A 78-year-old client diagnosed with a thrombotic cerebrovascular accident 5 days ago. 4. A 86-year-old client just admitted with malaise, a productive cough, and WBC 17,000 mm3.

1) Implementation: outcome not desired; program of good hygiene provides advantages without risks of circumcision 2) Implementation: outcome not desired; passing the buck 3) CORRECT-Assessment: outcome priority; open communication; initial assessment: acknowledges parents' feelings 4) Implementation: outcome not desired; closed communication; nurse assumes that pain is the issue

The parents of a newborn boy ask the nurse whether they should have their son circumcised. Which response by the nurse is MOST appropriate? 1. "The benefits of the procedure usually outweigh the risks of bleeding and infection." 2. "You should ask your obstetrician or pediatrician to advise you." 3. "It is not mandatory that your son have a circumcision. What are your concerns?" 4. "Some parents worry about the pain associated with circumcision, but there is actually very little discomfort."

1) Implementation: outcome not desired; only bicycle helmet is recommended; additional protective gear with skateboarding or rollerblading 2) Implementation: outcome not desired; guns and ammunition should be kept in separate locked areas 3) CORRECT-Implementation: outcome desired; injury prevention facilitated by age-appropriate safety education 4) Implementation: outcome not desired; school-aged children are developmentally ready for less supervision; parents should encourage interaction with peers

The school nurse teaches accident-prevention to the parents of school-aged children. Which statement, if made by a parent to the nurse, indicates teaching is effective? 1. "I'm going to make sure my child wears a helmet, shin guards, and gloves when he rides his bike." 2. "I keep my guns and ammunition in a locked cabinet in the basement." 3. "The next time we go to the park, I'm going to teach my child the correct way to climb on the monkey bars." 4. "I'm going to make sure my wife and I observe our child when he plays outside with friends."

1) Implementation: outcome not desired; more important to protect from injury during the seizure; no indication oxygen is needed 2) CORRECT-Implementation: outcome desired; protects client from injuries; stay with client 3) Implementation: outcome not desired; rectal diazepam used to treat status epilepticus in children; not indicated for single seizure 4) Implementation: outcome not desired; turn client to side after the seizure to reduce risk of aspiration; should protect extremities during seizure

While playing on the floor in the hospital room, a 2-year-old has a tonic-clonic seizure. Which action should the nurse take FIRST? 1. Begin oxygen at 2 liters per minute through a nasal cannula. 2. Place a pillow under the client's head. 3. Administer diazepam (Diastat) 5 mg rectally. 4. Turn the client to the side.