HESI Comprehensive A

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

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

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 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.

Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with osteomyelitis? A."Has your child had an ear infection recently?" B."Does your child seem resistant to toilet training?" C."Is your child a picky eater?" D."Do you have a family history of bone disorders?"

A Osteomyelitis can be caused by internal infections, such as otitis media (A). (B and C) are normal developmental findings for a 2-year-old. Osteomyelitis is caused by a bacterial infection, so (D) is not relevant.

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

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

47. The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A.A client who is 2 days postoperative with a right total knee replacement B.A client who is scheduled for a sigmoid colostomy surgery today C.A client who has a surgical abdominal wound with dehiscence D.A client who is 1 day postoperative following a right-sided mastectomy

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

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

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

Prior to administering an oral suspension, which intervention is most important for the nurse to implement? A.Assess the client's ability to swallow liquids. B.Obtain applesauce in which to mix the medication. C.Determine the client's food likes and dislikes. D.Auscultate the client's breath sounds.

A An oral suspension is a liquid, so the nurse needs to assess the client's ability to swallow liquids (A) to ensure that the client will not choke. If the client has difficulty swallowing liquids, a thickening substance may be used (B). If a food product is used to thicken the liquid, (C) would be beneficial. (D) may also be warranted, but only if the client is at risk for aspiration, determined by (A).

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 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 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 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 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).

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

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

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 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 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 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)

Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff? A.Team 1: RN team leader, PN; team 2, PN team leader, UAP B.Team 1, RN team leader, UAP; team 2, PN team leader, PN C.Team 1, PN team leader, PN; team 2, RN team leader, UAP D.Team 1, PN team leader, UAP; team 2, RN team leader, PN

A Team 1 includes high-risk clients who require a higher level of assessment and decision making, which should be provided by an RN and PN (A). Team 2 has stable clients at lower risk than those on team 1. Although two clients on team 2 require frequent care, the care is routine and predictable in nature and can be managed by the PN and UAP. (B, C, and D) do not use the expertise of the nursing staff for the high-risk clients.

A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first? A.Check the client's blood pressure. B.Teach her to elevate her feet when sitting. C.Obtain a 24-hour diet history to evaluate for the intake of salty foods. D.Assess the fetal heart rate.

A The blood pressure (A) should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and have chronic hypertension are at increased risk. Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. (B, C, and D) can be done if the blood pressure is normal.

46. 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 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).

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 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.

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 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.

78. A child is having a generalized tonic-clonic seizure. Which action should the nurse take? A.Move objects out of the child's immediate area. B.Quickly slip soft restraints on the child's wrists. C.Insert a padded tongue blade between the teeth. D.Place in the recovery position before going for help.

A The first priority during a seizure is to provide a safe environment, so the nurse should clear the area (A) to reduce the risk of trauma. The child should not be restrained (B) because this may cause more trauma. Objects should not be placed in the child's mouth (C) because it may pose a choking hazard. Although (D) should be implemented after the seizure, the nurse should not leave the child during a seizure to get help.

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

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

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 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.

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

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

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

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

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

ABD 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.

98. 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.

ABD 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).

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

ACD 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.

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

ACD All these interventions can be used to evaluate fluid status in children and are helpful assessment functions (A, C, and D), but the age of the child makes a fontanel check impractical (B). The posterior fontanel closes at 2 months and the anterior fontanel closes at 18 months of age.

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

ACE (A, C, and E) are therapeutic interventions for foot care in the diabetic patient. (B and D) are contraindicated and could cause foot infection or injury.

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.

ACE 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).

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

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

94. 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

AE 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).

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.Abdominal pain is relieved and perianal skin integrity is maintained. D.Normal bowel patterns are reestablished.

B 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).

The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members? A.Assign the PNs to perform am care and assist with feeding the clients. B.Assign the UAPs to take vital signs and obtain daily weights. C.Assign the RNs to answer the call lights and administer all medications. D.Assign the PNs to assist health care providers on rounds and perform glucometer checks.

B A UAP can take vital signs and daily weights on stable clients (B). UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the PN (A). All team members can answer call lights and PNs can administer some of the medications, so assigning the RN (C) these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds (D), and the UAP can perform glucometer checks, so assigning the PN these tasks is not an effective use of available personnel.

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

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

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 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 is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of Regular and NPH insulin. Which statement indicates that the client needs further instruction? A."I should balance my daily exercise with my dietary intake and insulin dosages." B."When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." C."I should inject my insulin into a different site to reduce the development of scar tissue." D."I should remove the dose of clear insulin first and then the dose of cloudy insulin from the vials."

B Aspiration (B) is not necessary when giving insulin because it could increase tissue trauma and affect the absorption rate. (C) helps minimize tissue atrophy, which can affect the absorption of the insulin. (A and D) are correct procedures. The client should balance an active physical lifestyle with diet, insulin, and blood glucose monitoring to ensure good serum glucose control. When mixing insulins in the same syringe, the clear (Regular) insulin is withdrawn first to avoid contamination of the clear vial with cloudy NPH insulin, which will alter the absorption rate of the remaining Regular insulin.

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

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

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 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.

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

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

44. The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a client who has had a appendectomy. The IV tubing being using delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is necessary, round to the nearest whole drop.) A.15 B.31 C.64 D.50

B Flow rate = 15 gtt/mL × (1000 mL/8 hr) × (1 hr/60 min) = 31 gtt/min

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 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.

21. A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? A."It sounds like you're feeling very sad." B."Tell me more about how you're feeling." C."How often do you have crying spells?" D."Do you want to talk about these feelings?"

B It is most therapeutic to ask an open-ended question and encourage the client to explore his or her feelings (B). (A) is a leading response, and the client may not be feeling sad. (C and D) are close-ended questions that do not facilitate communication.

The nurse is obtaining a client's sexual history. Which finding requires additional follow-up regarding the client's self-image? A.Sexual intercourse with the spouse occurs four times a week. B.The spouse has never seen the client naked. C.The client has had surgery for permanent birth control. D.A history of a 20-lb weight loss occurred in the past year.

B It is usual for spouses to see each other without clothing, so a follow-up question about (B) should provide additional information about the client's self-concept and body image. (A and C) are choices within the continuum of normal and acceptable sexual needs based on each couple's preferences. Body image is a perception of one's physical self and weight gain or loss normally affects one's self-image (D).

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 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.

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

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

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

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

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

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

When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include? A.Keep the residual limb elevated during positioning. B.Instruct the client to grasp the overhead trapeze bar. C.Maintain alignment with an abduction pillow. D.Use pillow support to prevent turning to a prone position.

B The client will gain upper body strength and independence by using the overhead trapeze bar for positioning (B). Elevation of the residual limb is controversial (A) because a flexion contracture of the hip may result, so it is not necessary to maintain elevation during positioning. (C) is used for alignment following some hip surgeries. A prone position (D) should be encouraged to stretch the flexor muscles and prevent flexion contracture of the hip.

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

B The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the client should be reeducated if the client swims (B) or allows water to enter the external ear. (A, C, and D) reflect correct responses.

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 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.

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

B Use the following calculation (B): 20 gtt/mL × (1000 mL/4 hr) × (1 hr/60 min) = 83 gtt/min

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

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

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

BC 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.

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

C (C) requires communication skills and assessment skills beyond the educational level of a PN or UAP. Establishing a therapeutic, one on one relationship with a depressed client is beyond the scope of practice for a PN. In addition, Tylenol is extremely hepatotoxic and careful assessment is essential. (A, B, and D) could all be cared for by a PN under the supervision of the RN.

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 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.

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 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.

Which instruction should the nurse provide to a client whose vision is being tested with a Snellen chart? A.Stand on a line drawn 10 feet from the chart. B.Read each sentence slowly and carefully. C.Cover one eye while reading the chart with the other. D.Begin by identifying the first line that is hard to read.

C Each eye should be tested separately (C) because visual acuity can vary from one eye to the other. A Snellen chart scores vision in comparison with what a person with normal vision can read at a distance of 20 feet (A). The Snellen chart is comprised of letters, not sentences (B). The client should be instructed to begin at or near the top of the chart with the line that can be easily read, moving down until a line is reached that cannot be read (D)

41. 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 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 electricL 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.

95. 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. A. B, C, A, D B. A, C, B, D C. C, B, A, D D. D, C, B, A

C 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).

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

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

A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client's stress associated with repeated hospitalization? A.Allow the client to discuss the seriousness of the illness. B.Ensure that the client is provided with information about medications. C.Encourage as much independence in decision making as possible. D.Include the client in planning the course of treatment.

C Hospitalization compromises an individual's sense of control and independence, which contributes to stress, so allowing the client as much independence in decisions as possible (C) helps reduce stress experienced with repeated hospitalization. (A, B, and D) are important components in stress reduction, but the isolation and dependence associated with hospitalization alter the client's sense of control and affect the client's cognitive ability to understand (B) and participate (D) in the hospitalized plan of care.

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

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

A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement? A.Perform a digital evaluation for fecal impaction. B.Administer a PRN dose of psyllium (Metamucil). C.Obtain a stool specimen for culture and sensitivity. D.Instruct the UAP to obtain incontinent pads for the client.

C Long-term use of levofloxacin (Levaquin) can cause foul-smelling diarrhea because of Clostridium difficile infection or associated colitis, so it is most important to obtain a stool specimen (C). Impaction is unlikely, so (A) is of less priority and may not be necessary. (B) is a bulk-forming agent that may be used for constipation or diarrhea. Treatment of the diarrhea and client comfort (D) are important interventions but of less priority than determining the cause of the client's diarrhea.

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 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.

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

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

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

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

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

A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement? A.Teach the client testicular self-examination (TSE). B.Assess for the presence of blood in the urine. C.Ask about scrotal pain or blood in the semen. D.Inquire about a history of kidney stones.

C Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms (C). Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer (A). Although hematuria (B) is associated with renal disease or calculi (D), the client's pain is associated with ejaculate, not urine.

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

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

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

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

The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP? A.Obtain the remainder of the preoperative admission information. B.Check the vomiting client for signs of tube feeding aspiration. C.Position the client who has vomited on his side and obtain vital signs. D.Teach the preoperative client coughing and deep breathing exercises.

C The UAP can be assigned to perform tasks that do not require the judgment of the nurse, such as positioning the client and obtaining vital signs (C). (A and B) involve assessment, which should be performed by a nurse. (D) involves initial client teaching, which should be performed by the nurse.

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 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.

Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP? A.An adolescent who was readmitted to the hospital because of a postoperative infection B.A woman with a new colostomy who requires discharge teaching C.A woman who had a hip replacement and may be transferred to the home care unit D.A man who had a cholecystectomy and currently has a nasogastric tube set to intermittent suction

C The charge nurse will be responsible for providing a report to the home care unit if the transfer occurs (A). The client is infected and an employee who works on an OB unit should be assigned to clean cases in case the employee is required to return to the OB unit (B). This requires the skills of a registered nurse (RN) to do discharge teaching and provide emotional support (D). This may require skills beyond the level of this UAP.

A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? A.The client is noncompliant with his medications. B.The client recently consumed large quantities of pears or nuts. C.The client's renal function has affected his potassium level. D.The client needs to be started on a potassium supplement.

C The client has a normalized potassium level despite diuretic use (C). The kidney automatically secretes 90% of potassium consumed, but in chronic renal insufficiency (CRI), less potassium is excreted than normal. Therefore, the two potassium-wasting drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is no reason to believe that the client is noncompliant with his treatment (A). Pears and nuts do not affect the serum potassium level (B). There is no need for a potassium supplement (D) because the client's potassium level is within the normal range.

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.

C 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.

57. A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation? A.Advocate for the rights of the staff to watch television once their assignments are complete. B.Confront the administrator about making a decision that will negatively affect the residents. C.Offer to develop an alternate solution so that the residents can continue to watch television. D.Remind the administrator that watching television helps the night shift staff remain awake.

C The role of the nurse-manager in the mediation process is to assess the problem, analyze the information, and reframe it in a manner that might provide compromise (C). The staff do not have the right to watch television (A) while being paid to work. (B) challenges the administrator and is likely to alienate the administrator, causing anger and shutting off further communication. (D) is not a sound rationale for the use of the television.

A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client? A.As women age, they often become rounder in the middle because they do not exercise properly. B.Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur with aging. C.With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. D.Because there is no evidence of a diseased colon, there is no need to worry about abdominal size

C With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and constipation are age-related changes. (D) dismisses the client's concerns and does not help her understand the changes that she is experiencing.

50. 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.

CDF 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.

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

D A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is (D). (A) is high in fat and sugar. (B and C) are high in fat and sodium.

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

D A client's delusional statements are best addressed by identifying the feeling associated with the delusion (D). Distraction (A) may be helpful but ignores the feelings that the client is experiencing. Delusional clients often argue with statements that contradict their belief system (B). The client is unlikely to understand the relationship between the news and the thoughts experienced (C).

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

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

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

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

A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? A.High Fowler's position without a pillow behind the head B.Semi-Fowler's position with a single pillow behind the head C.Right side-lying position with the head of the bed elevated 45 degrees D.Sitting upright and forward with both arms supported on an over the bed table

D Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to increase the longitudinal and anterior-posterior size of the thoracic cage. Sitting upright and leaning forward with the arms supported on an over the bed table (D) allows the thoracic cage to expand in all four directions and reduces dyspnea. A high Fowler's position does not allow maximum expansion of the posterior lobes of the lungs (A). A semi-Fowler's position restricts expansion of the anterior-posterior diameter of the thoracic cage (B). Positioning a client on the right side with the head of the bed elevated (C) does not facilitate lung expansion.

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 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.

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

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

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 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).

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 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.

The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? A."What makes you think we did anything to your baby?" B."Are you or any of your blood relatives of Asian descent?" C."Those are stork bites and will go away in about 2 years." D."Those are Mongolian spots and will gradually fade in 1 or 2 years."

D Mongolian spots (D) are areas of bluish-black or gray-blue pigmentation seen primarily on the dorsal area and buttocks of infants of Asian or African decent or dark-skinned babies. (A) is a defensive answer. Although Mongolian spots occur more frequently in those of Asian and African decent, (B) does not respond to the father's concern. Telangiectatic nevi, frequently referred to as stork bites (C), appear reddish-purple or red and are usually on the face or head and neck area.

Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)? A.Clients' names are not used while they are in a public waiting room. B.Nurses should not recommend any community self-help groups by specific name, such as Alcoholics Anonymous. C.Clients must pick up their filled prescriptions from a pharmacy in person with a photo identification card. D.Old medical records are kept in a locked file cabinet in the department.

D Past medical records must be "secured" and "reasonably protected" from inadvertent viewing (D). A locked room or file cabinet can serve this purpose, and when any protected health information (PHI) is discarded, it must be shredded. A person's name only (without their diagnosis or treatment) is not considered confidential or PHI (A). Nurses may suggest categories of community resources, with examples, such as Alcoholics Anonymous (B), but cannot market a specific program in which they have a financial interest. Others can pick up a client's filled prescriptions (C).

A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client? A.Reduced peripheral edema B.Urinary output of at least 70 mL/hr C.Decrease in urine osmolarity D.Serum sodium level of 137 mEq/L

D Syndrome of inappropriate antidiuretic hormone (SIADH) results from an abnormal production or sustained secretion of antidiuretic hormone, causing fluid retention, hyponatremia, and central nervous system (CNS) fluid shifts. The client's normalization of the serum sodium level (normal is 135 to 145 mEq/L) (D) is the most important outcome because sudden and severe hyponatremia caused by fluid overload can result in heart failure. Fluid retention of SIADH contributes to daily weight gain, which can predispose to peripheral edema (A), but the higher priority outcome is the effect on serum electrolyte levels. Although (B and C) are findings associated with resolving SIADH, they do not have the priority of (D).

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

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

7? A male client with Parkinson's disease has been taking the antiparkinsonian agent amantadine HCl (Symmetrel) for 4 months. He tells the home health nurse, "The medicine doesn't seem to be working anymore." Which information should the nurse provide to this client? A.The dosage probably needs to be increased. B.The medication needs to be changed immediately. C.The medication needs to be taken more frequently. D.The effects of this drug tend to decrease after 3 months.

D The beneficial effects of Symmetrel usually decrease in 3 to 6 months (D). It must be discontinued gradually if necessary (B). Sometimes it is discontinued for a period of time and then resumed at a higher dosage, and although (A) is partially correct, (D) is more correct. Sometimes Symmetrel is given with other antiparkinsonian medications as an adjunct, but (C) would have little effect.

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

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

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 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).

73. Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP.

D The greatest risk associated with opioids such as morphine (D) is respiratory depression that causes an increase in Pco2, which increases ICP and masks the early signs of intracranial bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a client with increased ICP.

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

D The new nurse should be assigned the least complicated client to gain experience and confidence, as well as protect client safety. Of the clients available for assignment, (D) is progressing well and is the least complicated. (A, B and C) have actual or potential complications and should be assigned to a more experienced nurse.

A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? A.The respiratory settings on the ventilator B.Only the client's spontaneous respirations C.The ventilator-assisted respirations minus the client's independent breaths D.The ventilator setting for respiratory rate and the client-initiated respirations

D The nurse should count the client's respirations, and document both the respiratory rate set by the ventilator and the client's independent respiratory rate (D). Never rely strictly on (A). Although the client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture of the client (B and C).

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

D The older woman who wishes she could change the choices she has made in her lifetime is expressing despair and is still searching for integrity (D). The nurse uses Erikson stages of development over the life span to assess an older client's adjustment to aging and plans teaching strategies to assist the clients attain integrity versus despair. (A, B, and C) are normal developmental tasks of older adults.

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

D The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular sample, alters cytology analysis, and masks bacterial or sexually transmitted disease infections, so the Pap test should be postponed (D). Although (A, B, and C) are indicated, the client needs further teaching for the return visit to perform the Pap smear test.

A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's hips are externally rotated. Which intervention is most important for the nurse to implement? A.Request a prescription for a bed board to provide increased back support. B.Reposition the client so that both feet are supported by the bed board. C.Move the trapeze bar to allow the client to pull with the upper extremities. D.Place trochanter rolls on the lateral aspects of the client's thighs.

D Trochanter rolls (D) should be placed on the lateral aspects of the thighs to prevent external rotation of the hips when the client is in a supine position. Although (A, B, and C) are supportive equipment used to maintain proper positioning of the client who is immobile, it is most important to maintain the lower extremities in the aligned anatomical position. A bed board (A) provides increased back support, especially with a soft mattress. The footboard (B) maintains the feet in dorsiflexion and prevents foot drop. The trapeze bar (C) allows the client to participate while turning in the bed, during transfers in and out of bed, or performing upper arm exercises.

25. The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A.Prepare to evacuate the unit, starting with the bedridden clients. B.UAPs should report to the emergency center to handle transports. C.The licensed staff should begin counting wheelchairs and IV poles on the unit. D.Continue with current assignments until more instructions are received.

D When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received (D). Evacuation is typically a response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are anticipated. (C) is poor utilization of personnel.