HESI Comprehensive B, Comprehensive Exam A, 2020 exit v 2 ?????

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45. When interviewing the parents of a child with asthma, it is most important to gather what information about the child's environment? A) Household pets B) New furniture C) Lead based paint D) Plants such as cactus

46. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse

42. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance? A) Metabolic acidosis B) Metabolic alkalosis C) Some increase in the serum hemoglobin D) A little decrease in the serum potassium

65. The nurse planning care for a 12 year-old child with sickle cell disease in a vasoocclusive crisis of the elbow should include which one of the following as a priority? A) Limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise

25. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C) Was appropriate in view of the client's history of violence D) Was necessary to maintain the therapeutic milieu of the unit

26. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety related to pain

32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower

34. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills

40. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? A) Hourly urine output B) White blood count C) Blood glucose every 4 hours D) Temperature every 2 hours

68. The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? A) Lethargy B) Irritability C) Negative Moro D) Depressed fontanel

50. A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse? A) Telfa dressing with antibiotic ointment B) Moist sterile non adherent dressing C) Dry sterile dressing that is occlusive D) Sterile occlusive pressure dressing

101. The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) Formula or breast milk B) Broth and tea C) Rice cereal and apple juice D) Gelatin and ginger ale

103. The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to A) Assess for abdominal distention B) Maintain infant in an upright position C) Begin formula feedings when infant is alert D) Pump the shunt to assess for proper function

132. What assessment data should the nurse obtain next? A) Status of the eyes and the tongue B) Description of play activity C) History of fluid intake D) Dietary patterns

152. A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of Digoxin to this client? A) Assess the apical pulse, counting for a full 60 seconds B) Take a radial pulse, counting for a full 60 seconds C) Use the pulse reading from the electronic blood pressure device D) Check for a pulse deficit

156. A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse should recognize that the client may be developing which complication? A) Acute compartment syndrome B) Thromboemolitic complications C) Fatty embolism D) Osteomyelitis

158. Which statements by the client would indicate to the nurse an understanding of the issues with end stage renal disease? A) I have to go at intervals for epoetin (Procrit) injections at the health department. B) I know I have a high risk of clot formation since my blood is thick from too many red cells. C) I expect to have periods of little water with voiding and then sometimes to have a lot of water. D) My bones will be stronger with this disease since I will have higher calcium than normal.

18. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fibrillation and heart failure - PN B) Client who had a major stroke 6 days ago - PN nursing student C) A child with burns who has packed cells and albumin IV running - charge nurse D) An elderly client who had a myocardial infarction a week ago - UAP

24. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcement of the manipulative behavior C) Confront the client about the negative effects of behaviors on other clients and staff D) Develop a behavior modification plan that will promote more functional behavior

41. The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance? A) Assume a decision-making role B) Seek input from staff C) Use a non-directive approach D) Shared decision-making with others

49. The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse? A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improves the health of mother and fetus."

52. A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The most appropriate intervention for this client is A) Position client in upright position while eating B) Place client on a clear liquid diet C) Tilt head back to facilitate swallowing reflex D) Offer finger foods such as crackers or pretzels

58. The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated to the findings in the infant? A) DTaP B) Hepatitis B C) Polio D) H. Influenza

78. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? A) Solid foods are introduced 1 at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake D) Solid foods should be mixed with formula in a bottle

82. A client is recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? A) Tetany and paresthesia B) Mild stridor and hoarseness C) Irritability and insomnia D) Headache and nausea

85. The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied A) When it is 1/3 to 1/2 full B) Prior to meals C) After each fecal elimination D) At the same time each day

88. The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period? A) Estrogen replacement therapy B) 10% less than ideal body weight C) Hypersensitivity to heparin D) History of hepatitis

89. The nurse is planning discharge for a 90 year-old client with musculoskeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls? A) Place nightlight in the bedroom B) Wear eyeglasses at all times C) Install grab bars in the bathroom D) Teach muscle strengthening exercises

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

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

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

A Rationale: (A) specifically relates to foot care. (B, C, and D) provide worthwhile information to obtain but do not have the importance of (A).

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

A Rationale: A black box warning is a notice required by the FDA on a prescription drug that warns of potentially dangerous side effects (A). (B, C, and D) are all desired effects of the drug.

After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing chronic complications of diabetes? A.Blood pressure, 159/98 mm Hg B.Hemoglobin A1c (HbA1c), 6% C.Creatinine level, 1.0 mg/dL D.Chronic sciatica

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

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

A Rationale: A decrease in level of consciousness is a sign of decreased oxygenation and requires immediate intervention (A). The others are expected findings (B, C, and D).

The nurse is assessing a client at 20 weeks' gestation. Which measurement should be compared with the client's current weight to obtain the most accurate data about her weight gain during pregnancy? A.Usual prepregnant weight B.Weight at the first prenatal visit C.Weight during previous pregnancy D.Recommended pattern of weight gain

A Rationale: Comparing the client's current weight with her prepregnant weight (A) allows for the calculation of weight gain. By the time of the first prenatal visit (B), she may have already gained weight. (C) may not be relevant to weight gain with the current pregnancy. (D) should be evaluated based on serial weights, not just a single current weight.

A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation is most significant? A.Heart palpitations B.Leg cramps C.Nausea D.Tetany

A Rationale: Hypokalemia can cause heart palpitations, which are indicative of a dysrhythmia that could progress to a medical emergency (A). (B and C) are also of concern but are not as life threatening. (D) is a symptom of hypocalcemia.

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

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

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

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

An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take? A.Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. B.Hold the next dose of digoxin until the health care provider can be notified because the serum digoxin level is elevated. C.Administer the next dose of digoxin and notify the health care provider that the child is showing signs of toxicity. D.Notify the health care provider that the child's pulse rate is below normal for her age group.

A Rationale: Nausea and vomiting are early signs of digoxin toxicity. However, the normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min and the therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, (A) is the best of the choices provided because the serum digoxin level is within normal levels. (B) is not warranted by the data presented. The digoxin level is within the therapeutic range and the child is not showing signs of toxicity (C). The child's pulse rate is within normal range for her age group (D).

The nurse is caring for a hospitalized client with myasthenia gravis. Which finding requires the most immediate action by the nurse? A.O2 saturation, 89% B.Reports diplopia C.Ptosis to left eye D.Difficulty speaking

A Rationale: Respiratory failure is a life-threatening complication that can occur with myasthenia gravis (A). (B, C, and D) are signs of the disease but are not as life threatening as decreased oxygen saturation.

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

A Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with Thorazine. It is most important for the nurse to administer an anticholinergic such as Cogentin to reverse these effects (A). The others (B, C, D) may be appropriate interventions but are not as urgent as (A).

Which vaccination should the nurse administer to a newborn? A.Hepatitis B B.Human papilloma virus (HPV) C.Varicella D.Meningococcal vaccine

A Rationale: The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is not recommended until adolescence (B). Varicella immunization begins at 12 months (C). Meningococcal vaccine is administered beginning at 2 years (D).

The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the licensed practical nurse (LPN)? A.A client with nausea who needs a nasogastric tube inserted B.A client in hypertensive crisis who needs titration of IV nitroglycerin C. A newly admitted client who needs to have a plan of care established D.A client who is ready for discharge who needs discharge teaching

A Rationale: This client has a need for a skill that is within the scope of practice for the LPN (A). Titration of an IV drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not delegated (B, C, and D).

54. The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? A) Risk for dehydration B) Ineffective airway clearance C) Altered nutrition D) Risk for injury

69. The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? A) Perform traumatic procedures B) Use minimal physical contact C) Proceed from head to toe D) Explain the exam in detail

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

A,B Rationale: These are normal findings (A and B). The others indicate abnormalities or complications and should be reported to the primary health care provider (C, D, and E).

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

A,B,D Rationale: These are all signs of abruptio placentae (A, B, and D). The others are signs of placenta previa (C and E).

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

A,B,D,E Rationale: Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E); however, the disease is not spread from person to person (C).

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

A,B,D,E Rationale: Metabolic syndrome is a name for a group of risk factors that increase the risk for coronary artery disease, type 2 diabetes, and stroke (A, B, D, and E). Hypoglycemia is not a risk factor for metabolic syndrome (C).

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

A,C,E Rationale: (A, C, and E) are all candidates for RhoGAM. RhoGAM should never be given to an infant or father (B and D).

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. "Has your child had an ear infection recently?" Rationale: 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.

60. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive personnel (UAP)? A client with A) Difficulty swallowing after a mild stroke B) an order of enemas until clear prior to colonoscopy C) an order for a post-op abdominal dressing change D) transfer orders to a long term facility

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

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

The 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. 50 mg/dL Rationale: 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.

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 client who is 2 days postoperative with a right total knee replacement Rationale: (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.

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

A. A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) Rationale: 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.

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. Assess the client's ability to swallow liquids. Rationale: 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).

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

A. Blood pressure of 90/56 mm Hg Rationale: 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 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. Check the client's blood pressure. Rationale: 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.

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

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

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

A. Encourage staff to participate in online in-service education. Rationale: 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).

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. Ensure that the client receives breakfast within 30 minutes. Rationale: 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 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. Examine for clamp closures. Rationale: 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.

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

A. Help the client dangle his legs. Rationale: 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.

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

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

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

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

The nurse 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. Increased oxygen saturation Rationale: 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.

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

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

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

A. Oral hygiene should be performed before the medication. Rationale: 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).

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.

A. Record wet diapers. C. Examine skin turgor. D. Observe mucous membranes. Rationale: 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.

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. Reduced renal excretion Rationale: 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.

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.

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

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

A. Save the next urine sample. Rationale: 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.

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

A. Shave the area where the TENS will be placed. C. Place the TENS unit directly over or near the site of pain. E. Describe the use of TENS for postoperative procedures such as dressing changes. Rationale: 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).

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. Speak privately with the nurse. Rationale: 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.

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: RN team leader, PN; team 2, PN team leader, UAP Rationale: 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 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 client's usual sleeping pattern Rationale: 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.

62. The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately? A) Prolonged inspiration with each breath B) Expiratory wheezes that are suddenly absent in 1 lobe C) Expectoration of large amounts of purulent mucous D) Appearance of the use of abdominal muscles for breathing

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

A. The color of the dialysate outflow is opaque yellow. Rationale: 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.

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.

A. Use lanolin to moisturize the tops and bottoms of the feet. C. Wash feet daily and dry well, particularly between the toes. E. Wear leather shoes that fit properly. Rationale: (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.

63. The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best? A) Fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk

10. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? A) Why don't we now have the client turn back to the left side. B) That was done correctly. Did you have any problems with the insertion? C) Let's check to see if the suppository is in far enough. D) Did you feel any stool in the intestinal tract?

102. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. What is the physiological basis for this instruction? A) Retards pepsin production B) Stimulates hydrochloric acid production C) Slows stomach emptying time D) Decreases production of hydrochloric acid

107. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? A) "The injury is expected to heal quickly because of thin periosteum." B) "In some instances the result is a retarded bone growth." C) "Bone growth is stimulated in the affected leg." D) "This type of injury shows more rapid union than that of younger children

12. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? A) Void a little, clean the meatus, then collect specimen B) clean the meatus, begin voiding, then catch urine stream C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine

13. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? A) spaghetti B) watermelon C) chicken D) tomatoes

150. Which of the following times is a depressed client at highest risk for attempting suicide? A) Immediately after admission, during one-to-one observation B) 7 to 14 days after initiation of antidepressant medication and psychotherapy C) Following an angry outburst with family D) When the client is removed from the security room

151. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time? A) What are you taking for pain and does it provide total relief? B) What does the skin on the testicles look and feel like? C) Do you have any questions about your care? D) Did you know a consequence of epididymitis is infertility?

16. A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? A) Comatose, breathing unlabored B) Glascow Coma Scale 8, respirations regular C) Appears to be sleeping, vital signs stable D) Glascow Coma Scale 13, no ventilator required

19. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Restlessness and increased mucus production C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor

2. Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary

22. A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? A) Converse with the client to determine if the mucous membranes are impaired B) Report hourly outputs of less than 30 ml/hr C) Monitor client's ability for movement in the bed D) Check skin turgor every 4 hours

23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? A) Our child had chickenpox 6 months ago. B) Strep throat went through all the children at the day care last month. C) Both ears were infected over 3 months age. D) Last week both feet had a fungal skin infection.

27. The provisions of the law for the Americans with Disabilities Act require nurse managers to A) Maintain an environment free from associated hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider both mental and physical disabilities

3. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered

37. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? A) Dyspnea B) Heart murmur C) Macular rash D) Hemorrhage

38. A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to A) Stabilize thermoregulation B) Maintain alveolar surface tension C) Begin normal pulmonary blood flow D) Regulate intra cardiac pressure

4. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? A) An infant with intermittent bulging anterior fontanel between crying episodes B) A toddler with severe deep abrasions over 98% of the body C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture D) A school-age child with singed eyebrows and hair on the arms

73. A 2 year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water

74. The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication? A) Nebulized treatments for home care B) Adding a spacer device to the MDI canister C) Asking a family member to assist the client with the MDI D) Request a visiting nurse to follow the client at home

76. When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the nurse would suggest for the parents to give sips of which substance? A) Tea B) Water C) Milk D) Soda

77. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicate a potential hazard for this test? A) Reflex incontinence B) Allergic to shellfish C) Claustrophobia D) Hypertension

87. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings

92. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? A) Complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) Continue to take prophylactic doses for at least 5 years after the diagnosis

94. The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized? A) Call the Poison Control Center once the situation is identified B) Empty the child's mouth in any case of possible poisoning C) Have the child move minimally if a toxic substance was inhaled D) Do not induce vomiting if the poison is a hydrocarbon

98. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first? A) Notify the health care provider B) Administer the PRN dose of Albuterol C) Apply oxygen at 2 liters per nasal cannula D) Repeat the peak flow reading in 30 minutes

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

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

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

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

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

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

The nurse is assessing suicide risk for a client recently admitted to the acute psychiatric unit. Which finding is the most significant risk factor? A.High level of anxiety present B.History of previous suicide attempt C.Family history of depression D.Self-care deficit is noted

B Rationale: A previous history of a suicide attempt is the most significant risk factor for future suicide attempts because the client has previously implemented a plan (B). The others (A, C, and D) may also be risk factors but are not as significant as a history of previous attempts.

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

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

A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action should the nurse take first? A.Administer an antianxiety medication PRN. B.Assess the client's vital signs. C.Notify the primary health care provider. D.Determine coping mechanisms used in the past.

B Rationale: Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is important that the nurse assess the patient and rule out physiologic causes (B). Nonpharmacologic measures should be taken first (A). (C and D) may be considered but are not as high priority as the initial physiologic assessment.

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

B Rationale: An expected finding is between 400 and 750 mL in 12 hours = average of 30 mL/hr (B). Ammonia odor is an expected finding (A). Size 14- to 18-French catheters are common sizes used in the adult female (C). Below the level of the bladder is the correct position for the drainage bag (D).

Which data obtained during a respiratory assessment for a 78-year-old client is most important to report to the primary health care provider? A.Auscultation of vesicular breath sounds B.Pulse oximetry reading of 89% C.Arterial Pao2 of 86% D.Resonance on percussion of the lungs

B Rationale: An oxygen saturation lower than 90% indicates hypoxia (B). (A, C, and D) are all normal findings.

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

B Rationale: As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone of rolling over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is common from 7 to 9 months (C). Speaking a few words is expected at about 12 months (D).

When blood or blood products are administered, which task can be assigned to the licensed practical nurse (LPN)? A.Initiation of the blood product B.Obtaining vital signs after infusion has begun C.Assessment of client's condition prior to blood administration D.Evaluation of client's response after receiving blood product

B Rationale: Blood and blood products must be initiated by the registered nurse (RN) (B); however, obtaining vital signs may be delegated as long as the results are evaluated by the RN. (A, C, and D) are all part of the nursing process and the scope of the RN.

The nurse plans to teach blood glucose self-monitoring to a client who is newly diagnosed with diabetes mellitus type 1, and the health care provider has given the client a schedule for testing. In addition to the prescribed schedule, the nurse should also instruct the client to check the blood glucose level in which circumstance? A.Any time the client awakens during the night B.Whenever the client has feelings of dizziness C.Right after meals if insulin is not administered 30 minutes before the meal D.Only at scheduled times; additional testing harmful to fingertips

B Rationale: Clients should be instructed to always check their blood glucose level whenever they feel faint or dizzy (B). There is great variability in recommendations for the frequency of blood glucose testing. When first diagnosed, clients are often advised to test before and after meals and at bedtime, and then after meals and at bedtime for a short period. Once they are stable, clients may be advised to test four times a day or as little as once each week, depending on the consistency of their diet and exercise and stability of their blood sugar level. (A, C, and D) provide inaccurate information.

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

B Rationale: Cyclophosphamide (Cytoxan) is an immunosuppressive drug used to treat lymphoma and puts the client at risk for infection. Signs and symptoms of an infection should be reported to the oncologist immediately (B). These are expected signs and symptoms of non-Hodgkin's lymphoma (A and C). (D) is a normal side effect of cyclophosphamide.

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

B Rationale: Defibrillation is the first and most effective emergency treatment for ventricular fibrillation (B). The others may follow the first action (A, C, and D).

A nurse working in the emergency department admits a client with full-thickness burns to 50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse take first? A.Insert a large-bore IV for fluid resuscitation. B.Prepare to assist with maintaining the airway. C.Cleanse the wounds using sterile technique. D.Administer an analgesic for pain.

B Rationale: High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with lung injury. Airway management is the first priority of care (B). (A, C, and D) are all appropriate interventions in managing the client with a burn but are not as critical as establishing an airway.

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

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

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

B Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).

The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? A.Assess the need to change a central line dressing. B.Obtain a fingerstick blood glucose level. C.Answer a family member's questions about the client's plan of care. D.Teach the client side effects to report related to the current medication regimen.

B Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP.

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

B Rationale: Planning (B) allows the nurse to set goals for care and elicit the expected outcome by identifying appropriate nursing actions. Assessment, implementation, and evaluation are part of the care for the client but are not the appropriate actions for formulating the expected outcome (A, C, and D).

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

B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).

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

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

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

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

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

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

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

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

When caring for a client with a tracheostomy, which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? A.Teach the family about signs and symptoms of hypoxia. B.Take the vital signs and obtain an O2 saturation level. C.Evaluate the need for tracheal suctioning. D.Revise the plan of care to include tracheostomy care.

B Rationale: The nurse may delegate obtaining vital signs and O2 saturation; however, the nurse is responsible for following up on any reported data (B). (A, C, and D) are all part of the nursing process and should not be delegated under the nurse's scope of practice.

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

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

A client who is first day postoperative after a mastectomy becomes increasingly restless and agitated. Vital signs are temperature, 100° F; pulse, 98 beats/min; respirations, 24/breaths/min; and blood pressure, 120/80 mm Hg. Which intervention should the nurse implement first? A.Administer a PRN dose of a prescribed analgesic. B.Assess the incision for any drainage or redness C.Instruct the UAP to take vital signs hourly. D.Assist the client to a more comfortable position.

B Rationale: The nurse's priority is to observe for possible hemorrhage (B). The client is at high risk for hypovolemic shock and is exhibiting early symptoms of shock. Remember, in early shock the blood pressure may be stable or increase slightly as a compensatory mechanism. If there is no obvious indication of bleeding, the client should then be assessed for the need of an analgesic (A, C, and D) should be implemented.

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

B Rationale: The patient in DKA experiences severe dehydration and must be rehydrated before insulin is administered (B). The other actions will follow rehydration (A, C, and D).

The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct? A.Using one syringe, first insert air into the regular vial and then insert air into the NPH vial. B.Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. C.Avoid combining the two insulins because incompatibility could cause an adverse reaction. D.Administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate stick.

B Rationale: The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH (B). Air should first be injected into the NPH vial and then air should be inserted into the regular vial (A). NPH and regular insulin are compatible, and combining will reduce the number of injections (C). The insulin is ordered subcutaneously and NPH cannot be given IV (D).

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

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

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

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

93. An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice? A) Bologna sandwich, pudding, milk B) Frankfurter, baked potato, milk C) Chicken strips, corn on the cob, milk D) Grilled cheese sandwich, apple, milk

Which instruction(s) should the nurse include in the discharge teaching plan of a male client who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.) A.Keep the medication in your pocket so that it can be accessed quickly. B.Call 911 if chest pain is not relieved after one nitroglycerin. C.Store the medication in its original container and protect it from light. D.Activate the emergency medical system after three doses of medication. E.Do not use within 1 hour of taking sildenafil citrate (Viagra).

B,C Rationale: Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B). The medication should be kept in the original container to protect from light (C). Keeping the medication in the shirt pocket provides an environment that is too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never be taken with Viagra (E).

The nurse is planning the care for a client who is admitted with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.) A.Salt-free diet B.Quiet environment C.Deep tendon reflex assessments D.Neurologic checks E.Daily weights

B,C,D,E Rationale: Correct responses are (B, C, D, and E). SAIDH results in water retention and dilutional hyponatremia, which causes neurologic changes when serum sodium levels are less than 115 mEq/L. The nurse should maintain a quiet environment (B) to prevent overstimulation and assess deep tendon reflexes (C) and perform neurologic checks (D) to monitor for neurologic deterioration. Daily weights (E) should be monitored to assess for fluid overload. (A) would contribute to dilutional hyponatremia.

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

B,C,E Rationale: Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).

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

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

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

B,D,E Rationale: The fundus should be palpated and massaged frequently to prevent hemorrhage (B). The lochia should be assessed to detect for hemorrhage (D) and ice packs and witch hazel can decrease edema and discomfort (E). Bed rest is only recommended for the first 2 hours (A). A full bladder is suspected if the fundus is deviated to the right or left of the umbilicus (C).

A 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. "Swimming can begin on the tenth postoperative day." Rationale: 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.

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. "Tell me more about how you're feeling." Rationale: 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 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. "When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." Rationale: 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 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. 32 C. 64 D. 50

B. 32 Rationale: Use the following calculation (B): Flow rate = 15 gtt/mL × (1000 mL/8 hr) × (1 hr/60 min) = 32 gtt/min

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

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

B. Allow the client to sit on the side of the bed for a few minutes before transferring. Rationale: 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.

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

B. Assess the client for pain and administer pain medication as prescribed. Rationale: 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 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. Assign the UAPs to take vital signs and obtain daily weights. Rationale: 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.

95. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? A) Drowsiness, lethargy, and inactivity B) Dry mouth, nasal congestion, and blurred vision C) Rash, blood dyscrasias, severe depression D) Hyperglycemia, weight gain, and edema

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. Assist the client with toileting. Rationale: 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.

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. B, C, A, D Rationale: 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).

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

B. Blood urea nitrogen >25 mg/dL Rationale: 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.

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. Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. Rationale: 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.

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

B. Guaiac-positive stool Rationale: 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.

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. Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. Rationale: 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).

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

B. Hypotension Rationale: 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.

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. Immunization history Rationale: 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.

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. Instruct the client to grasp the overhead trapeze bar. Rationale: 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.

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. Leave the room and discuss the incident privately with the staff member. Rationale: 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).

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

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

B. Take the vital signs to determine the client's response for a potential blood loss. Rationale: 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 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. The spouse has never seen the client naked. Rationale: 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 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. This sensation occurs as breast milk moves to the nipple. Rationale: 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.

96. The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? A) Antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside within the first 24 hours

5. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to A) Change whichever item is incorrect to the correct information B) Use the bracelet and admission form until a replacement is supplied C) Notify the admissions office and wait to apply the bracelet D) Make a corrected identification bracelet for the client

51. A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boil the tap water for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled "lead free" to mix the formula

53. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from... A) a tissue bank." B) a pig." C) my thigh." D) synthetic skin."

59. The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS

64. A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to A) Limit milk and milk products B) Encourage bed activities and games C) Plan nursing care around lengthy rest periods D) Promote a diet rich in iron

67. The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken A) Once each day B) 3 times daily after meals C) With each meal or snack D) Each time carbohydrates are eaten

70. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? A) A report of 10 pounds weight loss in the last month B) A comment by the client "I just can't sit still." C) The appearance of eyeballs that appear to "pop" out of the client's eye sockets D) A report of the sudden onset of irritability in the past 2 weeks

71. Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required? A) pH below 7.3 B) Potassium of 5.0 C) HCT of 60 D) Pa O2 of 79%

97. A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? A) Cheese crackers B) Peanut butter sandwich C) Potato chips D) Vanilla cookies

79. The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? A) Storing the packed red cells in the medicine refrigerator while starting IV B) Slow the rate of infusion if the client develops fever or chills C) Limit the infusion time of each of the unit to a maximum of 4 hours D) Assess vital signs every 15 minutes throughout the entire infusion

80. A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on this data, what is the first nursing action? A) Review other lab data B) Notify the health care provider C) Administer oxygen D) Calm the client

83. A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these? A) Negative room ventilation B) Face mask with sheild C) Particulate respirator mask D) Airborne precautions

84. A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? A) The client lost 2 pounds in 24 hours B) The client's potassium level is 4 mEq/liter. C) The client's urine output was 1500 cc in 5 hours D) The client is to receive another dose of Lasix at 10 PM

86. Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice

9. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident C) 72 year-old recovering from surgery after a hip replacement 2 hours ago D) 75 year-old who is in skin traction prior to planned hip pinning surgery.

90. An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the following allergies. Of these allergies which one should all health care personnel be aware of? A) Shellfish B) Molds C) Balloons D) Perfumed soap

91. The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing

39. An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be A) Response to stimuli B) Bladder control C) Respiratory function D) Muscle weakness

43. Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform? A) Take a history on a newly admitted client B) Adjust the rate of a gastric tube feeding C) Check the blood pressure of a 2 hours post operative client D) Check on a client receiving chemotherapy

44. A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is A) Call for emergency transport to the hospital B) Immobilize the limb and joints above and below the injury C) Assess the child and the extent of the injury D) Apply cold compresses to the injured area

48. A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse? A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device

104. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? A) "I think you or your partner needs to stay with the child while in the hospital." B) "Oh, that behavior will stop in a few days." C) "Keep in mind that for the age this is a normal response to being in the hospital." D) "You might want to "sneak out" of the room once the child falls asleep."

105. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic reponse to the drug? A) Bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time

109. During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse? A) "Mongolian spots are a normal finding in dark-skinned children." B) "Port wine stains are often associated with other malformations." C) "Telangiectatic nevi are normal and will disappear as the baby grows." D) "The child is too young for consideration of surgical removal of these at this time."

11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? A) airborne precautions B) droplet precautions C) contact precautions D) compromised host precautions

110. A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? A) Ambulate the client 4 hours after procedure B) Maintain client on NPO status for 24 hours C) Monitor vital signs D) Change dressing every 8 hours

14. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? A) Look up the policy on needle sticks B) Contact employee health services C) Immediately wash the hands with vigor D) Notify the supervisor and risk management

153. A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem? A) Chest pain B) Pallor C) Inspiratory crackles D) Heart murmur

154. A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation? A) Abnormal breath sounds B) Cyanosis of the lips C) Increasing pulse rate D) Pulse oximeter reading of 92%

155. Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis? A) Active and passive range of motion exercises twice a day B) Every 4 hours incentive spirometer C) Chest physiotherapy twice a day D) Repositioning every 2 hours around the clock

17. A client enters the emergency department unconscious via ambulance from the client's work place. What document should be given priority to guide the direction of care for this client? A) The statement of client rights and the client self determination act B) Orders written by the health care provider C) A notarized original of advance directives brought in by the partner D) The clinical pathway protocol of the agency and the emergency department

20. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "The urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D) "We notice muscle weakness and some unsteadiness."

28. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? A) "I have problems with diarrhea." B) "I have difficulty falling asleep." C) "I have diminished sexual function." D) "I often feel jittery."

30. Which statement best describes time management strategies applied to the role of a nurse manager? A) Schedule staff efficiently to cover the needs on the managed unit B) Assume a fair share of direct client care as a role model C) Set daily goals with a prioritization of the work D) Delegate tasks to reduce work load associated with direct care and meetings

36. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states "I demand to be released now!" The appropriate action is for the nurse to A) You cannot be released because you are still suicidal. B) You can be released only if you sign a no suicide contract. C) Let's discuss your decision to leave and then we can prepare you for discharge. D) You have a right to sign out as soon as we get an order from the health care provider's discharge order.

99. What finding signifies that children have attained the stage of concrete operations (Piaget)? A) Explores the environment with the use of sight and movement B) Thinks in mental images or word pictures C) Makes the moral judgement that "stealing is wrong" D) Reasons that homework is time-consuming yet necessary

A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: "My child seems to have problems in learning to count and recognizing basic colors." Based on this data, the nurse suspects that the child is most likely showing the effects of which problem? A) Congenital abnormalities B) Chronic toxoplasmosis C) Fetal alcohol syndrome D) Lead poisoning

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

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

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

C Rationale: Charting actions prior to implementing them is an example of fraudulent charting and the graduate nurse should receive further education (C). (A, B, and D) are appropriate charting examples.

100. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? A) Protime (PT) and partial thromboplastin time (PTT) B) Red blood cell and white blood cell counts C) Blood urea nitrogen and creatinine clearance D) Liver enzymes (AST and ALT)

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

C Rationale: A hemoglobin level of 8.4 g/dL is abnormally low and may indicate hemorrhage (C). The others are all expected findings after a TURP (A, B, and D).

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

C Rationale: A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could worsen the condition.

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

C Rationale: A therapeutic range for digoxin is 0.5 to 2 ng/mL (C). The digoxin should be continued to maintain a therapeutic range (C). The others actions are not indicated for a therapeutic range (A, B, and D).

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

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

An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen? A.Long-acting medication is more effective than daily medication. B.A client with substance abuse must not take any oral medications. C.There will continue to be a risk of alcohol and drug interaction. D.Support groups are only helpful for substance abuse treatment.

C Rationale: Alcohol enhances the side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. Therefore, the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM (C). (A, B, and D) provide incorrect information.

106. The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? A) Vomiting of dark emesis B) Complaints of throat pain C) Apical heart rate of 110 D) Increased restlessness

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

C Rationale: Checking the blood glucose level is a low-risk task that can be safely delegated to the UAP in most circumstances (C). Teaching, assessment, and evaluation are all within the scope of practice of the RN and should not be delegated to the UAP (A, B, and D).

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

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

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

C Rationale: Girls experience a growth spurt at 9.5 to 14.5 years of age and boys at 10.5 to 16 years of age (C). There are insufficient data to support (A); growth trends must be assessed to reach such a conclusion. (B) is not unexpected. The fact that the children are twins has less to do with their growth than the fact that they are male and female (D).

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

C Rationale: Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia (C). (A, B, and D) state incorrect information for symptoms of leukemia.

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

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

When administering an intramuscular injection, which factor is most important to ensure the best medication absorption? A.Compress the syringe plunger quickly. B.Select a small-gauge needle. C.Inject the needle at a 90-degree angle. D.Select a small-diameter syringe.

C Rationale: Injecting the needle at a 90-degree angle allows the medication to be injected into the muscle so that appropriate absorption can occur (C). Too rapid injection of the medication (A) may be painful and may cause medication leakage and reduced absorption. (B) will reduce injection discomfort but will not affect absorption. A syringe barrel that is too small (D) increases the pressure during the injection and may traumatize tissue without improving medication absorption.

A client is admitted to a mental health unit because of mild depression. When asked, he denies suicidal ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on aspirin 5 years earlier. Which intervention is most important for the nurse to implement? A.Orient the client to activities on the unit. B.Document suicide precautions on the shift report. C.Assign the client to a semiprivate room. D.Obtain a verbal no-suicide contract with the client.

C Rationale: It is most important to prevent the risk of self-harm from social isolation, so the client should be assigned to a semiprivate room (C). (A) does not have the priority of (C). (B and D) can be implemented if the client admits suicidal ideation. However, based on the fact that this client is mildly depressed and that he attempted suicide 5 years ago using a method that is usually nonlethal (aspirin overdose), it is most important to prevent social isolation.

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

C Rationale: Positioning the patient in a high Fowler's position with dangling feet will decrease further venous return to the left ventricle (C). The other actions should be performed after the change in position (A, B, and D).

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

C Rationale: Primary prevention is aimed at preventing disease or injury. Training rescue workers prior to a disaster is an example of minimizing or preventing injury (C). (A) is an example of secondary prevention. (B) is an example of tertiary prevention. (D) is an example of secondary prevention.

The nurse prepares to administer digoxin, 0.125 mg IV, to an adult client with atrial fibrillation. Which client datum requires the nurse to withhold the medication? A.The apical heart rate is 64 beats/min. B.The serum digoxin level is 1.5 ng/mL. C.The client reports seeing yellow-green halos. D.The potassium level is 4.0 mEq/L.

C Rationale: Reports of yellow-green halos and blurred vision are a sign of digoxin toxicity (C). The others are normal findings (A, B, and C).

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

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

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

C Rationale: Some information, such as a suicide plan, must be shared with other team members for the client's safety and optimal therapy (C). HIPAA does not prevent a member of the health care team from repeating all conversations, particularly if safety is an issue (A). Ensuring a client that a conversation will remain confidential puts the nurse at risk, particularly if safety is an issue (B). Although pertinent information should be documented, the nurse is not legally required to document all conversations with a client (D).

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

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

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

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

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

C Rationale: The normal heart rate for a 6- to 10-year-old is 70 to 110 beats/min (C). The others are all within normal range for those ages (A, B, and D).

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

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

The nurse assesses a pressure ulcer on a client's heel and notes full-thickness tissue loss, with some visible subcutaneous fat. How should the nurse stage this pressure ulcer? A.Stage I B.Stage II C.Stage III D.Stage IV

C Rationale: The statement above describes a stage III ulcer which is defined as full-thickness tissue loss in which subcutaneous fat may be exposed but without exposure of bone, tendon, or muscle (C). A stage I ulcer includes intact skin with nonblanchable redness of a localized area (A). A stage II ulcer is described by partial-thickness loss of dermis, including a shallow open ulcer with a pinkish red wound bed (B). Full-thickness tissue loss with exposed bone, tendon, or muscle and slough or eschar is indicative of a stage IV ulcer (D).

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

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

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

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

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

C Rationale: Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment (C). Distorted color perception (A), opacity of the lens (B), and gradual vision loss (D) are expected signs and symptom of cataracts, but do not need immediate attention.

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

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

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

C. Encourage the client to ambulate every 3 hours. Rationale: 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.

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. A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) Rationale: (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.

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. A client with normal vision can read at 100 feet what this client reads at 20 feet. Rationale: 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.

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. A woman who had a hip replacement and may be transferred to the home care unit Rationale: 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 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. Ask about scrotal pain or blood in the semen. Rationale: 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.

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

C. Breath sounds Rationale: 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.

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. C, B, A, D Rationale: 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).

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. Cover one eye while reading the chart with the other. Rationale: 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).

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. Encourage as much independence in decision making as possible. Rationale: 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.

108. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what? A) Dystonia B) Akathesia C) Brady dysknesia D) Tardive dyskinesia

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

C. Explain the benefits of remaining in the hospital. D. Instruct the client to take medications as prescribed. F. Notify the health care provider of the client's intention. Rationale: 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 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. Inability to flex the chin to the chest Rationale: 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.

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. Individuals interested in having children Rationale: 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 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. Notify the health care provider of the change in mental status. Rationale: 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 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. Obtain a stool specimen for culture and sensitivity Rationale: 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.

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. Offer to develop an alternate solution so that the residents can continue to watch television. Rationale: 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.

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

C. Pain scale measurement Rationale: 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.

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. Position the client who has vomited on his side and obtain vital signs. Rationale: 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.

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. Rest in bed with the head of the bed elevated 20 degrees and flex the knees. Rationale: 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.

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

C. Sending medical records to health care providers via the Internet Rationale: 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.

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. Serum potassium level is 2.5 mEq/L Rationale: 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 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's renal function has affected his potassium level. Rationale: 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.

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. The oral mucosa is pink and intact. Rationale: 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.

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

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

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. When the cervix is completely dilated Rationale: 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).

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 age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. Rationale: 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.

1. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa." D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper."

149. A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not want it." The nurse's best response is A) "This is a common occurrence after birth, but you will come to accept the baby." B) "Many women have postpartum blues and need some time to love the baby." C) "What a beautiful baby! Her eyes are just like yours." D) "You seem upset; tell me what the pregnancy and birth were like for you."

15. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? A) Ask the student: "What did you forget to do?" B) Stop. Tell me why aspiration is needed. C) Loudly state: "You forgot to aspirate." D) Walk up and whisper in the student's ear "Stop. Aspirate. Then inject."

157. The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the mother supports the presence of this problem? A) When I put my finger in the left hand the baby doesn't respond with a grasp. B) My baby doesn't seem to follow when I shake toys in front of the face. C) When it thundered loudly last night the baby didn't even jump. D) When I put the baby in a back lying position that's how I find the baby.

159. The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action? A) Lower extremity pitting edema B) Rales C) Jugular vein distension D) Weakness in left arm

21. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? A) Ask the teenager to wait until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from the partner C) Refer the teenager to a community pediatric hospital emergency department D) Proceed with the triage process in the same manner as any adult client

29. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? A) "I will keep the cast for the next day uncovered to prevent burning of the skin." B) "I can apply an ice pack over the area to relieve itching inside the cast." C) "The cast should be propped on at least 2 pillows when my child is lying down." D) "I think I remember that standing cannot be done until after 72 hours."

31. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness

33. The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self scheduling knowing that this method will A) Improve the quality of care B) Decrease staff turnover C) Minimize the amount of overtime payouts D) Improve team morale

35. The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to A) Walk up to the health care provider and quietly state: "Stop this unacceptable behavior." B) Allow the staff nurse to handle this situation without interference C) Notify the of the other administrative persons of a breech of professional conduct D) Request an immediate private meeting with the health care provider and staff nurse

47. A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem? A) Allergies B) Scabies C) Regression D) Pinworms

55. A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return

56. During the initial home visit a nurse is discussing the care of a newly diagnosed client with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time? A) Leave a book about relaxation techniques B) Write out a daily exercise routine for them to assist the client to do C) List actions to improve the client's daily nutritional intake D) Suggest communication strategies

57. The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to A) Maintain previous calorie intake B) Keep a candy bar available at all times C) Reduce carbohydrates intake to 25% of total calories D) Keep a regular schedule of meals and snacks

6. The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? A) Leave the order for the oncoming staff to follow-up B) Contact the charge nurse for an interpretation C) Ask the pharmacy for assistance in the interpretation D) Call the provider for clarification

66. As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate? A) High doses of aspirin will be continued for some time B) Complete recovery is expected within several days C) Active range of motion exercises should be done frequently D) The measles, mumps and rubella vaccine should be delayed

7. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: A) check the carotid pulse B) deliver 5 abdominal thrusts C) give 2 rescue breaths D) open the client's airway

72. The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate? A) The parents' name and telephone number B) The currency of the immunization and allergy history of the child C) The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance D) The affected child's age and weight

75. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair

8. A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? A) Ask the client if there are any breathing problems B) Have the client void as much as possible C) Check the vital signs D) Auscultate the lungs

81. A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? A) I got back from Central America a few weeks ago. B) I had the best raw oysters last week. C) I have many different sex partners. D) I had a blood transfusion 15 years ago.

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

D Atropine (Isopto Atropine) is a mydriatic drug, which causes pupil dilation and paralysis in preparation for surgery or examination (D). (A, B, and C) do not describe the therapeutic effects of atropine sulfate ophthalmic drops prior to cataract surgery.

The nurse is caring for a client with respiratory distress whose arterial blood gas (ABG) results are as follows: pH, 7.33; Pco2,50 mm Hg; Po2, 70 mm Hg; HCO3, 26 mEq/L. How should the nurse interpret these results? A.Metabolic acidosis B.Respiratory alkalosis C.Metabolic alkalosis D.Respiratory acidosis

D Rationale: A pH <7.25 and Pco2 >45 mm Hg with a normal HCO3 indicates respiratory acidosis (D). The others are incorrect analyses of the ABGs (A, B, and C).

A client comes to the obstetric clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the nurse, "I'm having second thoughts about wanting to have this baby." Which response is best for the nurse to make? A."It's normal to feel ambivalent about a pregnancy when you are not feeling well." B."I think you should discuss these feelings with your health care provider." C."How does the father of your child feel about your having this baby?" D."Tell me about these second thoughts you are having about this pregnancy."

D Rationale: Although ambivalence is normal during the first trimester, (D) is the best nursing response at this time. It is reflective and keeps the lines of communication open. (A) is not the best response because it offers false reassurance. (B) dismisses the client's feelings. The nurse should use communication skills that encourage this type of discussion, not shift responsibility to the care provider. (C) may eventually be discussed, but it is not the most important information to obtain at this time.

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

D Rationale: An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be stopped. The antidote for heparin is protamine sulfate (D). Increasing the rate would increase the risk for hemorrhage (A). The infusion should be stopped, and vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the infusion at the current rate would increase the risk for hemorrhage (C).

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

D Rationale: An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider (D). Digitalis should be held when the heart rate is lower than 60 beats/min (A). The client with heart failure should weigh himself or herself daily and report a gain of 2 to 3 lb (B). An increase in fluid can worsen heart failure (C).

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

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

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

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

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

D Rationale: Maintaining airway during a seizure is priority for safety (D). (A, B, and C) are contraindicated during a seizure and may cause further injury to the client.

A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test results indicate that the medication is producing the desired effect? A.Increased hemoglobin and hematocrit levels B.Increased serum calcium level C.Decreased white blood cell (WBC) count D.Decreased triiodothyronine (T3) and thyroxine (T4) levels

D Rationale: Propylthiouracil (PTU) is an adjunct therapy used to control hyperthyroidism by inhibiting the production of thyroid hormones (D). It is often prescribed in preparation for thyroidectomy or radioactive iodine therapy. It is does not affect (A). (B) must be monitored after surgery in case the parathyroid glands were removed, but preoperative PTU does not increase the serum calcium level. If the client has an infection preoperatively, antibiotics will be given and (C) monitored.

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

D Rationale: Risk assessment for falls is a critical element in caring for the older adult. (A, B, and C) are important components in assessing client risk, but a history of prior falls puts the older client at very high risk for falling again (D).

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

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

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

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

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

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

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

D Rationale: The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings (D). Giving false reassurance or personal suggestions are not therapeutic communication for the client (A, B, and C).

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

D Rationale: The women with epigastric pain should be called first (D). One of the cardinal signs of eclampsia, a life-threatening complication of pregnancy, is epigastric pain. (A, B, and C) are less serious and should be called after (D).

The nurse prepares to administer amoxicillin clavulanate potassium (Augmentin) to a child weighing 15 kg. The prescription is for 15 mg/kg every 12 hours by mouth. How many milliliters should the nurse administer when supplied as below? A.0.5 B.1.8 C.5 D.9

D Rationale:15 mg/kg × 15 kg = 225 mg to be administered Supply = 125 mg/5 mL (5 mL/125 mg) × 225 mg = 9 mL or (225 mg/125 mg) × 5 ml = 9 mL

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

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

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

D. "Did your daughter also start her menstrual period at 12 years of age?" Rationale: 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. "Does anyone in your family have glaucoma?" Rationale: Glaucoma has a definite genetic link, so clients should be screened for a positive family history, especially an immediate family member (D). (A and C) are not related to glaucoma. Glaucoma rarely causes pain (B), which is why screening is so important.

A 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. "Listening to the news seems to be frightening you." Rationale: 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).

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. "Those are Mongolian spots and will gradually fade in 1 or 2 years." Rationale: 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.

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. 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 Rationale: 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.

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. A client with renal calculi whose urine needs to be strained Rationale: 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.

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. A multiparous client who is dilated 5 cm and 50% effaced Rationale: 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.

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

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

A 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. Consult the agency's policies and procedures manual and follow the guidelines. Rationale: 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.

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

D. Continue to monitor the client. Rationale: 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).

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. Continue with current assignments until more instructions are received. Rationale: 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.

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.

D. Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours. Rationale: 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.

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. Face the client and speak in a normal tone of voice. Rationale: 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 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. Inform the client that the scheduled Pap test cannot be done today. Rationale: 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.

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. Offer the client emotional support. Rationale: 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.

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. Old medical records are kept in a locked file cabinet in the department. Rationale: 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).

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. Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. Rationale: 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 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. Place trochanter rolls on the lateral aspects of the client's thighs. Rationale: 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.

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. Serum sodium level of 137 mEq/L Rationale: 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 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. Sitting upright and forward with both arms supported on an over the bed table Rationale: 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.

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. The drug is hepatotoxic and contraindicated Rationale: 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 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 effects of this drug tend to decrease after 3 months. Rationale: 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.

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 ventilator setting for respiratory rate and the client-initiated respirations Rationale: 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)

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

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

Rationale: Two-hour postprandial levels greater than 120 mg/dL may indicate the need for the initiation of insulin to maintain adequate blood glucose levels; consequently, a value greater than 120 mg/dL (B) should be assessed further. Fasting blood sugars between 80 and 85 mg/dL are normal (A). (C and D) are healthy behaviors for a women with gestational diabetes.

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