Hesi level 2 (Nsg 170)

Which social detriment has shown to increase the rate of teen pregancies in a community? A. Poverty. B. Age. C. Culture. D. Ethnicity.

A. Poverty A social detriment of health that influences the teen pregnancy rate is poverty. One-third of pregnant teenagers come from a low socioeconomic background regardless of ethnicity. Other risk factors for teen pregnancy rates include education, social support systems, and living environment.

The nurse is evaluating a 20-month-old child with mild fluid volume deficit. Which intervention should the nurse implement to best evaluation the toddler? A. Weigh diapers. B. Assess anterior fontanel. C. Palpate posterior fontanel. D. Check skin turgor.

A. Weigh diapers Diaper weight in grams converted to ml (1 gram = 1 mL) provides the most accurate output, which is used to calculate fluid volume deficit in infants and toddlers.

An adult client is given a prescription for a scopolamine patch (Transderm Scop) to prevent motion sickness while on a cruise. Which information should the nurse provide to the client? A. Apply the patch at least 4 hours prior to departure. B. Change the patch every other day while on the cruise. C. Place the patch on a hairless area at the base of the skull. D. Drink no more than 2 alcoholic drinks during the cruise.

A) Apply the patch at least 4 hours prior to departure. Scopolamine, an anticholinergic agent, is used to prevent motion sickness and has a peak onset in 6 hours, so the client should be instructed to apply the patch at least 4 hours before departure (A) on the cruise ship. The duration of the transdermal patch is 72 hours, so (B) is not needed. Scolopamine blocks muscarinic receptors in the inner ear and to the vomiting center, so the best application site of the patch is behind the ear, not at the base of the skull (C). Anticholinergic medications are CNS depressants, so the client should be instructed to avoid alcohol (D) while using the patch.

A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide? A. Estrogen deficiency causes the vaginal tissues to become dry and thinner. B. Infrequent intercourse results in the vaginal tissues losing their elasticity. C. Dehydration from inadequate fluid intake causes vulva tissue dryness. D. Lack of adequate stimulation is the most common reason for dyspareunia.

A) Estrogen deficiency causes the vaginal tissues to become dry and thinner. Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells, so vaginal tissues tend to become thinner, drier (A), and the rugae become smoother which reduces vaginal stretching that contributes to dyspareunia. Dyspareunia is not related to (B or C). While (D) can contribute to discomfort during intercourse, the primary cause is hormone-related.

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension.

A) Inquire about the source and type of pain Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain (A). (B, C, and D) are important, but do not focus on "miseries" (pain).

The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? A. She sustained an insect bite to her left arm yesterday. B. She has lost twenty pounds since the surgery. C. Her healthcare provider now prescribes a calcium channel blocker for hypertension. D. Her hobby is playing classical music on the piano.

A) She sustained an insect bite to her left arm yesterday. A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema (A). (B) is not a factor. Lymphedema is not significantly related to vascular circulation (C). Only overuse of the arm, such as weight-lifting, would cause lymphedema--(D) would not.

While caring for a child and mother from Cambodia, what action should the nurse implement to accommodate the clients' cultural needs? A. Speak initially with the oldest family member to show respect. B. Realize that Southeast Asians may not take Western medications. C. Ask the husband to step out during the mother's pelvic examination. D. Tell the family that planning health care is provided in private with the client.

A) Speak initially with the oldest family member to show respect. Members of the Asian culture have high respect for others, especially those in positions of authority. Extended family members need to be included in the nursing care plan (A). Southeast Asians do not necessarily refuse Western medications (B). Asians also believe that touching strangers is not acceptable, particularly health professionals whom they have not previously known, so the husband should be allowed to remain with his wife during the pelvic exam (C). Provided that the presence of other family members is not harmful to the client's well-being, (D) is not correct.

The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia? A. Sweating, trembling, tachycardia. B. Polyuria, polydipsia, polyphagia. C. Nausea, vomiting, anorexia. D. Fruity breath, tachypnea, chest pain.

A) Sweating, trembling, tachycardia. Sweating, dizziness, and trembling are signs of hypoglycemic reactions related to the release of epinephrine as a compensatory response to the low blood sugar (A). (B, C, and D) do not describe common symptoms of hypoglycemia.

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

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

A 17-year-old unmarried, pregnant client with drug addiction is a high school dropout, homeless, and has a history of past abuse arrives at the clinic for her first prenatal visit. Which findings should the nurse document as health risk factors for the client? (Select all that apply.) A.Age. B.Drug addiction. C.History of abuse. D.Pregnancy. E.Homelessness. F.Unmarried.

A, B, C, D, E Health risk factors for this client include age, drug addiction, pregnancy, history of abuse and homelessness. Each factor should be considered individually. The client, as an adolescent mother, is at high risk for nutritional deficits, anemia, gestational diabetes and hypertension, which also impact the fetus' risk for small for gestational age, fetal anomalies, and fetal demise.

The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What actions should the nurse implement prior to assisting the client to the chair? (Select all that apply.) A. Pre-medicate the client with an analgesic. B. Inform the client of the plan for moving to the chair. C. Obtain and place a portable commode by the bed. D. Ask the client to push the IV pole to the chair. E. Clamp the indwelling catheter. F. Assess the client's blood pressure.

A, B, D Pre-medicating the client with an analgesic reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair and encourage the client to participate by pushing the IV pole when walking to the chair. The nurse should assess the client's blood pressure prior to mobilization, which can cause orthostatic hypotension.

The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) A. Nail polish. B. Hearing aid. C. Wedding band. D. Left leg brace. E. Contact lenses. F. Partial dentures.

A, B, E, F The removal of nail polish provides a more accurate pulse oximetry readings and evaluation of capillary refill. Hearing aids, contact lenses, and partial dentures are removed to prevent damage, loss or misplacement, or injury during surgery. Ideally, give the client's significant other the contact lenses if they are not the disposable ones, hearing aids and partial dentures once placed in an appropriate labeled container to hold for safe keeping. If no significant other is not able to hold onto the items, then secured them in an appropriate and safe place.

The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the nurse document that are consistent with diminished peripheral circulation? (Select all that apply.) A. Diminished hair on legs. B. Bruising on extremities. C. Skin cool to touch. D. Capillary refill less than 3 seconds. E. Darkened skin on extremities.

A, C Diminished hair on the legs and skin that is cool to touch are symptoms of decreased arterial blood flow. The other choices are not indicators for impaired peripheral circulation.

Which side effects should the nurse monitor for a client who is receiving dexamethasone (Decadron) following neurosurgery? (Select all that apply.) A. Mood swings. B. Decreased appetite. C. Increased weight gain. D. Serum glucose level of 65 mg/dl. E. Delayed incisional wound healing. F. Serum hemoglobin level of 9 mg/dl.

A, C, E, F Dexamethasone (Decadron) is a long-acting glucocorticoid prescribed for neurosurgical procedures because it suppresses inflammation and has a low sodium-retaining ability, which is important in averting cerebral edema. However though the medication does produce the following side effects such as: mood swings; an increase in appetite, resulting in weight gain; hyperglycemia (serum glucose level above 120 mg/dl) which is related to the gluconeogenesis properties of corticosteroids; delayed in wound healing related to immune suppression properties; and complete blood count resulting in a decreased in WBC and hemoglobin (less than 12mg/dl). When a client is receiving dexamethasone, they should be monitor for these side effects.

In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) A. Set the infusion pump to infuse the albumin within four hours. B. Compare the client's blood type with the label on the albumin. C. Assign a UAP to monitor blood pressure q15 minutes. D. Administer through a large gauge catheter. E. Monitor hemoglobin and hematocrit levels. F. Assess for increased bleeding after administration.

A, D, E, F Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded. Albumin administration does not require blood typing. Vital signs should be monitored periodically to assess for fluid volume overload. A large gauge catheter allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB and HCT levels should be monitored. While monitoring for bleeding because of the increased blood volume and blood pressure.

What information should the nurse include in a teaching plan about the onset of menopause? (Select all that apply). A. Smoking. B. Oophorectomy with hysterectomy. C. Early menarche. D. Cardiac disease. E. Genetic influence. F. Chemotherapy exposure.

A,B, C, E Menopausal symptoms are related to the cessation of ovarian function. Factors influencing the onset of menopause include smoking, genetic influences, early menarche, surgical removal, and exposure to chemotherapy agents and radiation. Cardiovascular disease is unrelated.

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? A. "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue." B. "We want your baby to be healthy, and this is the only way we can make sure that will happen." C. "I know you're upset. Would you like to talk about some things you could do while in bed?" D. "Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties."

A. "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue." The healthcare provider prescribed activity restriction and complete bedrest to this client in order to help preserve cardiac reserves.

The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for testicular cancer. Which statement indicates that the client understands his postoperative care and prognosis? A. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." B. "I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle." C. "I should always use a condom because I am at increased risk for acquiring a sexually transmitted disease." D. "I should make sure my sons know how to perform TSE because they are at increased risk for this type of cancer."

A. "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining testicle, so early recognition is the best prevention. The client's understanding is reflected in the statement to perform monthly TSE for changes in size, shape, or consistency of the testis that may indicate early cancer.

Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy? A. "Protein helps the fetus grow while I am pregnant." B. "Gestational diabetes is prevented by eating protein." C. "Anemia is averted by consuming enough protein." D. "My baby will develop strong teeth after he is born."

A. "Protein helps the fetus grow while I am pregnant." Adequate protein intake is essential to meet increasing demands of rapid growth of the fetus and maternal changes during pregnancy, such as enlargement of the uterus, mammary glands, and placenta, increase in the maternal blood volume, and formation of amniotic fluid. Protein is essential for anabolism, but its consumption does not prevent gestational diabetes. Iron found in high protein foods, such as meat, helps prevent anemia, but the basic need for protein is the anabolic growth processes of the fetus. Although calcium is needed for fetal bone and teeth development, it is not found in all protein food sources.

The nurse is admitting a client diagnosed with hyperosmolar hyperglycemic state (HHS) who is severely dehydrated. The client's vital signs are blood pressure 78/46 mmHg, pulse 130 beats/minute, respirations 22 breaths/minute, CVP 6, and MAP 58. Which intravenous solution should the nurse expect to administer to this client? A. 0.9% sodium chloride (normal saline). B. 0.45% sodium chloride (1/2 normal saline). C. 5% dextrose in lactated ringers (D5LR). D. 5% dextrose in 0.45% sodium chloride (D5 ½NS).

A. 0.9% sodium chloride (normal saline). The client is demonstrating a sign of hypovolemic shock, the fluid of choice for fluid replacement is 0.9% sodium chloride (normal saline) with an initial bolus of one (1) liter of normal saline to replace the extracellular fluid volume deficit.

The nurse is caring for a young adult who is having an oral glucose tolerance tests (OGTT). Which laboratory result should the nurse assess as a normal value for the two hour postprandial result? A. 140 mg/dl. B. 160 mg/dl. C. 180 mg/dl. D. 200 mg/dl.

A. 140 mg/dl. The two hour postprandial level should be less 140 mg/dl for a young adult client.

A client with diabetes mellitus asks the nurse how many grams of carbohydrates can be consumed each day if the healthcare provider prescribes a 2000 calorie diet. What answer should the nurse provide? A. 250 grams. B. 300 grams. C. 350 grams. D. 200 grams.

A. 250 grams According to the American Diabetes Association, carbohydrates should be 50% of daily intake. Carbohydrates provide 4 calories/gram, so a 2000 calorie per day diet should include 1000 calories from carbohydrates, or 250 grams (1000 calories :: 4 calories/1 gram = 250 grams).

The nurse is teaching a male adolescent and his family about receiving injections of growth hormone for idiopathic hypopituitarism. Which information should the nurse plan to discuss with the adolescent and his family? A. Administration at bedtime. B. Lethargy and fatigue requiring hospitalization. C. Increased facial hair. D. Weight and height measured on awakening.

A. Administration at bedtime. Growth hormone (GH), somatotropin hormone STH), is produced by the anterior pituitary gland, which normally releases GH during the first 45-90 minutes after the onset of sleep. The nurse should explain that the most effective time to administer GH is at bedtime.

A low-birth-weight newborn with an abdominal skin temperature of 97.7oF (36.5oC) requires a neutral thermal environment. What action should the nurse implement to reduce the risk of cold stress? A. Apply warmed blankets that are stored in a warmer. B. Keep disposable diapers under the warming lights. C. Maintain a low-humidity atmosphere. D. Use humidified oxygenation via a hood.

A. Apply warmed blankets that are stored in a warmer. A neutral thermal environment provides adequate warmth for a newborn to maintain a normal temperature that minimizes oxygen consumption and calorie expenditure. Low-birth-weight infants are especially vulnerable to temperature instability and cold stress. Placing warmed blankets that are stored in a warmer help to decrease conductive heat loss and minimize the risk of cold stress.

A female client visits the clinic stating she had a positive result on a home pregnancy test. The first day of her last period was July 13. What is the estimated date of birth? A. April 20. B. October 20. C. January 16. D. December 10.

A. April 20. Naegele's rule estimates expected delivery dates by subtracting 3 months and adding 7 days from a client's last menstrual period. If the first day of the last period was July 13, the client is due April 20.

Which strategy should the nurse suggest when counseling a client with obesity about modifying food behaviors? A. Avoid driving past favorite food places. B. Eat from a larger plate during meals. C. Limit food treats to twice every week. D. Diminish the social aspect of eating.

A. Avoid driving past favorite food places. Strategies for changing food behaviors that lead to excess body fat include minimizing situations that are associated with problem foods, putting temptation out of reach, and making the problem behavior as difficult as possible to perform. The client should avoid driving past favorite food spots to help minimize cues that lead to problematic behavior.

An adolescent female reports to the nurse that she is experiencing a glutinous, gray-white vaginal discharge. A vaginal smear reveals no infectious organism in the sample. Which information should the nurse provide? A. Avoid use of deodorant tampons. B. Stop taking any current antibiotics. C. Begin to douche with vinegar solution BID. D. Use an over-the-counter sexual barrier.

A. Avoid use of deodorant tampons. Leukorrhea, a glutinous, gray-white discharge, is often caused by physical, chemical or infectious agents. Removal of the irritant is usually all that is necessary to reduce symtoms. The nurse should recommend that the client stop using deodorant tampons or bubble baths, that cause vaginal irritation.

A client is admitted to the intensive care unit with asthma and an upper respiratory infection. The client is experiencing severe bronchospasms and develops status asthmaticus. Which prescription should the nurse administer first? A. Beta 2-antagonist. B. Antihistamine. C. Decongestant. D. IV antibiotics.

A. Beta 2-antagonist. Beta2-antagonists and corticosteroids are used to treat status asthmaticus. Beta2-antagonists facilitate smooth muscle relaxation, while steroids decrease inflammation of the airways and enhance the effects of beta2-antagonists.

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? A. Between the time the temperature falls and rises. B. Between 36 and 48 hours after the temperature rises. C. When the temperature falls and remains low for 36 hours. D. Within 72 hours before the temperature falls.

A. Between the time the temperature falls and rises. In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone making between the time of the temperature fall and rise is the best time to try to conceive.

A male client comes into the clinic with a history of penile discharge with painful, burning unirnation. Which action should the nurse implement? A. Collect a culture of the penile discharge. B. Palpate the inguinal lymph nodes gently. C. Observe for scrotal swelling and redness. D. Express the discharge to determine color.

A. Collect a culture of the penile discharge Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of the penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed through culture to identify the organism and ensure effective treatment.

The nurse is caring for a client who has recently immigrated into the country. Which factor should the nurse consider when providing care? A. Cultural changes may be difficult for the client. B. The client desires to adapt to the new culture. C. The client views their cultural differences as abnormal. D. Information may be given to help the client adapt to the new culture.

A. Cultural changes may be difficult for the client. Providing culturally competent care includes the understanding of the characteristics of culture. It is important for the nurse to recognize that cultural changes may be difficult for the client to make. Care should be designed around the client's culture as long as it is not detrimental to the client's health.

A preschool-aged child who speaks Spanish is starting kindergarten in an English-speaking school. The child cries most of the time, appears helpless, and is unable to function in the new situation. What nursing diagnosis should the nurse include in the plan of care for this child? A. Culture shock secondary to unfamiliar environment. B. Growth and development, impaired. C. Cultural incompetence due to inability to adjust. D. Defiance behavior as evidenced by outbursts of crying.

A. Culture shock secondary to unfamiliar environment A child who experiences a language barrier is unable to communicate in the spoken language in school and may lack the skills necessary to participate. Culture shock describes feelings of discomfort, disorientation, fears, and stress when adapting to new cultural settings.

Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation? A. Decrease in pulse rate. B. Decrease in blood pressure. C. Increase in heart sounds (S1, S2). D. Increase in red blood cell production.

A. Decrease in pulse rate.

The nurse is caring for a client who is demonstrating signs of impending death. The family is experiencing emotional distress as the client's condition declines. Which information should the nurse provide the family to facilitate the process? A. Encourage the family to give the client permission to die. B. Revoke the "do not resuscitate" advanced directive. C. Send the family to an area to seek spiritual comfort. D. Give the client pain medication during the end of life hours.

A. Encourage the family to give the client permission to die. Family members often have difficulty letting go of a dying family member. The nurse should encourage the family to give the client permission to die.

Which items should the nurse include when developing a daily meal plan for a client with hypertension? A. Five servings of vegetables. B. Nine servings of fruit. C. Four servings of dairy. D. Two servings of whole grains.

A. Five servings of vegetables When developing a daily meal plan for a client with hypertension, the nurse should include four to five servings of vegetables in the client's meal plan as recommended by the National Institutes of Health in the Dietary Approaches to Stop Hypertension (DASH) diet. The DASH diet is recommended to prevent and control hypertension.

The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition? A. Gestational diabetes. B. Elevated blood pressure. C. Urinary tract infection. D. Swelling in lower extremities.

A. Gestational diabetes The nurse should evaluate the client for gestational diabetes because terbutaline (Brethine) increases blood glucose levels.

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? A. Have the client empty her bladder. B. Request the client lie on her left side. C. Perform Leopold's maneuvers first. D. Give the client some cold juice to drink.

A. Have the client empty her bladder Bladder must be empty to accurately measure fundal height

The nurse caring is caring for a client with advanced metastatic cancer that has not responded to treatment. The healthcare provider prescribes palliative care only. Which intervention should the nurse withhold? A. Intubation with mechanical ventilation. B. Around-the-clock pain medication. C. Regular diet as tolerated. D. Bronchodilators for shortness of breath.

A. Intubation with mechanical ventilation. Palliative care provides clients with comfort measures as they near the end of life. When the healthcare provider prescribes palliative care only, the nurse should withhold life-saving interventions, such as intubation with mechanical ventilation.

Which information should the nurse provide when teaching a client with diabetes about the role of glucose in the body? A. It provides energy for cells. B. It synthesizes proteins. C. It stimulates osteogenesis. D. It exacerbates cachexia.

A. It provides energy for cells. Normal control mechanisms ensure sufficient circulating blood glucose to meet the body's constant energy needs (including basal metabolic energy needs during sleep) because glucose is the body's preferred fuel. Under normal conditions, the body converts glucose to adenosine triphosphate (ATP), which provides the energy needed for the body's metabolic processes.

A client with diabetic ketoacidosis is admitted to the intensive care unit and is manifesting respirations that are rapid and deep. Which descriptive term should the nurse use to document the client's breathing pattern? A. Kussmaul respirations. B. Cheyne stokes respirations. C. Apnea. D. Orthopnea.

A. Kussmaul respirators Metabolic acidosis in DKA causes compensatory responses to increase the blood pH which results in Kussmaul respiration in a effort to blow off CO2 and adjust blood pH. The nurse should document the client's respiratory rate and Kussmaul respiratory pattern.

After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. Which action should the nurse implement? A. Notify the surgeon that the consent form has not been signed. B. Read the consent form to the client before witnessing the client's signature. C. Determine if the client's spouse is willing to sign the consent form. D. Administer an opioid antagonist prior to obtaining the client's signature.

A. Notify the surgeon that the consent form has not been signed. Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon.

On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. What would be this client's expected date of delivery (EDD)? A. November 22. B. November 8. C. December 22. D. October 22.

A. November 22 November 22 is the answer. The nurse correctly applied Nägele's rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15+7=22).

Which information should the nurse provide clients about the advantages of an organic diet? A. Organic food is produced without using harmful chemicals. B. Organic foods are easier to prepare than regular foods. C. All populations have easy access to organic foods. D. Food produced by organic farming is more nutrient-dense.

A. Organic food is produced without using harmful chemicals. Organic farming is on the rise across the globe. Organic foods are grown without adding harmful chemicals such as synthetic pesticides and fertilizers

A client placed on hospice care is admitted for palliative radiation treatments to the neck. Which assessment should the nurse identify as a priority? A. Pain assessment. B. Respiratory assessment. C. Cardiovascular assessment. D. Integumentary assessment.

A. Pain assessment. Frequent pain assessments are the most important interventions in delivering end-of-life care for a client. The goal of end-of-life treatment is to manage a client's symptoms to provide a pain-free and stress-free environment to improve a client's quality of life.

Which signs and symptoms are associated with arterial insufficiency? A. Pallor, intermittent claudication. B. Pedal edema, brown pigmentation. C. Blanched skin, lower extremity ulcers. D. Peripheral neuropathy, cold extremities.

A. Pallor, intermittent claudication. Pallor and intermittent claudication are signs related to stage II of peripheral vascular disease, which results in arterial insufficiency

A healthcare provider prescribes cefadroxil (Duricef) for a client with a postoperative infection. It is most important for the nurse to assess for what additional drug allergy before administering this prescription? A. Penicillins. B. Aminoglycosides. C. Erythromycins. D. Sulfonamides.

A. Penicillins Cross-allergies exist between penicillins and cephalosporins, such as cefadroxil (Duricef), so checking for penicillin allergy is a wise precaution before administering this drug.

The nurse is interviewing a female client who states she has a persistent productive cough during the winter caused by bronchitis. Which additional finding should the nurse assess for bronchitis? A. Phlegm production and wheezing. B. Smoking history. C. Hemoptysis. D. Night sweats.

A. Phlegm production and wheezing. A chronic seasonal cough related to bronchitis is likely accompanied with phlegm production and wheezing. Although smoking can contribute to a chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes.

The nurse reports findings to the healthcare provider for a client who is admitted to the intensive care unit today with chronic obstructive pulmonary disease (COPD). When the nurse completes the report using the SBAR format, which statement best supports the nurse's reason for calling the healthcare provider? A. Prescription for an additional respiratory treatment. B. Admission today with difficulty breathing. C. History of COPD. D. Presence of expiratory wheezes in the lower lobes.

A. Prescription for an additional respiratory treatment. The SBAR reporting format uses client information that includes the Situation, Background, Assessment, Recommendation. The nurse should complete the report with a recommendation, such as a prescription for an additional breathing treatment.

A school-aged boy with a chronic disability frequently cries about being different from siblings. The child often wants others to do things for him that he is capable of doing for himself. Which intervention should the nurse implement to best motivate the child and normalize activities of daily living? A. Recommend the family redirect the behavior to a "you can do it" attitude. B. Encourage the parents to role model ways to act when one is disappointed. C. Suggest that all the children are included in family decision making. D. Evaluate the proper use of equipment that is provided to improve the child's lifestyle.

A. Recommend the family redirect the behavior to a "you can do it" attitude. Focusing on the child, and not the condition, is essential in assisting the child to adapt to a chronic disability or illness. The goal is to assist the child to compensate for any disability and emphasize consistent expectations of acceptable behavior.

The nurse is caring for a premature infant who needs an IV access restarted. What action should the nurse take to remove the transparent adhesive film dressing? A. Remove the adhesive dressing with water, mineral oil, or petrolatum. B. Change the adhesive dressing daily and PRN if edge is loose. C. Use scissors to release the edge and remove the adhesive dressing. D. Grasp the adhesive dressing edge and peel off in one direction.

A. Remove the adhesive dressing with water, mineral oil, or petrolatum. The use of adhesives should be minimized as much as possible in pre-term neonates due to fragile skin that tears easily. The nurse should remove the adhesive dressing using small amounts of water, mineral oil, or petrolatum that is applied with a small cotton tipped applicator.

A client is brought to the Emergency Center after a snow-skiing accident. Which intervention is most important for the nurse to implement? A. Review the electrocardiogram tracing. B. Obtain blood for coagulation studies. C. Apply a warming blanket. D. Provide heated PO fluids.

A. Review the electrocardiogram tracing. While airway, breathing, and circulation are priorities in client assessment and treatment, continuous cardiac monitoring is also indicated because hypothermic clients have an increased risk for dysrhythmias.

A client calls the clinic and states that she forgot to take her oral contraceptives for the past two days. Which instruction is best for the nurse to provide to this client? A. Take 2 pills a day for 2 days and use an alternate method of contraception for 7 days. B. Quit the pills for this cycle, use an alternate method of contraception, and resume pills on the fifth day of menstruation. C. Take one extra pill per day for the rest of this cycle, then resume taking pills as usual next cycle. D. Take 4 pills now and use an alternate method of contraception for the rest of this cycle.

A. Take 2 pills a day for 2 days and use an alternate method of contraception for 7 days. If two pills are missed in a roll, the client should take 2 pills a day for two days and used an alternative form of birth control for seven days.

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.

A. The client voluntarily signed the form. (The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client signature is authentic, and that the client is otherwise competent to give consent. It is the HCP responsibility to ensure the client fully understands the procedure.)

A male client who is in the terminal stage of cancer is cared for at home by his family and receives a prescription for morphine at a rate to control intractable pain. When the hospice nurse visits, the client awakens, moans in severe pain, and asks for an increase in the morphine dosage. After determining the client's respirations are 10 breaths per minute, what is the best action for the nurse to implement? A. Titrate the morphine dose upward until the client has adequate pain relief. B. Suggest to the family that they can also give the client ibuprofen, a non-narcotic analgesic. C. Hold additional morphine until the client's respirations are at least 16 per minute. D. Inform the client that an increased dose of morphine increases side effects without additional pain control.

A. Titrate the morphine dose upward until the client has adequate pain relief Tolerance can occur in a client who requires large doses of opioids for intractable pain management, and an increased titration of the analgesic or an additional drug in the same or a different classification may provide more effective pain management. The client's basic need for comfort during the last stages of a terminal malignancy is the main priority for this hospice client.

The nurse is preparing to teach a community prenatal class about transplacental infections. Which infection should the nurse include in the presentation? A. Toxoplasmosis. B. Group B streptococcus. C. Chlamydia. D. Herpes simplex virus.

A. Toxoplasmosis Toxoplasmosis is a vertically transmitted infection that passes from the mother to the fetus through the placenta.

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs at what time? A. Two weeks before menstruation. B. Immediately after menstruation. C. Immediately before menstruation. D. Three weeks before menstruation.

A. Two weeks before menstruation. Because menstruation varies for many women, the nurse should explain that ovulation occurs 14 days before the first day of the menstrual period.

The nurse is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the nurse that the client is stabilizing? A. Urine output of 40 mL/hour. B. Apical pulse 100 and blood pressure 76/42. C. Urine specific gravity 1.001. D. Tented skin on dorsal surface of hands.

A. Urine output of 40 mL/hour. A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal range, 40 mL/hour, the client's kidneys are perfusing adequately and indicates the client's status is stablizing.

A client comes to the clinic with a report of fever and a recent exposure to someone who was diagnosed with meningitis. Which nursing assessment should be completed during the initial examination of this client? A. Level of consciousness. B. Gait characteristics. C. Presence of trauma. D. Bladder control ability.

A. level of consciousness Initial symptoms of meningitis include headache, fatigue, stiff neck, and changes in level of consciousness. It is necessary to determine if the client is demonstrating signs of meningitis before planning immediate care.

The nurse is giving a liquid iron preparation to a 3-year-old child. Which technique should the nurse implement to engage the child's cooperation? A. Use a colorful straw. B. Mix the medication in water. C. Administer the medication using an oral syringe. D. Ask the pharmacy to provide an enteric tablet.

A. use a colorful straw A liquid iron preparation administered through a straw may help the child to accept the medication since young children consider drinking from a colorful straw fun. (B) may cause staining of the child's teeth. (C) is often used if the child is uncooperative. (D) is ineffective and should be requested from the healthcare provider.

A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the birth? A.Ask the family if they would like to see and hold the infant after birth. B.Inquire if the parents want a picture taken after the infant is born. C.Discuss with the parents which funeral home should be notified. D.Find out if the client has a special outfit for the infant after the birth.

A.Ask the family if they would like to see and hold the infant after birth. Interventions and support from the nursing staff during a prenatal loss are extremely important in the grief process and healing of the parents. Research had shown it is most helpful for a mother and father to see and hold their deceased infant after delivery, so the parents should be given this opportunity initially after birth. The other actions should be done after determining the parents' wishes and providing the opportunity for bonding and closure with their infant.

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8 weeks' gestation. What type of emotional response should the nurse anticipate? A.Grief related to her perceptions about the loss of this child. B.Relief of ambivalent feelings experienced with this pregnancy. C.Shock because she may not have realized that she was pregnant. D.Guilt because she had not followed her healthcare provider's instructions.

A.Grief related to her perceptions about the loss of this child. Clients can experience grief/loss response at all stages of pregnancy loss.

When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? A.Place a small book or magazine on the abdomen and make it rise while inhaling deeply. B.Purse the lips while inhaling as deeply as possible and then exhale through the nose. C. Wrap a towel around the abdomen and push against the towel while forcefully exhaling. D. Place one hand on the chest, one hand the abdomen and make both hands move outward.

A.Place a small book or magazine on the abdomen and make it rise while inhaling deeply. Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation, so placing a book or magazine, helps the client visualize the rise and fall of the abdomen.

The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system complication should the nurse include in the teaching? A. Altered sexual response. B. Sterility. C. Urinary incontinence. D. Decreased pelvic muscle tone.

A: Altered sexual response. Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing of the arteries and reduced blood flow to the extremities. PAD is known to alter the blood flow to the male's penis and is associated with erectile dysfunction in men.

Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)? A. Obtain a prescription for an adjusted dose of insulin. B. Administer an oral anti-diabetic agent. C. Give an insulin dose using parameters of a sliding scale. D. Withhold insulin while the client is NPO.

A: Obtain a prescription for an adjusted dose of insulin. Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin.

An adolescent female is taking oral doxycycline (Vibramcyin) for acne vulgaris. What instruction should the nurse include in the client's teaching plan? A. Avoid sunscreen to prevent skin irritation. B. Cleanse the skin at least 4 times a day. C. Take the medication with food. D. Monitor menstrual cycle for irregularity.

C. Take the medication with food Photosensitivity and sunburn are common side effects of doxycycline, which can also cause significant gastrointestinal distress. Clients should be instructed to take the medication with food to minimize GI distress.

The nurse is caring for an Asian client who refuses to make eye contact during conversations. How should the nurse assess this client's response? A. The client cannot understand the nurse. B. The client is uncomfortable with the nurse. C. The client is treating the nurse with respect. D. The client is purposefully disrespecting the nurse.

C. The client is treating the nurse with respect. In some Asian cultures, it is not appropriate to look a person of authority in the eye, so the client is being respectful by looking down while speaking with the nurse.

Which client finding should the nurse document as a positive sign of pregnancy? A. Last menstrual cycle occurred 2 months ago. B. A urine sample with a positive pregnancy test. C. Presence of Braxton Hicks contractions. D. Fetal heart tones (FHT) heard with a doppler.

D. Fetal heart tones (FHT) heard with a doppler Fetal heart tones are a positive sign of pregnancy because these signs are attributed to the presence of a fetus.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.

B) A decreased flow rate could result in the formation of a thrombosis Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration

A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain? A. Amount of weight gain or weight loss during the previous year. B. An accurate menstrual cycle diary for the past 6 to 12 months. C. Skin pigmentation and hair texture for evidence of hormonal changes. D. Previous birth-control methods and beliefs about the calendar method.

B) An accurate menstrual cycle diary for the past 6 to 12 months. The fertile period, which occurs 2 weeks prior to the onset of menses, is determined using an accurate record of the number of days of the menstrual cycles for the past 6 months, so it is most important to emphasize to the client that accuracy and compliancy of a menstrual diary (B) is the basis of the calendar method. (A and C) may be partially related to hormonal fluctuations but are not indicators for using the calendar method. (D) may demonstrate client understanding and compliancy but is not the most important aspect.

The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note? A. A history of obesity. B. An allergy to sulfa drugs. C. Cessation of smoking three years ago. D. Numbness in the soles of the feet.

B) An allergy to sulfa drugs. An allergy to sulfa drugs may make the client unable to use some of the most common antihyperglycemic agents (sulfonylureas). The nurse needs to highlight this allergy for the healthcare provider. (A) is common and warrants counseling, but does not have the importance of (B). (C) does increase the risk for vascular disease, but it is not as important to the treatment regimen as (B). Diabetic neuropathy, as indicated by (D), is common with diabetics, but when the serum glucose is decreased, new onset numbness can possibly improve.

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

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

A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? A. Frequent urinary tract infections. B. Inability to get pregnant. C. Premenstrual syndrome. D. Chronic use of laxatives.

B) Inability to get pregnant. Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility (B) is another common finding associated with endometriosis. Although (A, C, and D) are common, nonspecific gynecological complaints, the most common complaints of the client with endometriosis are pain and infertility.

A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide? A. "Check it again in one month, and if it is still there schedule an appointment." B. "Most lumps are benign, but it is always best to come in for an examination." C. "Try not to worry too much about it, because usually, most lumps are benign." D. "If you are in your menstrual period it is not a good time to check for lumps."

B) Most lumps are benign, but it is always best to come in for an examination. (B) provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem. (A) postpones treatment if the lump is malignant, and does not relieve the client's anxiety. (C and D) provide false reassurance and do not help relieve anxiety.

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

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

A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) A.Marijuana cigarettes do not affect sperm count. B.Alcohol consumption can cause erectile dysfunction. C.Low testosterone levels affect sperm production. D.Cessation of smoking improves general health and fertility. E.Obesity has no effect on sperm production.

B, C, D Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected by low testosterone levels and obesity.

The nurses determines a client's IV solution is infusing at 250 mL/hr. The prescribed rate is 125 mL/hr. What action should the nurse take first? A. Determine when the IV solution was started. B. Slow the IV infusion to keep vein open rate. C. Assess the IV insertion site for swelling. D. Report the finding to the healthcare provider.

B. Slow the IV infusion to keep vein open rate. The nurse should first slow the IV flow rate to keep vein open (KVO) rate to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started and the appearance of the IV insertion site before contacting the healthcare provider for further instructions.

Which statement by a client warrants further instruction by the nurse about the changing insulin needs of a diabetic client during pregnancy? A. "Episodes of hypoglycemia are more likely to occur during the first 3 months." B. "I will increase my insulin dosage by 5 units each month during the first trimester." C. "Insulin dosage will likely need to be increased during the second and third trimesters." D. "Breastfeeding will decrease my insulin needs to lower than my prepregnancy levels."

B. "I will increase my insulin dosage by 5 units each month during the first trimester." Insulin needs during pregnancy are determined individually according to the client's glucose levels. Insulin needs in the first trimester may actually decrease, so the client's statement about increasing her insulin dose, indicates the need for reteaching

A client who is 5 foot 5 inches (165 cm) tall and weighs 200 pounds (90.9 kilograms) is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment? A. "What is your daily calorie consumption?" B. "What vitamin and mineral supplements do you take?" C. "Do you feel that you are overweight?" D. "Will a clear liquid diet be okay after surgery?"

B. "What vitamin and mineral supplements do you take?" In the preoperative assessment, the nurse should assess the client's use of vitamin and mineral supplements. These products may impact medications used during the operative period. The nature of the surgery and anesthesia will determine the need for a clear liquid diet, rather than the client's preference. Addressing long-term diet therapy is best done after surgery and recovery.

The healthcare provider prescribes furosemide (Lasix) 15 mg IV STAT for a client. On hand is an ampoule labeled, furosemide (Lasix) 20 mg/2mL. How many milliliters should the nurse administer? A. 1 mL B. 1.5 mL C. 1.75 mL D. 2 mL

B. 1.5 mL The correct calculation: Dosage on hand/amount on hand = Dosage desired/X amount. 20 mg : 2 mL = 15 mg : X 20X = 30 X = 30/20 = 1 1/2 or 1.5 mL

A client is to receive an IV of Sodium Chloride 0.9% injection (Normal Saline) 250 mL with KCl 10 mEq IV over 4 hours. What rate should the nurse program the client's IV infusion pump? A. 13 mL/hour. B. 63 mL/hour. C. 80 mL/hour. D. 125 mL/hour.

B. 63 mL/hour To calculate the infusion rate, the dose of KCl is not used in the calculation. Using the total volume of Normal Saline solution, 250 mL/4 hours = 63 mL/hour.

A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? A. Sleeping six to eight hours. B. Achieve a sense of control. C. Utilize problem solving skills. D. Increased focus of attention.

B. Achieve a sense of control. The experience of psychological discomfort may be as real as physical pain for the client and should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of control is a key need (B) before (A, C and D) are addressed.

The healthcare provider prescribes a protein supplement for a client who is recovering after surgery. What information should the nurse provide for the family about the value of protein supplement? A. An increase of protein supplies fuel for energy in the client. B. Additional protein promotes tissue healing postoperatively. C. Protein supplements stimulate the client's appetite. D. Increased protein satiates cravings for carbohydrates.

B. Additional protein promotes tissue healing postoperatively. Incised tissue needs additional protein to help build and repair cells therefore, adding a protein supplement to the diet provides additional amino acid building blocks to promote healing of the surgical site. The other options do not explain the value of increasing protein in the post surgical period.

When caring for a client who abuses alcohol regularly, the nurse should assess the client for which condition? A.Gout. B.Anemia. C.Scurvy. D.Rickets

B. Anemia One of the most prevalent health problems encountered in population surveys is iron-deficiency anemia. Clients who abuse alcohol are more prone to have mineral-deficient diets that require additional iron to prevent anemia.

The nurse is preparing an orientation class for new employees at an inner city clinic that serves a low-income population. Which information should the nurse include in the presentation to these new employees? A. A lack of transportation is the major impediment for the clinic's clients. B. Basic physiologic needs are likely to be unmet in this clinic's client population. C. Printed material is less effective for this population that has limited reading skills. D. A group education class is often poorly attended by non-compliant clients.

B. Basic physiologic needs are likely to be unmet in this clinic's client population Low-income clients are at risk for basic physiologic needs being unmet because they do not have the funds to pay for healthcare services, whether preventive or acute.

The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 mL/hour. Which infusion device should the nurse use? A. Portable syringe pump. B. Cassette infusion pump. C. Volumetric controller. D. Nonvolumetric controller.

B. Cassette infusion pump. A cassette pump should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precision, such as mL/hour. A syringe pump is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric and nonvolumetric controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variations in drop size.

The nurse tells a client in her first trimester that she should increase her daily intake of calcium to 1,200 mg during pregnancy. The client responds, "I don't like milk." What dietary adjustments should the nurse recommend? A. Increase organ meats in the diet. B. Eat more green, leafy vegetables. C. Add molasses and whole-grain breads to the diet. D. Choose more fresh citrus and other fruits daily.

B. Eat more green, leafy vegetables. For pregnant women who do not like milk, other sources of calcium include enriched cereals, legumes, nuts, dried fruits, green leafy vegetables, and canned salmon and sardines that contain bones.

An 6-year-old child receives a prescription for the antibiotic tetracycline. Which side effect should the nurse review with the prescriber? A. Nephrotoxicity and ototoxicity with long term use. B. Enamel hypoplasia and discoloration in developing teeth. C. Skin rash last time ampicillin was prescribed. D. Cross-hypersensitivity to penicillins.

B. Enamel hypoplasia and discoloration in developing teeth. Tetracyclines cause enamel hypoplasia and tooth discoloration in children whose permanent teeth that are still developing and have not erupted.

A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? A. Suggest that other cultural practices be substituted by the family members. B. Examine one's own culturally based values, beliefs, attitudes, and practices. C. Explain to the family that multiple visitors are exhausting to the client. D. Allow the situation to continue until a family member's action may harm the client.

B. Examine one's own culturally based values, beliefs, attitudes, and practices. Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values to compare, recognize, and acknowledge cultural bias.

The nurse is assessing a client prior to administering the prescribed dose of atenolol (Tenormin) PO. The client's blood pressure is 120/68, and the telemetry monitor shows sinus bradycardia with a rate of 58 beats/minute, and a P-R interval of 0.24. Based on this assessment, what intervention should the nurse implement? A. Lower the head of the bed and assess the client for orthostatic vital sign changes. B. Give the medication as prescribed and continue to monitor the client. C. Prepare to administer atropine sulfate IVP. D. Hold the prescribed dose and contact the healthcare provider.

B. Give the medication as prescribed and continue to monitor the client Since the BP is within normal limits, and the pulse is above 50 with a first degree block, the medication can be administered. Atenolol (Tenormin) is a beta-blocker that slows the heart rate and lowers the blood pressure; this drug is generally held if the heart rate is less than 50 or the client exhibits dizziness related to hypotension.

An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. What is the priority nursing diagnosis for this client? A. Risk for injury. B. Impaired comfort. C. Disturbed body image. D. Ineffective health maintenance.

B. Impaired comfort. In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the vaginal walls to become thinner, drier, and susceptible to infection which leads to atrophic vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, which supports the primary nursing diagnosis, "Impaired comfort."

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? A. Supplementary iron is more efficiently utilized during pregnancy. B. It is difficult to consume 18 mg of additional iron by diet alone. C. Iron absorption is decreased in the GI tract during pregnancy. D. Iron is needed to prevent megaloblastic anemia in the last trimester.

B. It is difficult to consume 18 mg of additional iron by diet alone. Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to meet the demands of pregnancy is difficult so iron supplements are often recommended.

Which action should the nurse implement to complete an assessment for a client while using an interpreter? A. Ask closed-ended questions with the assistance of the interpreter. B. Maintain eye contact with the client while listening to the translation. C. Instruct interpreter to answer questions from interpreter's point of view. D. Protect the client's privacy by asking a limited number of questions.

B. Maintain eye contact with the client while listening to the translation. When completing an assessment, the nurse should maintain eye contact with the client to gather additional information from the client's nonverbal cues.

During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide? A. Discontinue all forms of contraception. B. Make sure to include adequate folic acid in the diet. C. Lose weight so more weight is gained during pregnancy. D. Continue to take any medications that are taken regularly.

B. Make sure to include adequate folic acid in the diet. A healthy diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. Folate or folic acid intake in the periconception period reduces the risk of neural tube defects. Recommendations to stop or continue medications during pregnancy should be evaluated on an individual basis. Losing weight so more can be gained during pregnancy is not indicated as a generalization and may place the client at risk for nutritional deficiencies.

The nurse receives the laboratory results of theophylline level of 25 mcg/dL for a child with asthma. What action should the nurse implement? A. Share the results during end of shift report. B. Notify the healthcare provider. C. Repeat the laboratory test after the next dose. D. Administer the medication as ordered.

B. Notify the healthcare provider. The therapeutic level of theophylline is 10 to 20 mcg/dl, so the child's level is outside the therapeutic range. The nurse should report the findings to healthcare provider so dose adjustments can be prescribed

A client with heart failure is prescribed spironolactone (Aldactone). Which information is most important for the nurse to provide to the client about diet modifications? A. Do not add salt to foods during preparation. B. Refrain for eating foods high in potassium. C. Restrict fluid intake to 1000 ml per day. D. Increase intake of milk and milk product

B. Refrain for eating foods high in potassium Spironolactone (Aldactone), an aldosterone antagonist, is a potassium-sparing diuretic, so a diet high in potassium should be avoided, along with table salt substitutes that generally contain potassium chloride that can lead to hyperkalemia.

A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding? A. Frequency of emesis in the last 8 hours. B. Serum BUN and creatinine levels. C. Current blood sugar level. D. Appearance of the stool.

B. Serum BUN and creatinine levels Regardless of a client's age, adequate renal function must be present before adding potassium to IV fluids

The nurse is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the nurse instruct the client to use at home? A. Exercise bicycle. B. Sphygmomanometer. C. Blood glucose monitor. D. Weekly medication box.

B. Sphygmomanometer Self-awareness is the best way for a client to manage chronic hypertension, so the client should obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record.

A preschool-aged child with polyuria has pedal pulses palpable at +1 and no edema is observed. The child's vital signs are heart rate of 118 beats/minute, respirations 24 breaths/minute, and blood pressure 80/40. What action is most important for the nurse to implement? A. Insert an indwelling urinary catheter. B. Start an IV infusion of normal saline. C. Document the child's findings and vital signs. D. Review the child's serum electrolyte results.

B. Start an IV infusion of normal saline. The child's vital sign and decreased peripheral pulse volume indicate that the child is experiencing fluid volume deficit due to the polyuria. The priority action is to start an infusion of normal saline to restore fluid volume

A child is admitted to the postanesthesia care unit (PACU) after receiving general anesthesia in surgery. When the child becomes reactive, the nurse identifies that the child is febrile and has rigid muscles. Which finding requires the nurse to immediately call the urgent response team, including the surgeon and anesthesiologist? A. Brown or cola-colored urine. B. Tachydysrhythmias. C. Flushed skin. D. Diaphoresis.

B. Tachydysrhythmias Malignant hyperthermia, a potentially life threatening genetic myopathy, causes a reaction to general anesthesia and is manifested by a significantly change in vital signs that demands immediate intervention in the perioperative period. Tachycardia and tachydysrhythmias, including muscle rigidity, require prompt treatment with antiarrythmic drugs and muscle relaxants, such as dantrolene (Dantrium) to stop muscular metabolism.

A client at 25-weeks' gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide? A. This is a demonstration of the fetus's acoustical reflex. Incorrect B. The fetus can respond to sound by 24-weeks' gestation. C. It is a coincidence the fetus responded at the same time. D. Report the fetus's behavior to the healthcare provider.

B. The fetus can respond to sound by 24-weeks' gestation At 24-weeks' gestation, the fetus's ability to hear loud environment sounds can illicit a startle response.

A female client who wants to delivery at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide? A. Birth in the home setting is the preference for a using a midwife for delivery. B. The pregnancy should progress normally and be considered low risk. C. Natural child birth without analgesia is used to manage pain during labor. D. An obstetrician should also follow the client during pregnancy.

B. The pregnancy should progress normally and be considered low risk. A nurse midwife is an advanced practice nurse who is prepared to provide quality perinatal care for a low-risk obstetric client.

A client at 29-weeks' gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? A. Amniocentesis. B. Ultrasonography. C. Chorionic villus sampling. D. Maternal serum alpha-fetoprotein

B. Ultrasonography Gestational age, fetal growth, and the status and position of the placenta are monitored by ultrasound.

The nurse is auscultating the lung fields of a child with asthma who is wheezing. Which finding associated with wheezing is consistent with the pathophysiology of asthma? A. Inspiratory stricor B. Wheezing on expiration. C. Adventitious wheezes occur only with coughing episodes. D. Audible high pitched wheezes occur only at night.

B. Wheezing on expiration. The pathophysiological wheeze of asthma occurs on expiration and results from bronchospasm and diffuse airway narrowing of the small bronchi and bronchioles.

A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. What is the best response for the nurse to provide? A. "Tell your friends and family so that they can help you." B. "Get involved with a support group. I will give you some names." C. "Talk only to other friends who are infertile since only they can help." D. "Start adoption proceedings immediately since obtaining an infant is very difficult."

B: "Get involved with a support group. I will give you some names." A support group provides a safe haven for the couple to share their feelings and experience, gain insight from others dealing with the same experience, and assure the couple that they are not alone in their situation.

After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples? A. 15 minutes before and 15 minutes after the next dose. B. One hour before and one hour after the next dose. C. 5 minutes before and 30 minutes after the next dose. D. 30 minutes before and 30 minutes after the next dose.

C) 5 minutes before and 30 minutes after the next dose. Peak drug serum levels are achieved 30 minutes after IV administration of aminoglycosides. The best time to draw a trough is the closest time to the next administration (C). (A, B, and D) are not as good a time to draw the trough as (C). (B and D) are not the best times to draw the peak of an aminoglycoside that has been administered IV.

The nurse is assessing a client who is experiencing anaphylaxis from an insect sting. Which prescription should the nurse prepare to administer this client? A. Dopamine. B. Ephedrine. C. Epinephrine. D. Diphenhydramine.

C) Epinephrine. Epinephrine (C) is an adrenergic agent that stimulate beta receptors to increase cardiac automaticity in cardiac arrest and relax bronchospasms in anaphylaxis. Dopamine (A) is a vasopressor used to treat clients with shock. Ephedrine (B) causes peripheral vasoconstriction and is used in the treatment of nasal congestion. Diphenhydramine (D) is an antihistamine decongestant used in the treatment of mild allergic reactions and motion sickness.

Which postmenopausal client's complaint should the nurse refer to the healthcare provider? A. Breasts feel lumpy when palpated. B. History of white nipple discharge. C. Episodes of vaginal bleeding. D. Excessive diaphoresis occurs at night.

C) Episodes of vaginal bleeding. Postmenopausal vaginal bleeding (C) may be an indication of endometrial cancer, which should be reported to the healthcare provider. Compared to a new-onset of a single lump, breasts that feel lumpy (A) overall may be a normal variant or a finding consistent with nonmalignant fibrocystic disease. Up to 80% of women experience (B), depending on sexual stimulation or hormonal levels, and is no longer recommended as a reportable symptom when discovered during breast self-exam (BSE). The client may need further teaching concerning (D), a disturbing symptom, but it is not as important as (C).

An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete? A. Palpate the pedal pulse volume. B. Count the brachial pulse rate. C. Measure the blood pressure. D. Assess for a carotid bruit.

C) Measure the blood pressure. Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure (C) should be determined. (A, B, and D) are less likely to provide data related to the client's tachycardia.

A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? A. Lymph node involvement is not significant. B. Small tumors are aggressive and indicate poor prognosis. C. The tumor's estrogen receptor guides treatment options. D. Stage I indicates metastasis.

C) The tumor's estrogen receptor guides treatment options. Treatment decisions (C) and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are well-differentiated, have a lower chance of recurrence, and are receptive to hormonal therapy. Tumor staging designates tumor size and spread of breast cancer cells into axillary lymph nodes, which is one of the most important prognostic factors in early-stage breast cancer, not (A). Larger tumors are more likely to indicate poor prognosis, not (B). Stage I indicates the cancer is localized and has not spread systemically (D).

What teaching should the nurse provide a client who has received a new prescription for sildenafil (Viagra)? (Select all that apply.) A. Frequent use can lead to the development of hypertension. B. Most effective if taken after at least 6 hours of REM sleep. C. Take within 30 to 60 minutes of sexual stimulation. D. Report rebound priapism that occurs for 4 hours or more. E. Can cause facial flushing and headache.

C, D, E Sildenafil (Viagra) enhances the natural response to sexual stimuli, so a client should be instructed to take Viagra within 30 to 60 minutes before sexual intercourse to provide adequate time to enhance penile erection. Sildenafil does not cause erection directly, but priapism can occur and should be reported to the healthcare provider if it persists. Common side effects include headaches, facial flushing, and diarrhea. Viagra can potentiate vasodilators, such as alpha-adrenergic blockers, nitroglycerin, and other nitrates used for angina pectoris, and may cause hypotension, which decreases perfusion to vital organs.

Which client has the greatest risk for developing community-acquired pneumonia? A. A 40-year-old first-grade teacher who works with underprivileged children. B. A 75-year-old retired secretary with exercise-induced wheezing. C. A 60-year-old homeless person who is an alcoholic and smokes. D. A 35-year-old aerobics instructor who skips meals and eats only vegetables.

C. A 60-year-old homeless person who is an alcoholic and smokes Although age is a factor in the development of community-acquired pneumonia, other lifestyle behaviors, such as smoking, alcoholism, and exposure factors related to homelessness increase one's risk due to impaired nutrition and immune function.

A client at 32-weeks' gestation is hospitalized with severe pregnancy-induced hypertension (PIH). The healthcare provide prescribed magnesium sulfate is to control the symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved? A. 4+ reflexes. B. Urinary output of 50 mL per hour. C. A decrease in respiratory rate from 24 to 16. D. A decreased body temperature.

C. A decrease in respiratory rate from 24 to 16. Magnesium sulfate is a CNS depressant that helps prevent seizures. A decreased respiratory rate indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.) The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.

A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement? A. Determine if the client has also experienced breast tenderness and weight gain. B. Encourage the client to begin a regular, daily program of walking and exercise. C. Advise the client to notify the healthcare provider for immediate medical attention. D. Tell the client to stop taking the medication for a week to see if symptoms subside.

C. Advise the client to notify the healthcare provider for immediate medical attention Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention.

The nurse is visiting a client at home and recognizes that the client's cultural background is different than the nurse's cultural practices. Which action should the nurse prioritize when demonstrating cultural competence? A. Accept an invitation to eat a cultural meal with the client's family. B. Participate in cultural healing rituals with the client and family. C. Ask the client how culture plays a role in their health care preferences. D. Read articles about the specific culture to increase client communication.

C. Ask the client how culture plays a role in their health care preferences. Cultural competence means the nurse incorporates the client's culture into the health care plan. Asking the client about cultural beliefs and how they impact healthcare preferences demonstrates cultural competence.

A multigravida client at 35-weeks' gestation is diagnosed with pregnancy-induced hypertension (PIH). Which symptom should the nurse instruct the client to report immediately? A. Backache. B. Constipation. C. Blurred vision. D. Increased urine output.

C. Blurred vision Blurred vision, headache, visual changes, and epigastric discomfort are the most common symptoms experienced by a client with PIH and may indicate impending seizures and should be reported.

A female client calls the clinic and talks with the nurse to inquire about a possible reaction after taking amoxicillin for 5 days. She reports having vaginal discomfort, itching, and a white discharge. The nurse should discuss which action with the client? A. Discontinue the antibiotic because original symptoms have subsided. B. Continue taking medication until finished until the symptoms subside. C. Consult with healthcare provider about another treatment for this effect. D. Use an over-the-counter (OTC) vaginal wash to flush out the secretions.

C. Consult with healthcare provider about another treatment for this effect. A superinfection with normal flora yeast may occur during antibiotic therapy. If suspected, the new onset of findings should be reported to the healthcare provider for another prescribed treatment to treat the superinfection.

The nurse is planning for the care of a 30-year-old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcome? A. Mother's age. B. Amount of insulin required prenatally. C. Degree of glycemic control during pregnancy. D. Number of years since diabetes was diagnosed.

C. Degree of glycemic control during pregnancy. Clients with tight glucose control and no blood vessel disease should have positive pregnancy outcomes. Risk assessment is best done by evaluating the woman's blood glucose and blood vessels, not by evaluating mother's age, number of years since diabetes was diagnosed, or the amount of insulin required prenatally.

The nurse is giving discharge instructions for a client following a suction curettage for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide? A. Oral contraceptives prevent a reoccurrence of a molar pregnancy. B. Pregnancy within 1 year decreases the chances of a future successful pregnancy. C. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy. D. Molar reoccurrences are higher if conception occurs within 1 year after an initial mutation.

C. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy. The major risk after a molar pregnancy is the development of choriocarcinoma, which is detected by measuring the same hormone (hCG) that the body produces during pregnancy. Continued elevated hCG levels may be either from choriocarcinoma or a subsequent pregnancy making diagnosis and treatment difficult, so oral contraceptives are prescribed to prevent pregnancy for a year since it interferes with monitoring the return of hCG levels to normal.

Which age group of children is most likely to feel responsible for their parents' divorce? A. Infants. B. Toddlers. C. Early elementary. D. Adolescents.

C. Early elementary. Divorce of parents constitutes a major disruption for children of all ages and affects milestone development, coping mechanisms, and adjustment issues. Children in the early elementary years are most likely to blame themselves for their parents' divorce

A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? A. Suprapublic pain and distention. B. Bounding pulse at 100 beats/minute. C. Fingerstick glucose of 300 mg/dl. D. Small vesicular perineal lesions.

C. Fingerstick glucose of 300 mg/dl. Elevated fingerstick glucose levels needs to be reported tot he healthcare provider, so a plan of care can be adjusted to treat the elevated glucose level. Also elevated glucose levels, spills into the urine and provide a medium for bacterial growth.

A client with type 1 diabetes has recorded in the log book blood glucose values which are within target. The client's log book lists foods high in carbohydrate content. Which laboratory test would help the nurse to better understand the client's adherence to the diabetes treatment plan? A. Oral glucose tolerance test (GTT). B. 24-hour urine analysis. C. Hemoglobin A1c. D. Fasting cholesterol.

C. Hemoglobin A1c. The A1c measures the average blood glucose level over the past 3 months and should be used to compare with the client's diabetes self-care journal.

The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male? A. Increased WBC, decreased RBC. B. Increased serum bilirubin, slightly increased liver enzymes. C. Increased protein in the urine, slightly increased serum glucose levels. D. Decreased serum sodium, an increased urine specific gravity.

C. Increased protein in the urine, slightly increased serum glucose levels. In older adults, the protein found in urine slightly rises probably as a result of kidney changes or subclinical UTIs.

A 38-year-old gravida 2 para 2 is diagnosed with bacterial vaginosis 9-months postpartum. A prescription is written for metronidazole (Flagyl). Which information is most important for the nurse to obtain from the client before initiating treatment? A. Sexual history. B. Use of oral contraceptives. C. Method of infant feeding. D. Possibility of pregnancy.

C. Method of infant feeding Flagyl is contraindicated if the woman is breastfeeding because high concentrations have been found in breast milk fed to infants. If Flagyl must be prescribed, the woman should be instructed to pump and discard the milk during treatment and for 48 to 72 hours after the last dose.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? A. Wear support stockings. B. Reduce salt in her diet. C. Move about every hour. D. Avoid constrictive clothing.

C. Move about every hour. Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will straighten out the pelvic veins and increase venous return.

The hospice nurse is completing a focused assessment of an older female client with end stage Alzheimer's disease, who recently fractured her hip. What technique should the nurse use to determine the client's pain? A. Use the FACES pain scale. B. Ask client to rate pain on a scale of 1 to 10. C. Observe for facial grimacing. D. Review documentation of recent eating habits.

C. Observe for facial grimacing. Observing for facial grimacing is the best method for evaluating pain for a client who cannot communicate due to Alzheimer's disease.

A 3-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child's adjustment to hospitalization? A. Give detailed explanations of procedures. B. Use terms of endearment to establish rapport. C. Offer the child a choice when performing procedures. D. Encourage the parents to go home and rest.

C. Offer the child a choice when performing procedures. Altered daily schedules and loss of rituals are upsetting and increase separation anxiety in toddlers and preschool-aged children. The nurse's sensitivity to the needs and preferences of a child can minimize the negative effects of hospitalization. When possible, the nurse should offer the child a choice during procedures to help the child gain self control and cooperation.

An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion? A. Pain in the calf awakening him from a sound sleep. B. Calf pain on exertion which stops when standing in one place. C. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. D. Pain upon arising in the morning which is relieved after some stretching and exercise.

C. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. Thrombophlebitis pain is relieved by rest and elevation of the extremity. It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place

The nurse is teaching a 5-year-old child with type 1 diabetes mellitus. Based on developmental skills of a 5-year-old, which task is most appropriate for the nurse to teach the child? A. Selection of high carbohydrates foods from a chart. B. Administration of subcutaneous insulin injections. C. Performance of glucose testing. D. Preparation of the correct insulin dose

C. Performance of glucose testing. Developmentally, a 5-year-old should have the cognitive and psychomotor skills to use a glucose monitoring device and read or repeat the numeral results displayed on the digital screen.

A deficiency of intrinsic factor should alert the nurse to assess a client's history for which condition? A. Emphysema. B. Hemophilia. C. Pernicious anemia. D. Oxalic acid toxicity.

C. Pernicious anemia Pernicious anemia is a type of anemia due to failure of absorption of cobalmin (Vit B12). Th emost common cause of lack of intrinsic factor, a glycoprotein produced by the parietal cells of the gastric lining

The nurse is assess the parents' reaction to the news that their child has a chronic illness that is terminal. The parents' reactions are consistent with the grieving process. Which coping behaviors of the parents should the nurse explore further? A. Endowing the illness with meaning. B. Believing in faith and prayer. C. Planning an unrealistic future for the child. D. Requesting information about community resources.

C. Planning an unrealistic future for the child. Coping mechanisms are behaviors directed at reducing the tension of a crisis and help to promote healthy adjustment and resolution of the crisis. Persistent avoidance behaviors, including disbelief or denial in the grieving process, can result in maladaptation to the crisis. Planning for an unrealistic future for their child with a chronic or terminal disease should be explored further with the parents.

A client diagnosed with an end-stage terminal illness has decided to discontinue treatment. The client has become very detached and does not want to participate in the plan of care. Which action should the nurse implement first? A. Initiate a referral for a mental health consultation. B. Encourage the client to participate in their plan of care. C. Review the client's medical record for documented religious preference. D. Contact the hospital chaplain to provide spiritual counseling and guidance.

C. Review the client's medical record for documented religious preference. The nurse needs to confirm the client's religious preference first before initiating any other action. Individuals who follow the teachings of Buddha believe that "detachment" is the way to obtain relief from suffering. The teachings of Buddha also believe dying is natural process and in reincarnation. When an individual dies, the Buddhist believes the person is transitioning into a new life.

During a home health visit, a male client reports to the nurse that he felt a solid testicular mass during self-exam, but that it wasn't painful. What instruction should the nurse provide the client? A. Continue to monitor the mass until the next scheduled annual medical exam. B. Notify the healthcare provider if the mass becomes soft, painful, or starts to drain. C. Schedule an appointment with the healthcare provider for prompt evaluation. D. Testicular nodules are of concern only if they feel matted or are not easily movable.

C. Schedule an appointment with the healthcare provider for prompt evaluation. A painless testicular mass is an abnormal finding, and the nurse should instruct the client to obtain prompt medical evaluation. The other options place the client at risk, since they do not emphasize prompt medical evaluation.

A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide? A. Excretes prolactin and insulin. B. Produces nutrients for fetal nutrition. C. Secretes both estrogen and progesterone. D. Forms a protective, impenetrable barrier.

C. Secretes both estrogen and progesterone. One of the early functions of the placenta as an endocrine gland is the production of four hormones, hCG, hPL, estrogen, and progesterone, necessary to maintain the pregnancy and support the embryo and fetus

During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement? A. Start another IV of dextrose solution and stay with the child. B. Continue the transfusion and monitor the child's vital signs. C. Stop the infusion immediately and notify the healthcare provider. D. Slow the transfusion and assess for cessation of symptoms.

C. Stop the infusion immediately and notify the healthcare provider. The child is exhibiting signs of a reaction to the blood transfusion. The blood transfusion should be stopped immediately and the healthcare provider notified

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. Which assessment finding would provide the nurse the earliest indication that the client is experiencing primary side effects of terbutaline sulfate? A. Drowsiness and bradycardia. B. Depressed reflexes and increased respirations. C. Tachycardia and a feeling of nervousness. D. A flushed, warm feeling and a dry mouth.

C. Tachycardia and a feeling of nervousness. Terbutaline sulfate (Brethine), a beta-sympathomimetic drug which stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of "nervousness."

The nurse is teaching a mother to give 4 ml of a liquid antibiotic to a 10-month-old infant. Which statement by the parent indicates understanding of the medication administration technique? A. Once the baby feels better, the medication dose can be reduced. B. The dose of the medication can be measured to half the level of a tablespoon. C. The dropper dispensed with the antibiotic should be used to measure the dose. D. An antihistamine can be given if the baby develops a rash.

C. The dropper dispensed with the antibiotic should be used to measure the dose. The prescribed medication is 4 mL per dosage and is measured with the most accuracy using a syringe or the marked dropper dispensed with the liquid antibiotic.

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? A. The nurse will provide client instruction for daily foot care. B. The client will demonstrate proper trimming toenail technique. C. Upon discharge, the client will list three ways to protect the feet from injury. D. After instruction, the nurse will ensure the client understands foot care rationale.

C. Upon discharge, the client will list three ways to protect the feet from injury. An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. The sentence that states the client with peripheral vascular disease will be able to list the ways to prevent injury to the lower extremities by time of discharge is an example of a written learning objective.

The nurse is caring for a client who has pernicious anemia. Which vitamin deficiency is associated with this type of anemia? A. Vitamin D. B. Vitamin B6. C. Vitamin B12. D. Vitamin C.

C. Vitamin B12. In pernicious anemia, a deficit of hydrochloric acid secretion by the stomach also results in a deficit of intrinsic factor which is needed for the body to absorb vitamin B12 for utilization by the bone marrow in erythropoiesis.

Which information about mammograms is most important to provide a postmenopausal female client? A. Breast self-examinations are not needed if annual mammograms are obtained. B. Radiation exposure is minimized by shielding the abdomen with a lead-lined apron. C. Yearly mammograms should be done regardless of previous normal x-rays. D. Women at high risk should have annual routine and ultrasound mammograms.

C. Yearly mammograms should be done regardless of previous normal x-rays. The current breast screening recommendation is a yearly mammogram after age 40.

A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant? A. Give small, frequent feedings of fluids. B. Accurately chart observations regarding breath sounds. C. Have a bulb syringe readily available to remove secretions. D. Encourage older siblings to visit.

C. have a bulb syringe readily available to remove secretions A patient airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and making (C) the highest priority. (A) maintains hydration and prevents, but an open airway has the highest priority. (B) is important for evaluations of therapy. When asked "priority" questions, remember Maslow. Physical needs usually have a higher priority than psychosocial needs. An open airway is the highest physiological need

Which response by a client with a nursing diagnosis of Spiritual distress indicates to the nurse that a desired outcome measure has been met? A.Expresses concern about the meaning and importance of life. B.Remains angry at God for the continuation of the illness. C.Accepts that punishment from God is not related to illness. D.Refuses to participate in religious rituals that have no meaning.

C.Accepts that punishment from God is not related to illness Acceptance that her illness is not God punishing her, indicates a desired outcome for some degree of resolution of spiritual distress

A client who had a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement? A.Ready the client for discharge. B.Notify pastoral care to offer the client a blessing. C.Ask the client what name she had picked out for the infant. D.Inquire if the client would like to see what was obtained from her D&C.

C.Ask the client what name she had picked out for the infant The client's cues about her preparation for the baby indicate her need to express her feelings of loss, so encouraging further discussion about the infant's name provides an opportunity to offer support. The other actions are not indicated.

A mother brings her 4-month-old infant to the clinic for a well-child checkup. She asks if she should go back to work now or stay at home with the baby. How should the nurse respond to the mother? A.Mothers can promote healthy bonding by staying at home during the child's first years. B.Determine if other family relatives can stay at home with the baby. C.Ask the mother to talk about the options she has been considering. D.Returning to work when an infant is young helps the baby to adjust to other children.

C.Ask the mother to talk about the options she has been considering. It is common for mothers to feel ambivalent about returning to work and caring full time for children at home. The nurse should assist the mother to explore her feelings on the subject while focusing on the optimal, appropriate, safe, and available options for her child

A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp, cramping gas pains. What nursing intervention should be implemented? A.Obtain a prescription for a laxative. B.Withhold all oral fluid and food. C.Assist the client to ambulate in the hall. D.Administer the prescribed morphine sulfate.

C.Assist the client to ambulate in the hall. Postoperative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is stimulated, flatus passed and distention minimized by implementing early and frequent ambulation.

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

C.Decrease the IV infusion rate of the meperidine (Demerol) per protocol. The client is exhibiting symptoms of Demerol toxicity which is consistent with the large doses of Demerol received over four days. Decreasing the infusion rate of the Demerol as per protocol is the most effective action to immediately decrease the amount of serum Demerol. The next nursing action is for the nurse to notify the healthcare provider.

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? A.Present knowledge related to the skill of injection. B.Intelligence and developmental level of the client. C.Willingness of the client to learn the injection sites. D.Financial resources available for the equipment.

C.Willingness of the client to learn the injection sites. If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching.

A client in the preoperative holding area receives a prescription for midazolam (Versed) IV.  The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement? A.Give the drug and allow the client to read and sign the consent form. B.Counter-sign the client's initials on the consent form after giving the drug. C.Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. D.Call the healthcare provider to explain the surgical procedure before the client signs the consent.

C.Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. Midazolam, a benzodiazepine sedative, is commonly used for conscious-sedation intraoperatively and interferes with the client's cognition and level of consciousness, so the consent form should be signed before the drug is administered.

A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. What action should the nurse take? A. Obtain a specimen for serum glucose level. B. Administer insulin per sliding scale. C. Provide cheese and bread to eat. D. Collect a glycosylated hemoglobin specimen.

C: Provide cheese and bread to eat. Once blood glucose is greater than 70 mg/dL, the client should eat a regularly scheduled meal or a snack that contains protein and carbohydrates to help prevent hypoglycemia from recurring.

A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client? A. Fluid and electrolyte balance. B. Prevention of water toxicity. C. Reduced glucose in the urine. D. Adequate cellular nourishment

D) Adequate cellular nourishment. Diabetes mellitus Type 1 is characterized by hyperglycemia that precipitates glucosuria and polyuria (frequent urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Polyphagia is a consequence of cellular malnourishment when insulin deficiency prevents utilization of glucose for energy, so the outcome statement should include stabilization of adequate cellular nutrition (D). (A, B, and C) relate to subsequent osmolar fluid shifts related to glucosuria, polyuria, and polydipsia.

The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first? A. Place a chair at a right angle to the bedside. B. Encourage deep breathing prior to standing. C. Help the client to sit and dangle legs on the side of the bed. D. Allow the client to sit with the bed in a high Fowler's position.

D) Allow the client to sit with the bed in a high Fowler's position. The first step is to raise the head of the bed to a high Fowler's position (D), which allow venous return to compensate from lying flat and vasodilating effects of perioperative drugs. (A, B, and C) are implemented after (D).

Which change in data indicates to the nurse that the desired effect of the angiotensin II receptor antagonist valsartan (Diovan) has been achieved? A. Dependent edema reduced from +3 to +1. B. Serum HDL increased from 35 to 55 mg/dl. C. Pulse rate reduced from 150 to 90 beats/minute. D. Blood pressure reduced from 160/90 to 130/80.

D) Blood pressure reduced from 160/90 to 130/80. Diovan is an angiotensin receptor blocker, prescribed for the treatment of hypertension. The desired effect is a decrease in blood pressure (D). (A, B, and C) do not describe effects of Diovan.

A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still very small. Which information supports the explanation that the nurse should provide? A. Side effects are less likely if therapy is started early. B. Collateral circulation increases as the tumor grows. C. Sensitivity of cancer cells to CT is based on cell cycle rate. D. The cell count of the tumor reduces by half with each dose.

D) The cell count of the tumor reduces by half with each dose. Initiating chemotherapy while the tumor is small provides a better chance of eradicating all cancer cells because 50% of cancer cells or tumor cells are killed with each dose. (A, B, and C) vary based on the type of cancer.

The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group? A. The length of time each group member has resided at the nursing home. B. A brief description of each resident's family life. C. The age of each group member. D. The usual activity patterns of each member of the group.

D) The usual activity patterns of each member of the group. An older person's level of activity (D) is a determining factor in adjustment to aging as described by the Activity Theory of Aging. All information described in the options might be useful to the nurse, but the most useful information initially would be an assessment of each individual's adjustment to the aging process.

The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) A.Remove the diaphragm immediately after intercourse. B.Wash the diaphragm with an alcohol solution. C.Use the diaphragm to prevent conception during the menstrual cycle. D.Do not leave the diaphragm in place longer than 8 hours after intercourse. E. Replace the old diaphragm every 3 months.

D, E The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer than 8 hours to avoid the risk of TSS. The diaphragm should be replaced every 3 months to maintain integrity

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? A. "Herbs are a cornerstone of good health to include in your treatment." B. "Touch is also therapeutic in relieving discomfort and anxiety." C. "Your healthcare provider should direct treatment options for herbal therapy." D. "It is important that you want to take part in your care."

D. "It is important that you want to take part in your care." Clients need to be viewed holistically. By acknowledging the emphasis the client made to alternative and complementary therapies, such as herbal therapy, the client is empowered as an integral member of the healthcare team.

A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? A. "It may hurt a little because of the incision made in your throat." B. "It won't hurt because you're such a big boy." C. "It won't hurt because we put you to sleep." D. "It may hurt but we'll give you medicine to help you feel better."

D. "It may hurt but we'll give you medicine to help you feel better." Answering questions simply and directly provides comfort for the preschool-age child and builds confidence in the healthcare team.

A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client? A) I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight. B) I will let you have one cracker, but that is all you can have for the rest of tonight. C) What did the healthcare provider tell you about the test you are having tomorrow? D) The test you are having tomorrow requires that you have nothing by mouth tonight.

D. "The test you are having tomorrow requires that you have nothing by mouth tonight." Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic statement because the nurse is responding to the client's question and providing him the reason why.

A client in her second trimester of pregnancy asks if it is safe for her to have a drink with dinner. How should the nurse respond to the client? A. During second trimester beer can be consumed without harm to the fetus. B. Wine can be consumed several times a week after the first trimester. C. Only one drink with the evening meal is not harmful to the fetus. D. Abstinence is strongly recommended throughout the pregnancy.

D. Abstinence is strongly recommended throughout the pregnancy. A safe level of alcohol consumption during pregnancy has not yet been established, so although the consumption of occasional alcoholic beverages may not be harmful to the mother or her developing fetus, complete abstinence is strongly advised. Beer, wine or any alcoholic drink consumption is not recommended during the pregnancy.

A mother and her early adolescent son ask questions about taking growth hormones by injection to help him grow taller. What information should the nurse provide to address their concerns? A. Taking growth hormones is not always effective in improving height. B. Understanding there are more important qualities for males than height. C. Growing too tall may interfere with self esteem and social status. D. Achieving the goal of growing taller requires medications by injections.

D. Achieving the goal of growing taller requires medications by injections It is important to validate feelings about hormone therapy during adolescence. The nurse should address the questions about the route of administration to achieve growth before the epiphyseal plates close. The information about achieving therapeutic effects of growth hormone should re-enforce that hormonal therapy by injection is often prescribed several times a week during the growth years.

A male client with meningitis is prescribed cefotaxime (Claforan) IV and asks the nurse why he cannot receive an oral drug, such as cefaclor (Ceclor) or cefadroxil (Duricef), that he has taken before for infections. How should the nurse respond when considering the actions of cephalosporins? A. Cefazolin (Ancef) is another IV antibiotic that can be prescribed. B. Cefaclor (Ceclor) is a good alternative to suggest to the healthcare provider. C. Cefadroxil (Duricef) is usually prescribed when the IV is discontinued. D. Cefotaxime (Claforan) provides therapeutic CNS concentrations.

D. Cefotaxime (Claforan) provides therapeutic CNS concentrations. According to research studies, only third generation cephalosporins such as cefotaxime (Claforan), and ceftazidime have been shown effective in treating bacterial meningitis with the exception of cefuroxime, the only second generation cephalosporin shown to be effective. First generation cephalosporins have not been successful in the treatment of bacterial meningitis. IV administration of these antibiotics are preferred route of administration due to oral administration medication levels tend to be too low to be effective in comparison to parental administration.

An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom? A. Leukocytosis and febrile. B. Polycythemia and crackles. C. Pharyngitis and sputum production. D. Confusion and tachycardia

D. Confusion and tachycardia The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch.

The nurse is teaching a client who has mild hypertension about nutritional options. What should the nurse recommend that the client change in the daily diet? A. Avoid green leafy vegetables. B. Choose foods with simple sugars. C. Limit foods high in fiber. D. Decrease intake of canned foods.

D. Decrease intake of canned foods. The client with hypertension should select foods low in sodium. Decreasing the intake of canned foods can decrease salt intake. Increasing leafy green vegetables and fiber in a client's diet help maintain blood pressure and weight. Foods containing simple sugars should be exchanged for complex carbohydrates to aid in weight control.

What action should the nurse implement to provide analgesic titration for a client in pain? A. Teach the client to increase the time range between doses of pain medication. B. Monitor the effects of continuous intravenous infusion of narcotic analgesics. C. Plan with the client how to use a specific total dose of analgesic over a 24-hour period. D. Determine the optimal analgesic dosage required that causes the least side effects.

D. Determine the optimal analgesic dosage required that causes the least side effects. No given dosage of an analgesic provides the same level of pain relief for every client, and so titration upward or downward is determined based on the client's response, so that the optimal dosage achieves adequate pain relief with minimal side effects for the client. An individual's response to the medication dosage is the assessment for titration, and the titration dose should be implemented as long as analgesia is needed.

The nurse formulates the nursing diagnosis "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? A. Does not check capillary blood glucose as directed. B. Occasionally forgets to take daily prescribed medication. C. Cannot identify signs or symptoms of high and low blood glucose. D. Eats anything and does not think diet makes a difference in health.

D. Eats anything and does not think diet makes a difference in health. The nursing diagnosis of ineffective health maintenance related to lack of motivation refers to the client's choice not to identify, manage, and/or seek out help to maintain health. This is best exemplified in the client's demonstration and belief about the interaction between diet and health maintenance of Type 2 diabetes.

Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer? A. Neisseria gonorrhoea. B. Chlamydia trachomatis. C. Herpes simplex virus. D. Human papillomavirus.

D. Human papillomavirus According to the CDC (2017), it is estimated at least 80% of all women who are sexually active will contract the Human papillomavirus (HPV) in their lifetime. Certain types of HPV have been suspected to cause cervical cancer and HPV strain 16 and 18 have been identified to cause 70% of cervical cancers.

A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? A.Stage II. B.Invasive infiltrating ductal carcinoma. C. T1N0M0. D. Inflammatory with peau d'orange.

D. Inflammatory with peau d'orange Inflammatory breast cancer onset is very rapid and a very rare form of breast cancer and is considered the most aggressive form of breast malignancies. It is often mistaken for a breast infection because it has a thickened appearance like an orange peel (peau d'orange), causing the breast to become swollen and tender.

The nurse administers the initial dose of a fentanyl (Duragesic) transdermal patch to a client with chronic pain. When monitoring the client an hour later, which assessment is most important for the nurse to obtain? A. Level of consciousness. B. Moistness of mucosa. C. Bowel sound activity. D. Numeric pain scale.

D. Numeric pain scale. Transdermal fentanyl, an opioid analgesic, has an onset and peak of 6 to 12 hours after the initial dose, so it is most important to determine the client's level of pain, which can persist as breakthrough pain throughout the 72-hour duration of the patch.

An adolescent with suspected bacterial meningitis is admitted after a lumbar puncture specimen is collected and sent to the laboratory. Which action is most important for the nurse to implement next? A. Administer pain medication. B. Collect blood for serum electrolytes. C. Insert an indwelling urinary catheter. D. Place on droplet precautions.

D. Place on droplet precautions. Meningococcal meningitis, diagnosed by culture of cerebrospinal fluid, is transmitted via droplet transmission. Until laboratory results confirm the etiological organism, the client (pediatric or adult) with meningococcal meningitis should be placed on droplet precautions until 24 hours of appropriate antibiotic therapy is completed.

The school nurse is teaching a group of male adolescent clients about testicular self-examination. Which teaching aid should the school nurse use? A. Written instructions. B. Audio instructions. C. Illustrated pamphlet. D. Plastic model of testicles.

D. Plastic model of testicles. Teaching aids for adolescents should promote student engagement. A plastic model is something the adolescents can touch and use to practice return demonstrations.

A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator.

D. Request and document the name of the certified translator. A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented. Client information that is translated is private and protected under HIPAA rules, so enaging anyone as a translator is not the best action. Family members are not preferred translators as they may skew information and not translate the exact information.

A client receives a new prescription for pentazocine (Talwin), a mixed opioid agonist-antagonist, after an opioid agonist is discontinued. What is the advantage for the client when the new prescription is implemented? A. Tolerance does not occur. B. Less agitation is experienced. C. The analgesic ceiling is higher. D. Respiratory depression is less.

D. Respiratory depression is less Mixed agonist-antagonists bind as an agonist at the Kappa receptor and as antagonists or partial agonists on the mu receptor, which produces less respiratory depression than opioid agonists that are pure mu agonists.

The nurse is calculating the estimated date of confinement (EDC) using Nägele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? A. August 1. B. August 10. C. September 3. D. September 8.

D. September 8 Calculation of a client's EDC provides baseline data to monitor fetal gestation. Nägele's rule uses the formula: subtract 3 months and add 7 days to the first day of the last normal menstrual period, so December 1 minus 3 months + 7 days is September 8 (D). (A, B, and C) are incorrect use of this formula.

The nurse is giving preoperative instructions to a school-aged child who is scheduled for sedation for closed reduction for a broken tibia. Which response by the child best indicates understanding of self care? A. Written literature of instructions helps to remember self care. B. The same self care is indicated as a sibling who broke the arm. C. Playing with friends has no restrictions after 24 hours. D. Swelling of the toes should be reported to the healthcare provider.

D. Swelling of the toes should be reported to the healthcare provider. Verbalizing self care and observations about potential complications, such as swelling below the cast or below the fracture site, provide the best evaluation of teaching.

A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client? A. The client may have a bladder or kidney infection. B. Bladder capacity increases during pregnancy. C. During pregnancy a woman is especially sensitive to body functions. D. The growing uterus is putting pressure on the bladder.

D. The growing uterus is putting pressure on the bladder. Urinary frequency is a normal discomfort during the first trimester, when the enlarging uterus is still low in the pelvis. It encroaches on the bladder, reducing its capacity. Although urinary frequency is a symptom of bladder infection, it is usually accompanied by other symptoms such as burning on urination, and a kidney infection is usually accompanied by pain and fever. Bladder capacity does increase to about 1,500 mL during pregnancy, but increased capacity does not cause urinary frequency.

A client at 28-weeks' gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client A. It is not necessary to keep such a close watch on weight gain. B. Try to exercise more because too much weight has been gained. C. Increase the calories in your diet to gain more weight per week. D. The weight gain is acceptable for the number of weeks pregnant.

D. The weight gain is acceptable for the number of weeks pregnant. The normal pattern of weight gain is 2 to 4 pounds in the first trimester (by 13 weeks) and 1 pound per week after that. At 28-weeks' gestation, a weight gain between 17 and 20 pounds is acceptable.

The nurse working in a community health clinic that serves recent Somali immigrants notes that most mothers refuse to give permission for routine immunizations of their preschoolers. Which individual is likely to have the most influence on these women's perceptions about their children's healthcare needs? A. Husbands. B. Clinic healthcare provider. C. Older females. D. Tribal chief.

D. Tribal chief. While the elderly are respected in this community, the chief has greater authority and consequently a wider impact on this group's decision-making. Consulting with the tribal chief, who is the primary authority figure for Somalis as a cultural group, is the best strategy for changing mothers' opinions about the importance of immunizations for their children.

Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby? A.Tell them there is nothing to fear. B. Insist that they hold infant so they can grieve. C.Respect their wishes and release the body to the morgue. D.Keep the body available for a few hours in case they change their minds.

D.Keep the body available for a few hours in case they change their minds. Grieving parents should be encouraged to hold their infant after death to facilitate closure. If parents are hesitant about seeing or holding their dead infant, the fetus should be available for a few hours in the event they change their mind after the initial shock. The other actions are not indicated.

What is the primary nursing problem for a client with asymptomatic primary syphilis? A. Acute pain. B. Risk for injury. C. Sexual dysfunction. D. Deficient knowledge.

D: Deficient knowledge. An asymptomatic client with primary syphilis is most likely unaware of this disease, so to prevent transmission to others and recurrence in the client, the priority nursing diagnosis is deficient knowledge of the disease pathophysiology.

The home health nurse is teaching the family of a hospice client about pain control. Which information should the nurse include? A. Too much pain medication will cause the client to become dependent upon it. B. Pain medication should be given at regular intervals throughout a 24-hour period. C. Too much pain medication can affect the client's family about the quality of care. D. Wait to administer pain medication to the client until breakthrough pain occurs.

Pain medication should be given at regular intervals throughout a 24-hour period. Pain control is one of the primary goals of hospice care. Clients and their families should be taught that pain medication needs to be given at regularly scheduled intervals to maintain a therapeutic dose and to prevent breakthrough pain from occurring

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? A. The client's readiness to learn. B. The client's educational background. C. The order in which the information is presented. D. The extent to which the pregnancy was planned.

a. the client's readiness to learn When teaching any client, readiness to learn (A) is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be "ready to learn" about ways to relieve morning sickness.

A client receives a new prescription for an angiotensin-converting enzyme (ACE) inhibitor. What client history contraindicates its use? A. Asthma. B. Heart failure. C. Renal artery stenosis. D. Coronary artery disease.

c. Renal artery stenosis Angiotensin-converting enzyme (ACE) inhibitors can cause severe renal insufficiency in clients with bilateral renal artery stenosis or stenosis in the artery to a single remaining kidney.

A client with acute hemorrhagic anemia is to receive four units of packed red blood cells (RBCs) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs every 15 minutes for the first hour. D. Ensure the accuracy of the blood type match.

d. ensure the accuracy of the blood type match Rationale: Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. Preparing the tubing, checking the baseline hemoglobin, and monitoring vital signs should also be implemented prior to administering blood, but checking the blood type has the highest priority.