Incorrect NCLEX Questions Part 2

The emergency room nurse is caring for a Hispanic client following an anaphylactic reaction to a bee sting. The client needs education on self-administering an EpiPen for future use. Spanish is the client's primary language. Identify the proper steps the nurse needs to follow in order to correctly teach the client to use an EpiPen. All options must be used. 1 Request a Spanish-speaking interpreter. 2 Have the client take the EpiPen out of the carrying tube. 3 Tell the interpreter to tell the client to remove the outer safety release cap. 4 Demonstrate how to swing and inject firmly into the outer thigh region. 5 Show the client how to press firmly against thigh for 10 seconds and then massage. 6 Reinforce to the client to seek emergency medical attention if stung again.

A: -Request a Spanish-speaking interpreter. -Have the client take the EpiPen out of the carrying tube. -Tell the interpreter to tell the client to remove the outer safety release cap. -Demonstrate how to swing and inject firmly into the outer thigh region. -Show the client how to press firmly against thigh for 10 seconds and then massage. -Reinforce to the client to seek emergency medical attention if stung again. Rationale: The nurses priority action when teaching a client whose language is not the same as the nurse is to get an interpreter or use a phone interpreter. The next nursing actions should be teaching the client to use the EpiPen correctly, It is important to demonstrate the steps as well as just verbalize them. First, the client should remove it from the carrying tube, grasps the unit with the tip pointed downward and remove the gray outer safety-release cap. Then the client then holds the black tip near the outer thigh; swings and injects it firmly into the outer thigh until hearing a click with the device perpendicular to the thigh. Next, have the client hold the device firmly against the thigh for about 10 seconds, then removes it and massages the area for 10 seconds. Lastly, the nurse needs to reinforce that the client should always seek emergency medical attention if stung again.

During a psychotic episode, a client with schizophrenia is unable to focus on interactions. The client has cognitive disturbances and poor attention, concentration, and memory. The client also has a history of suicide attempts. The client tells the nurse, "I do not want you to contact my family. I don't even have to talk to you." Which statement is the most appropriate nursing response? -"I need you to trust me and the staff members in the facility." -"It sounds like you are not concerned about your problems and why you are in the hospital." -"This can just be between us, and I will share your progress only with the doctors and not your family." -"Anything you say about your feelings is confidential but your care involves the whole team so we can all work together."

A: "Anything you say about your feelings is confidential but your care involves the whole team so we can all work together." Rationale: Being truthful with the client and reinforcing the need for prevention of harm to self or others clarifies what the client can expect from the team. Challenging the client will contribute to a sense of low self-worth. "It sounds like you are not concerned about your problems and why you are in the hospital" is nontherapeutic and devalues the client's self-perception. Negotiating a special agreement or luring the client into the interview will not be therapeutic. "I need you to trust me and the staff members in the facility" does not offer a therapeutic way to establish trust.

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction? -"Apply ice packs for the first 12 to 18 hours." -"Apply heat packs for the first 24 to 48 hours." -"Apply ice packs for the first 24 to 48 hours, then apply heat packs." -"Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours."

A: "Apply ice packs for the first 24 to 48 hours, then apply heat packs." Rationale: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.

A parent calls the clinic to report their 9-month-old infant has had 5 soft to loose stools today, has a decreased appetite, but is alert and playing. Which advice is most appropriate for the nurse to give the parent? -"Call back if your infant has 10 stools in 1 day." -"Feed your infant clear liquids only." -"Continue your infant's normal feedings." -"Notify your infant's daycare of his illness."

A: "Continue your infant's normal feedings." Rationale: It is not unusual for infants to have several bowel movements per day, with breast-fed infants usually having more than formula-fed ones. If an infant has mild diarrhea lasting only one day with no change in energy level, the mother should be advised to continue the normal diet and to call back if the diarrhea continues or if the infant shows signs of dehydration. The nurse should teach the parent the symptoms of dehydration, such as decreased urine ouput, reduced tear production, or listlessness. There is no need to give the infant clear liquids only. Notifying the daycare about the infant's illness is important if the parent will be leaving the infant in their care, but it doesn't take priority.

The spouse of a client on hospice care expresses frustration to the nurse and states, "My spouse wants me to 'have hope' during this time, but I don't know what that means I should do." What is the nurse's most appropriate response? -"Have you considered that you provide hope by listening and supporting what is important to her?" -"Perhaps we should ask your spouse exactly how hope is defined during the process of dying." -"Sometimes people who are seriously ill act hopeful so that others do not suffer." -"I wonder if you have considered obtaining spiritual counseling for your spouse?"

A: "Have you considered that you provide hope by listening and supporting what is important to her?" Rationale: It is common for a spouse to ask what to do to be supportive of a dying partner. Hope-fostering actions include listening to the partner's wishes, communicating and sharing feelings, and being aware of what is important to the spouse. It is not necessary to have philosophical discussions about what hope means to the partner. Suggesting that the client is acting in a certain way and not being genuine is not an appropriate response. Although spiritual counseling may be helpful, this approach does not address the spouse's question and desire to be supportive.

The partner of a postpartum client asks the nurse what is wrong with the infant's mother and why she isn't more joyful about the birth of their child. Which would be the most appropriate response by the nurse? -"How many days has it been since she gave birth?" -"How many hours does she sleep at night?" -"What risk factors does she have for postpartum depression?" -"Do any family members suffer from depression?"

A: "How many days has it been since she gave birth?" Rationale: Weepiness and mood swings within the first 3 to 10 days postpartum are signs of postpartum baby blues. It would be important to know how many days postpartum the woman is to understand her symptoms better. Sleep may help to lessen the symptoms of baby blues, but this question does not assist the nurse in differentiating the mother's symptoms. It would not be important to ask the client if there are risk factors or a family history of depression at this time.

The nurse is teaching two unlicensed assistive personnel who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which statement is made? -"I need to check the client precisely at 15-minute intervals." -"Documenting suicide checks is absolutely necessary." -"Clients on one-to-one suicide precautions can never be left alone." -"All clients using razors must be supervised by staff."

A: "I need to check the client precisely at 15-minute intervals." Rationale: Clients on 15-minute suicide checks must be observed by a staff member every 15 minutes. However, the staff member must stagger the timing of the check so that the client cannot predict the precise time. The staff member could check the client at 10 minutes and then at 8 minutes, and so on, to protect the client from self-harm. The nurse would further explain the necessity of this procedure to help the staff understand its importance. Documenting that suicide checks have been done is absolutely necessary. Clients on one-to-one suicide precautions can never be left alone. All clients using razors must be supervised by staff.

The parent of an adolescent girl with Down syndrome tells the nurse that her daughter recently stated that she has a boyfriend. The parent is concerned that her daughter might become pregnant. Which is the most appropriate suggestion made by the nurse? -"I understand your concern; you may want to start your daughter on long-acting contraception." -"Women with Down syndrome are infertile, so you do not need to worry about her getting pregnant." -"I understand your concern; you may want to enroll your daughter in an abstinence program." -"This may be difficult, but you may want to suggest that your daughter break off the relationship."

A: "I understand your concern; you may want to start your daughter on long-acting contraception." Rationale: Children with Down syndrome range from having severe intellectual disability to having low average intelligence, Thus the adolescent's ability to make informed choices regarding sexual activity is limited. Long-acting contraception, such as an intrauterine device or a progestin implant, greatly reduces the risk of unwanted pregnancy. Most women with Down syndrome are fertile; however, children born to women with Down syndrome often have congenital defects. An abstinence program may not be effective due to the intellectual level of children with Down syndrome. Suggesting that the adolescent break off the relationship does not ensure that she will.

A client is scheduled for a creatinine clearance test. The client needs further instruction about preparing for the test after making which statement? -"I will restrict my protein intake for the day prior to the test to no more than 8 ounces." -"I will be sure to fast from midnight until the test begins at 8:00 am the following day." -"I can engage in normal activity the day before the test." -"I will stay well hydrated prior to the test."

A: "I will be sure to fast from midnight until the test begins at 8:00 am the following day." Rationale: The creatinine clearance test determines the kidneys' ability to remove a substance from the plasma in 1 minute. High levels of protein in the diet, especially prior to the test can lead to false abnormal test results. Similarly, staying hydrated is important, as fluid deficit or overload can also skew test results. A client may engage in normal activity the days before the test but should not engage in overly vigorous exercise, as this may cause muscle stress and alter the test results.

Which client statement indicates the need for further teaching about percutaneous umbilical blood sampling (PUBS) to assess fetal hemoglobin and hematocrit? -"I will lie on my back in a cylinder-type machine." -"My baby's heart rate might drop temporarily after this test." -"A blood transfusion can be given to my baby this way if the tests shows he needs it." -"A needle will be inserted into my belly for this test."

A: "I will lie on my back in a cylinder-type machine." Rationale: With PUBS, the client is scanned with an ultrasound, and a spinal needle is inserted into the client's abdomen and into the fetal vein. Fetal blood is aspirated into a syringe containing an anticoagulant. The client will not be placed in a cylindrical unit; this type of unit is used for magnetic resonance imaging.Transient fetal bradycardia is possible following this procedure.PUBS may be used for a fetal blood transfusion.With PUBS, the client is scanned with a linear-array ultrasound placed in a sterile glove, and a 25-gauge spinal needle is inserted into the client's abdomen and into the fetal vein. Fetal blood is aspirated into a syringe containing an anticoagulant.

The nurse is providing care for a client who is a Muslim. The client has recently received a diagnosis of type 1 diabetes and is receiving health education. What statement by the nurse best addresses this client's religious beliefs? -"Insulin used to be derived from pigs, but now it is produced synthetically." -"Diabetes likely will not have any bearing on the practices of fasting that you have followed in the past." -"You might have to begin eating some foods that are contrary to Islam in order to maintain stable blood glucose." -"You will be able to manage your diabetes while maintaining a vegetarian diet, but it requires careful management."

A: "Insulin used to be derived from pigs, but now it is produced synthetically." Rationale: A client who adheres to Islam may be concerned that insulin is porcine derived, since pork products are proscribed. Fasting produces special challenges that must be carefully addressed. There is no need to discard dietary restrictions to maintain glucose levels. Islam does not dictate a vegetarian diet.

A client is taking an antacid for treatment of a peptic ulcer. Which statement best indicates that the client understands how to correctly take the antacid? -"I should take my antacid before I take my other medications." -"I need to decrease my intake of fluids so that I do not dilute the effects of my antacid." -"My antacid will be most effective if I take it whenever I experience stomach pains." -"It is best for me to take my antacid 1 to 3 hours after meals."

A: "It is best for me to take my antacid 1 to 3 hours after meals." Rationale: Antacids are most effective if taken 1 to 3 hours after meals and at bedtime. When an antacid is taken on an empty stomach, the duration of the drug's action is greatly decreased. Taking antacids 1 to 3 hours after a meal lengthens the duration of action, thus increasing the therapeutic action of the drug. Antacids should be administered about 2 hours after other medications to decrease the chance of drug interactions. It is not necessary to decrease fluid intake when taking antacids. If antacids are taken more frequently than recommended, the likelihood of developing adverse effects increases. Therefore, the client should not take antacids as often as desired to control pain.

The nurse is caring for an adolescent with the above skin disorder. Which client statement indicates a need for further teaching? -"My breakouts are exacerbated by eating fatty foods." -"I wash my face with soap and water every morning and night." -"I use topical retinoids as prescribed at night on my skin." -"Stress and hormones worsen my breakouts."

A: "My breakouts are exacerbated by eating fatty foods." Rationale: The common skin condition on the adolescent is acne. Acne is a skin condition that occurs when hair follicles become plugged with oil and dead skin cells. Acne is not exacerbated by eating fatty foods. This information would need clarification. Treatment for acne is washing the face with soap and water and using topical retinoids. Stress and fluctuating hormones can cause acne breakouts.

A nurse completes an afternoon assessment of a client who is a nurse and who is visiting the area on vacation. The client states that the nurse must be having a busy shift and asks about the maximum number of clients that the nurse is allowed to care for. What is the nurse's best response? -"Some jurisdictions have staffing laws that allow for nurses to be involved in staffing ratios." -"Staffing laws are standardized across all jurisdictions." -"When was the last time you were involved in your staffing committee?" -"This facility does not need to disclose to the public about our staffing pattern and ratios."

A: "Some jurisdictions have staffing laws that allow for nurses to be involved in staffing ratios." Rationale: Staffing laws exist in some jurisdiction, but not others. Staffing laws tend to fall into one of three general approaches: The first is to require hospitals to have a nurse-driven staffing committee that creates staffing plans that reflect the needs of the patient population and matches the skills and experience of the staff. The second approach is for legislators to mandate specific nurse to patient ratios in legislation or regulation. A third approach is requiring facilities to disclose staffing levels to the public and/or a regulatory body. A facility is required to disclose staffing levels to the public.

The unlicensed assistive personnel (UAP) obtained vital signs on a 7-month-old infant and recorded the peripheral pulse as 85 beats/minute. The RN immediately reassesses the child's pulse and discovers the pulse is 115 beats/minute. What should the nurse teach the UAP about obtaining an accurate heart rate in an infant? -"To assess a pulse under age 1, you should check the brachial artery." -"Always assess the pulse rate after you take the blood pressure." -"Here is a copy of normal heart rates in children so you can report abnormals." -"To assess a pulse in children, always assess the apical pulse."

A: "To assess a pulse under age 1, you should check the brachial artery." Rationale: The brachial artery is the best location for evaluating the pulse of an infant younger than age 1, and a normal heart rate in this age group while awake is 100-180 beats/minute. The radial artery may not be easily palpable, causing missed beats and a potentially inaccurately low result. Providing a list of normal heart rates does not demonstrate the UAP knows how to obtain the pulse rate correctly. Taking the blood pressure first may irritate the child and cause crying, which can affect the accuracy of the heart rate assessment.

The client with Addison's disease is taking glucocorticoids at home. Which statement indicates that the client understands how to take the medication? -"Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage." -"My need for glucocorticoids will stabilize and I will be able to take a predetermined dose once a day." -"Glucocorticoids are cumulative, so I will take a dose every third day." -"I must take a dose every 6 hours to ensure consistent blood levels of glucocorticoids."

A: "Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage." Rationale: The need for glucocorticoids changes with circumstances. The basal dose is established when the client is discharged, but this dose covers only normal daily needs and does not provide for additional stressors. As the manager of the medication schedule, the client needs to know signs and symptoms of excessive and insufficient dosages. Glucocorticoid needs fluctuate. Glucocorticoids are not cumulative and must be taken daily. They must never be discontinued suddenly; in the absence of endogenous production, Addisonian crisis could result. Two-thirds of the daily dose should be taken at about 0800 and the remainder at about 1600. This schedule approximates the diurnal pattern of normal secretion, with highest levels between 0400 and 0600 and lowest levels in the evening.

Parents bring their infant to the emergency department because the child has stopped breathing. A nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which question should the nurse ask the parents first? -"Was the infant sleeping while wrapped in a blanket?" -"Was the infant lying on his stomach?" -"What did the infant look like when you found him?" -"When had you last checked on the infant?"

A: "What did the infant look like when you found him?" Rationale: Because this is an especially disturbing and upsetting time for the parents, they must be approached in a sensitive manner. Asking what the infant looked like when found allows the parents to verbalize what they saw and felt, thereby helping to minimize their feelings of guilt without implying any blame, neglect, wrongdoing, or abuse. Asking if the child was wrapped in a blanket or lying on his stomach, or when the parents last checked on the infant, implies that the parents did something wrong or failed in their care of the infant, thus blaming them for the event.

A graduate nurse is discussing verbal orders with the nurse preceptor. What statement by the graduate nurse requires the nurse preceptor to provide further teaching? -"When I receive verbal orders, they must be carried out immediately to ensure clients get prompt care." -"The date and time the verbal orders were given during the emergency need to be noted." -"When documenting verbal orders, I need to write down the health care provider's name first and follow it with my name and title." -"The verbal orders need to be recorded in the client's medical record." -"The health care provider signs the orders with the name, title, and contact information."

A: "When I receive verbal orders, they must be carried out immediately to ensure clients get prompt care." Rationale: The graduate nurse needs further teaching when saying that verbal orders need to be carried out immediately. Although orders need to be carried out right away, the nurse needs to read the verbal order back to verify accuracy first. The nurse needs to record the date and time that the verbal orders were given during the emergency. When documenting verbal orders, the nurse needs to write down the health care provider's name first and follow it with the name and title. Verbal orders need to be recorded in the client's medical record. The health care provider needs to sign the orders with the name, title, and pager number.

A nurse is teaching a client about nonpharmacologic comfort measures to alleviate postoperative pain. Which client statement indicates a need for further teaching? -"Music therapy can help me relax, so the pain won't be so bad." -"The transcutaneous electrical nerve stimulation, or TENS, unit uses an electrical stimulator to block painful stimuli." -"Applying warm moist compresses to my incision can relax my abdominal muscles." -"With patient-controlled analgesia, or PCA, I can control my pain by administering my own pain medication."

A: "With patient-controlled analgesia, or PCA, I can control my pain by administering my own pain medication." Rationale: PCA allows the client to self-administer I.V. pain medication. This intervention is not a nonpharmacologic comfort measure. Music therapy, TENS units, and heat applications are nonpharmacologic pain-relieving strategies.

A nurse is caring for an adolescent with paranoia who attempted to stab a family member. The client reports hearing voices but stabilizes after receiving haloperidol. The client's caregiver states, "There have been troubles in the past, but my child is a good person. Can I take my child home now?" Which response by the nurse is most appropriate? -"The health care provider has determined your child may be a danger to other people." -"You will need to discuss your concerns with the health care provider on duty." -"Your child is taking a very powerful medication and needs careful monitoring." -"A legal decision must be made before your child may go home."

A: "Your child is taking a very powerful medication and needs careful monitoring." Rationale: The caregiver's behavior does not indicate comprehension of the seriousness of the child's condition; the caregiver must be educated about the child's situation and how the paranoia and auditory hallucinations are managed. The nurse is in a key position to provide such education by explaining the client's medication and the need for careful monitoring. Telling the caregiver to talk with the health care provider dismisses the caregiver's concerns and deflects an opportunity to develop a therapeutic relationship. Stating the child is a danger to other people might unnecessarily alarm the caregiver and does not provide sufficient information about the child's condition. There is no indication that any legal restrictions or orders are in place.

A 54-year-old client with generalized anxiety disorder is admitted to the facility. Which therapeutic modalities are typically used to treat this disorder? Select all that apply. -Biofeedback -Buspirone therapy -Relaxation techniques -Fluphenazine therapy -Electroconvulsive therapy

A: -Biofeedback -Buspirone therapy -Relaxation techniques Rationale: Therapy for generalized anxiety disorder includes biofeedback, buspirone therapy, and relaxation techniques. Fluphenazine is prescribed to treat schizophrenia. Electroconvulsive therapy is indicated in severe depression and some cases of schizophrenia.

A nurse calls the unit manager to report that her purse has been stolen from the locked break room. The nurse says she thinks she knows which of the staff stole the purse. Which actions by the nurse manager would be appropriate? Select all that apply. -Confront the person the nurse suspects stole the purse. -Call hospital security to initiate an investigation. -Ask the nurse to document all the facts related to the missing purse. -Alert nursing administration that a staff's purse has been stolen. -Ask other staff to report any suspicious activity they may have observed.

A: -Call hospital security to initiate an investigation. -Ask the nurse to document all the facts related to the missing purse. -Alert nursing administration that a staff's purse has been stolen. -Ask other staff to report any suspicious activity they may have observed. Rationale: It is appropriate for the nurse manager to initiate a security investigation and ask the nurse to document all the facts about the missing purse. Alerting nursing administration is required. Seeking information from other staff will help with the investigation. It is inappropriate to confront any possible suspects while the investigation is ongoing.

The obstetrical triage nurse assesses a client with a term pregnancy. There has not been any change in the cervix for the past 2 hours despite irregular contractions. When discharging the client to her home, the nurse should tell the client to return to the hospital when which conditions occur? Select all that apply. -She feels more than three contractions an hour. -Contractions become more intense and closer together. -She notices vaginal bleeding. -She thinks the membranes have ruptured. -She notices an absence of fetal movement. -She feels the urge to push.

A: -Contractions become more intense and closer together. -She notices vaginal bleeding. -She thinks the membranes have ruptured. -She notices an absence of fetal movement. -She feels the urge to push. Rationale: Because there have been no cervical changes, the client is not in labor. The client should understand to return to the hospital if the contractions become more intense and regular, if she has vaginal bleeding, if she thinks her membranes rupture, if the baby is not moving, or if she has an urge to push. Three contractions an hour would be too infrequent to indicate active labor.

The nurse is preparing to interpret an ECG rhythm strip. Place the following steps for ECG rhythm analysis from first to last, in chronological order. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1 Determine the rate and rhythm. 2 Analyze the P waves. 3 Measure the PR interval. 4 Measure the QRS duration. 5 Interpret the rhythm.

A: -Determine the rate and rhythm. -Analyze the P waves. -Measure the PR interval. -Measure the QRS duration. -Interpret the rhythm. Rationale: ECG rhythm strip analysis requires a systematic approach using a five-step method. First, determine the rate and rhythm of both the atria and the ventricles. Then, analyze the P waves for consistency. Next, measure the PR interval and then the QRS duration. Finally, you can interpret the rhythm with all of the information that has been collected. If the nurse has answered all five steps within normal limits, the client is in sinus rhythm. The greater number of questions that the nurse notes inconsistent with normal limits, the greater the abnormal conduction through the heart.

A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises would the nurse provide to the child and family? Select all that apply. -Avoid foods high in folic acid. -Drink plenty of fluids. -Use cold packs to relieve joint pain. -Report a sore throat to an adult immediately. -Restrict activity to quiet board games. -Wash hands before meals and after playing.

A: -Drink plenty of fluids. -Report a sore throat to an adult immediately. -Wash hands before meals and after playing. Rationale: Sickle cell anemia is an autosomal recessive genetic disease passed down through families in which red blood cells form an abnormal sickle or crescent shape. Fluids would be encouraged to prevent stasis in the bloodstream, which can lead to sickling. Sore throats and all other cold symptoms would be reported promptly because they may indicate an infection, which can precipitate a crisis (red blood cells sickle and obstruct blood flow to tissues). Children with sickle cell anemia would learn appropriate measures to prevent infection, such as proper hand-washing techniques and good nutrition. Folic acid intake would be encouraged to help support new cell growth; new cells replace fragile sickled cells. Warm packs would be applied to promote comfort and relieve pain; cold packs cause vasoconstriction. The child would maintain an active, normal life but would avoid excessive exercise, which can precipitate an attack. When the child experiences a crisis, the child will typically limit activity according to the pain level.

The nurse is caring for a client after surgery. The client has reported at least one fall in the last 3 months. The client may ambulate with assistance, has a saline lock in place, and has demonstrated appropriate use of the call light to request assistance. What interventions should the nurse include in this client's plan of care? Select all that apply. -Choose a room down the hall from the nurses' station that will be quiet in order to give the client maximum privacy. -Ensure necessities are within the client's reach. -Identify the client as high risk with the visual identification system used at the agency. -Leave the wheelchair next to the bed for easy access. -Put all siderails up to ensure the client's safety. -Assess the client for pain and toileting needs.

A: -Ensure necessities are within the client's reach. -Identify the client as high risk with the visual identification system used at the agency. -Assess the client for pain and toileting needs. Rationale: The plan of care for all clients should ensure that their necessities are readily available, so they do not fall trying to obtain something out of reach; this client also has several factors that make the client a high fall risk. All clients who are high risk should be visually identified according to facility policy so that all providers are aware of increased fall risk. Assessing for and attending to pain and toileting needs regularly may help prevent a fall due to discomfort. Clients who are high fall risk should be placed closer to the nurses' station, so they may be monitored more closely, not further away. Leaving the wheelchair next to the bed may tempt even an alert client to get up without calling for assistance and is not in the client's best safety interest. Putting all side rails up may be considered a restraint in some facilities and is not recommended; a client intent on getting out of bed may attempt to climb over the side rails, creating further risk for falling.

The nurse is caring for a client in early labor. The client reports sudden abdominal pain and is noted to have bright red bleeding. What would the nurse include in the client's plan of care? Select all that apply. -Examine the fetal heart monitoring tracing. -Call the healthcare provider. -Administer oxygen to the client. -Examine the client's cervix. -Discontinue the IV fluid.

A: -Examine the fetal heart monitoring tracing. -Call the healthcare provider. -Administer oxygen to the client. Rationale: The client's symptoms describe placental abruption. The placenta has torn away from the uterine lining. Because of this, the mother and baby can both bleed to death. The fetal monitor tracing will help the nurse evaluate the ability of the fetus to tolerate the loss of blood. Because of the nature of placental abruption, the healthcare provider will need to know. Administering oxygen will help support the client and the fetus. Examining the cervix with active bleeding is contraindicated without further information. The client and fetus will need IV access for fluid replacement.

The nurse is caring for a client who is administering insulin for diabetes mellitus for the first time. The nurse is instructing the client on mixing Humulin N insulin and Humulin R insulin in one syringe. Arrange the instructions in order. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1 Gently roll both insulins between your hands. 2 Wipe with alcohol and inject air (equal to units ordered) into the Humulin N insulin. 3 Wipe with alcohol and inject air (equal to units ordered) into the Humulin R insulin. 4 Withdraw the Humulin R. 5 Withdraw Humulin N insulin. 6 Double check the total number of units in syringe.

A: -Gently roll both insulins between your hands. -Wipe with alcohol and inject air (equal to units ordered) into the Humulin N insulin. -Wipe with alcohol and inject air (equal to units ordered) into the Humulin R insulin. -Withdraw the Humulin R. -Withdraw Humulin N insulin. -Double check the total number of units in syringe. Rationale: Mixing insulin requires careful consideration. Both insulins are gently rolled to warm. Do not shake. Wipe the caps and inject air, first into the Humulin N and then Humulin R. Turn the Humulin R vial upside down and withdraw the number of units prescribed. Next, withdraw Humulin N. Double check syringe total against order.

A client has radiation seeds implanted into the prostate gland. Which action should the nurse take to safely provide care to this client? Select all that apply. -Learn the safe distance from the client. -Identify the safest amount of time to be at the bedside. -Obtain the necessary shielding when providing care. -Explain that the implanted seeds will be expelled through the urine. -Place a permanent divider to shield the client in a semi-private room.

A: -Learn the safe distance from the client. -Identify the safest amount of time to be at the bedside. -Obtain the necessary shielding when providing care. Rationale: Clients receiving internal radiation emit radiation while the implant is in place. Because of this, actions should be taken to prevent accidental exposure. The principles of time, distance, and shielding should be implemented to minimize the risk of radiation exposure. The safe distance should be identified. The safest amount of time that the nurse can be at the bedside should be identified. The type of shielding that care staff should wear must be identified and obtained. Expelling the seeds through the urine would not protect the nurse when providing care. The client with implantable radiation should always be in a private, not a semi-private, room.

The nurse is asked to develop an in-service to explain documents guiding professional nursing practice on the obstetrical unit. One of the documents included is the Code of Ethics. The nurse correctly explains that the Code of Ethics asks nurses to demonstrate which behaviors? Select all that apply. -Maintain integrity and shape social policy. -Develop, maintain, and improve health care environments. -Ask the hospital for fair compensation for work. -Be responsible and accountable for individual practice. -Increase professional competence and personal growth.

A: -Maintain integrity and shape social policy. -Develop, maintain, and improve health care environments. -Be responsible and accountable for individual practice. -Increase professional competence and personal growth. Rationale: The Code of Ethics describes those actions by the nurse that guide their practice. It is the responsibility of each nurse to be active in determining policy for health care for all citizens and assuring that the way nursing is practiced is of the highest caliber. Nursing needs to participate in the development of health care of the future, while caring for all members of society. In order to be productive in shaping policy, nurses need to be politically astute while growing personally and professionally to meet the needs of clients. The Code of Ethics does not address compensation for work.

The nurse is providing care for a client who has had a stroke. Since the onset of symptoms, the client has been experiencing left-sided hemianopsia. Which nursing interventions are appropriate? Select all that apply. -Place the client's belongings on the right side of the bed. -Approach the client from the left side. -Refuse to acknowledge the condition to promote the client's independence. -Stand on the right side of the bed when providing care. -Provide the client with an eye patch for the right eye. -Dim the lights in the room to prevent eye strain.

A: -Place the client's belongings on the right side of the bed. -Stand on the right side of the bed when providing care. Rationale: Hemianopsia is a condition in which the client has lost half of the visual field. It is most often associated with a stroke. In this case, the stroke has affected the client's left side; therefore, placing belongings on the right side of the bed will enable the client to best see them. Standing on the right side of the bed when providing care will ensure the client is able to see the nurse. Approaching the client from the left side is counterproductive because the client would not be able to adequately see the nurse. Using an eye patch or dimming the lights will not help with treating or managing the condition.

A nurse is preparing a teaching plan for a newly married female client with a cervical (C5) spinal cord injury. The client does not want to become pregnant at this time. What sexuality teaching will be important for the nurse to include? Select all that apply. -Provide brochures on adaptations for sexual practice. -Provide her husband with a vasectomy referral. -Encourage her to be patient and practice a variety of sexual techniques. -Instruct the client's spouse on how to properly insert a diaphragm. -Suggest she ask her spouse to substitute a vibrator in place of intercourse.

A: -Provide brochures on adaptations for sexual practice. -Encourage her to be patient and practice a variety of sexual techniques. -Instruct the client's spouse on how to properly insert a diaphragm. Rationale: The C5 cervical injury client will have paralysis of the legs, torso, wrists, and hands. Patience and adaptations for sexuality practices are to be encouraged for the couple because of the cervial injury.This client will not be able to insert any form of contraception by herself. If the couple does not use condoms, it is vital to provide her husband with instruction on insertion of a diaphragm. Providing the couple with literature on sexual practice will help to pave the way for discussion. While the couple does not wish to have children at this time, there is no indication that they never want to have children; therefore, providing a vasectomy referral is not appropriate. Suggesting that the couple suspend intercourse is an intimate decision that they should arrive at on their own, after exploring multiple options. It is premature and inappropriate to advise the use of a vibrator as a substitute for sexual intercourse for this newly married couple.

A nurse selects a priority nursing diagnosis of Fear related to being embarrassed in the presence of others for a client who exhibits symptoms of social phobia. Which outcomes, if met, would demonstrate improvement in client's symptoms? Select all that apply. -The client manages fear in group situations. The client develops a plan to avoid situations that may cause stress. -The client verbalizes feelings that occur in stressful situations. -The client develops a plan for responding to stressful situations. -The client denies feelings that may contribute to irrational fears. -The client uses antianxiety medication to deal with underlying fears.

A: -The client manages fear in group situations. -The client verbalizes feelings that occur in stressful situations. -The client develops a plan for responding to stressful situations. Rationale: When selecting an outcome for a nursing diagnosis, choose a statement that would demonstrate the progressing toward or achievement of the short-term or long-term goal. Improving stress management skills, verbalizing feelings, and anticipating and planning for stressful situations are adaptive responses to stress. Avoidance and denial are maladaptive defense mechanisms. Using antianxiety medication may be appropriate but does not indicate an improvement in client symptoms.

A student nurse is questioning a nursing instructor about the responsibility to have malpractice insurance. The nursing instructor confirms the safeguard of malpractice insurance by emphasizing which points regarding student liability? Select all that apply. -The student nurse is responsible for the student nurse's actions. -The student nurse is held to the same standard of care as a nurse. -The student can practice as an employee during clinical experiences. -The student nurse is not responsible for knowing the facility's policy and procedures. -The nursing instructor can be liable if the assignment is above the student's competency.

A: -The student nurse is responsible for the student nurse's actions. -The student nurse is held to the same standard of care as a nurse. -The nursing instructor can be liable if the assignment is above the student's competency. Rationale: Student nurses are responsible for their actions and are held to the same standard of care as a nurse. The nursing instructor can be liable if the student assignment is above the student's competency. Students can practice as employees during an educational clinical experience. Students are responsible to be familiar with hospital policy and procedures.

The nurse at a long-term care facility is caring for a client who has just died. At the bedside is the older adult spouse. Which nursing actions are appropriate at this time? Select all that apply. -allowing facility staff to express their sympathy to the spouse -advising the spouse to make the final arrangements talking about common interests to decrease the stress of the death -using therapeutic communication to support expression of feelings -assisting the spouse with the acceptance of the reality of the loss -setting a time frame for visitation with the deceased

A: -allowing facility staff to express their sympathy to the spouse -using therapeutic communication to -support expression of feelings assisting the spouse with the acceptance of the reality of the loss Rationale: The loss of a spouse is one of life's most difficult times. After a death, it is appropriate to have others who have cared for the client express their sympathy to the loved ones. This can be a comforting act. By using therapeutic communication, the nurse supports the expression of feelings assisting in the acceptance of the loss. Both are therapeutic for the spouse. Talking about common interests does not decrease the stress or fact that there has been a death. After a client has just died, it is inappropriate to suggest that the spouse make final arrangements or set a time limit for visitation with the deceased.

A pregnant client at 32 weeks' gestation has mild preeclampsia. She is discharged to home with instructions to remain on bed rest. She should also be instructed to call her healthcare provider if she experiences which symptoms? Select all that apply. -headache -increased urine output -blurred vision -difficulty sleeping -epigastric pain -severe nausea and vomiting

A: -headache -blurred vision -epigastric pain -severe nausea and vomiting Rationale: Headache, blurred vision, epigastric pain, and severe nausea and vomiting can indicate worsening maternal disease. Decreased, not increased, urine output is a concern because it could indicate renal impairment. Difficulty sleeping, a common complaint during the third trimester, is only a concern if it's caused by any of the other symptoms.

The nurse is instructing a client who follows Hindu dietary guidelines to increase protein in the diet. Which foods are appropriate to include in this client's diet? Select all that apply. -lentil soup -hamburger -steak -veal cutlet -broiled fish sandwich

A: -lentil soup -broiled fish sandwich Rationale: Hindus do not eat beef. Sufficient protein can be obtained from lentils and fish.

Which are appropriate identifiers to use when providing care or administering medications or treatments? Select all that apply. -room number -bed number -medical record number -name band -social security (social insurance) number

A: -medical record number -name band Rationale: A National Patient Safety Goal of the Joint Commission is to improve the accuracy of client identification; to attain that goal, health care personnel must use at least two client identifiers when providing care, treatment, or services. The medical record<glicon> number and name as printed on the client's name band are appropriate identifiers. Because the client can change rooms and beds, these are not to be used as identifiers. Social security numbers are not used as identifiers for health care or treatment purposes.

A home health nurse is providing care to a palliative care client with liver cancer. Which classifications of medications are anticipated on the medication administration record? Select all that apply. -chemotherapeutics -narcotics -depressants -stool softeners -antiemetics

A: -narcotics -stool softeners -antiemetics Rationale: The client with liver cancer who is also a palliative care client has decided to focus on quality of life and symptom management instead of curative treatment. Narcotics for pain relief, stool softeners to maintain a bowel regiment in light of narcotic use, and antiemetics to control nausea and vomiting all assist the client to meet these goals. Chemotherapeutic agents are aggressive therapy to kill liver cancer cells. Antidepressants are used for symptoms of depression.

The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply. -pepperoni pizza -oatmeal -bacon -cheese -apple juice -soft drinks

A: -pepperoni -pizza -bacon -cheese -soft drinks Rationale: Foods high in sodium include cheese, processed meats such as pepperoni and bacon, and soft drinks. Bacon and cheese also have a high fat content.

A client is admitted to the hospital with an exacerbation of multiple sclerosis after an MRI revealed progressive demyelination. The nurse should assess for which symptom? Select all that apply. -progressive weakness of the extremities -loss of cognition -increased appetite -inability to ambulate independently -urinary incontinence

A: -progressive weakness of the extremities -inability to ambulate independently -urinary incontinence Rationale: Multiple sclerosis is a chronic, progressive disease that results in the destruction of the myelin sheath. This eventually affects the proper transmission of nerve impulses and results in weakness of the extremities with exacerbations and remissions where the client may be wheelchair dependent. In later stages, urinary incontinence is present due to the lack of tone to the bladder. Increased appetite and loss of cognition are not symptoms of multiple sclerosis. The appetite may decrease due to weakness of muscles that involve chewing. Cognition is not affected. The client continues to be alert and oriented despite the other widespread neurological impairments.

The nurse is assessing a client's data with primary glomerular disease. Which assessment data will the nurse expect to verify progression to nephrotic syndrome? Select all that apply. -hypotension -proteinuria -diffuse edema -low serum cholesterol -hypoalbuminemia

A: -proteinuria -diffuse edema hypoalbuminemia Rationale: The nurse will see proteinuria, diffuse edema, and hypoalbuminemia with nephrotic syndrome. Hypertension and elevated serum cholesterol are associated with nephrotic syndrome.

The nurse is teaching a client about the pathophysiology of asthma. Place in chronological order the sequence of an asthma attack. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1 trigger by stimulus 2 inflammation 3 mucous production 4 airflow limitation 5 breathlessness 6 acute asthma attack

A: -trigger by stimulus -inflammation -mucous production -airflow limitation -breathlessness -acute asthma attack Rationale: Asthma is triggered by a stimulus. The stimulus may be environmental, stress related, or medication related. Inflammation in the airways occurs as a response to the stimulus, followed by an increase in mucus production. The presence of inflammation and mucous narrow the bronchi, causing limited airflow. At this point, the client experiences breathlessness, chest tightness, and wheezing—all symptoms of an acute asthma attack.

The nurse is caring for a seven-month-old infant with bronchiolitis. Which symptoms would the nurse expect to find during their assessment? Select all that apply. -wheezing -respiratory rate of 46 -heart rate of 128 -respiratory rate of 68 -heart rate of 82 -poor feeding

A: -wheezing -heart rate of 128 -respiratory rate of 68 -poor feeding Rationale: Severe bronchiolitis is characterized by increased respiratory effort, including tachypnea, wheezing, nasal flaring and intercostal, subcostal and suprasternal retractions. Lethargy and poor feeding accompany severe cases. The heart rate is typically normal, or slightly increased. A heart rate of 82 is considered bradycardic in this age group and would be a sign of impending cardiac compromise. A respiratory rate of 46 is normal for this age.

Which client, diagnosed with pneumonia, is most likely to have community-acquired pneumonia? -A client newly admitted to a long-term care facility -A client who recently traveled on a cruise ship -A client who has had multiple family visitors -A client whose spouse recently died

A: A client newly admitted to a long-term care facility Rationale: The client who is a new resident in a long term care facility is at high risk for community-acquired infections. Traveling is not likely to cause community-acquired pneumonia. Legionnaires' disease is a risk if traveling on a confined cruise ship. Receiving family visits and the death of a spouse are not typically causative factors associated with developing community-acquired pneumonia.

A newly admitted client diagnosed with paranoid schizophrenia is pacing rapidly and wringing his hands. He states that another client is out to get him. Then he says, "Protect me, select me, reject me." What should the nurse do next? -Administer his oral PRN lorazepam and haloperidol. -Place the client in temporary seclusion. -Call the health care provider (HCP) for a prescription for restraints. -Ask the other clients to leave the immediate area.

A: Administer his oral PRN lorazepam and haloperidol. Rationale: The client's anxiety as reflected in rapid pacing and clang associations is rising as a result of his paranoid delusions. Administering the lorazepam and haloperidol will help the anxiety and delusions. The client is not threatening others at this point, so seclusion, restraints, and asking clients to leave the area is not necessary.

What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy? -Antibiotics will need to be taken for 1 to 2 weeks. -Arm exercises will get rid of the cellulitis. -Ice pack should be applied to the affected area for 20 minute periods to reduce swelling. -The right extremity should be lowered to improve blood flow to the forearm.

A: Antibiotics will need to be taken for 1 to 2 weeks. Rationale: Treatment for cellulitis includes oral or intravenous antibiotics for 1 to 2 weeks, elevation of the affected extremity, and application of warm, moist packs to the site. Arm exercises help to reduce swelling, but do not treat the infection.

Following a scleral buckling, what should the nurse instruct the client to do during the postoperative period? -Perform deep breathing and coughing every 2 hours. -Assess for eye drainage. -Apply pressure dressings to both eyes. -Maintain strict bed rest.

A: Assess for eye drainage. Rationale: After eye surgery, the client should be taught to assess for excessive or purulent drainage that may indicate infection.Coughing should be avoided as this increases intraocular pressure.Pressure dressings are not applied to the eyes after surgery, although general eye patching may be used temporarily.Activity may vary but usually does not require strict bed rest.

A client is progressing through labor and has a gush of dark blood. What is the nurse's best action? -Assess placenta as expelled. -Instruct the client to take deep breaths. -Take vital signs and report to healthcare provider. -Turn client to left side.

A: Assess placenta as expelled. Rationale: A gush of blood may indicate the delivery of the placenta. It should be assessed for veins and arteries. The client does not need to be repositioned or given breathing instructions. Vital signs are not indicated at this time during labor.

The nurse is caring for a client who is 1 day post total hip replacement. The client has patient-controlled analgesia (PCA) but is reporting pain. Which action would be most important for the nurse to take in relation to the client's pain management? -Push the PCA button for the client to give a needed dose of pain medication. -Check the pump to determine how much medication the client has received. -Explain the use of PCA to the client and confirm that the client understands. -Assess the client's pain to determine whether the PCA dosage is adequate.

A: Assess the client's pain to determine whether the PCA dosage is adequate. Rationale: If the client continues to have pain despite the use of PCA, the nurse needs to do a thorough pain assessment to determine whether the client is receiving an adequate amount of medication. PCA is a patient-controlled device, and the nurse should not administer the dose. Although an explanation of how to use the pump is necessary, teaching is best conducted when the client is not in pain.

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? -Sit quietly with the client until the episode is over. -Ignore the behavior. -Attempt to divert the client's attention. -Tell the client that this behavior is unacceptable.

A: Attempt to divert the client's attention. Rationale: A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client's attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client's sense of isolation. Telling the client to stop is inappropriate.

After uncomplicated abdominal surgery, which measure would be most appropriate when determining if an alert school-aged child is ready to drink fluids? -Ask if the child wants something to drink. -Auscultate the child's abdomen for bowel sounds. -Determine that the child has a gag reflex. -Palpate the epigastric area for discomfort.

A: Auscultate the child's abdomen for bowel sounds. Rationale: After uncomplicated abdominal surgery, fluid intake resumes early in the postoperative period. However, before giving fluids, the nurse needs to auscultate the child's abdomen for bowel sounds, which indicate the return of peristalsis and a functioning GI tract. Fluids are withheld until bowel sounds are heard.Asking the child if he or she wants something to drink is inappropriate because medications used before and during surgery may cause thirst. Additionally, the child's degree of thirst is not an indicator for peristalsis.Determining if a gag reflex is present would be more appropriate for a child having undergone an upper GI procedure such as gastroscopy. Having a gag reflex is usually not a concern in a child who is alert and has had uncomplicated abdominal surgery.Palpating the epigastric area or abdomen for discomfort provides no information about the function of the GI tract. Pain is likely because the child has had abdominal surgery.

While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer a prescribed vitamin K intramuscular injection at 1 hour after birth. Which action should the nurse do first? -Bathe the neonate. -Place the neonate under a radiant warmer. -Wash the injection site with povidone-iodine solution. -Wait until the first dose of antiretroviral medication is given.

A: Bathe the neonate Rationale: Newborns are typically bathed 2 to 4 hours after birth when their temperatures have had time to stabilize, but early/immediate bathing is recommended for the infants of HIV-positive mothers to decrease blood exposure. Placing the neonate under the radiant warmer for the vitamin K injection is not necessary unless the neonate's temperature is subnormal. Washing the injection site with povidone-iodine is not recommended and may increase the risk for possible allergy to iodine preparations. The first dose of zidovudine is given when the newborn is 6 to 12 hours old, but vitamin K is recommended to be given within an hour of birth to be most effective. Therefore the vitamin K should not be delayed.

While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer a prescribed vitamin K intramuscular injection at 1 hour after birth. Which action should the nurse do first? -Bathe the neonate. -Place the neonate under a radiant warmer. -Wash the injection site with povidone-iodine solution. -Wait until the first dose of antiretroviral medication is given.

A: Bathe the neonate. Rationale: Newborns are typically bathed 2 to 4 hours after birth when their temperatures have had time to stabilize, but early/immediate bathing is recommended for the infants of HIV-positive mothers to decrease blood exposure. Placing the neonate under the radiant warmer for the vitamin K injection is not necessary unless the neonate's temperature is subnormal. Washing the injection site with povidone-iodine is not recommended and may increase the risk for possible allergy to iodine preparations. The first dose of zidovudine is given when the newborn is 6 to 12 hours old, but vitamin K is recommended to be given within an hour of birth to be most effective. Therefore the vitamin K should not be delayed.

Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next? -Bring a small glass of juice, and locate the client. -Call the client's health care provider (HCP). -Check the computerized care plan to determine what test was scheduled. -Send the nurse's assistant to the X-ray department to bring the client back to his room.

A: Bring a small glass of juice, and locate the client. Rationale: Glulisine is a rapid-acting insulin with an action onset of 15 minutes. The client could experience hypoglycemia with the insulin in the bloodstream and no breakfast. It is not necessary to call the client's HCP; the nurse should determine what test was scheduled and then locate the client and provide either breakfast or 4 oz (120 mL) of fruit juice. To bring the client back to the room would be wasting valuable time needed to prevent or correct hypoglycemia.

A client is receiving CPR from paramedics as he arrives in the emergency department (ED). The paramedics are ventilating the client through an endotracheal tube placed prior to transport. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of 55 bpm with a palpable pulse. Which action should the nurse take first? -Start an IV line and administer amiodarone -Check ET tube placement -Obtain an arterial blood gas (ABG) sample -Administer 1 mg atropine IV

A: Check ET tube placement Rationale: Endotracheal tube placement should be confirmed as soon as the client arrives in the ED. Once the airway is verified, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should establish IV access. If the client experiences symptomatic bradycardia, atropine should be administered as ordered. The ABG sample would verify effectiveness of CPR ventilations. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation, and atrial flutter.

If a client's central venous catheter accidentally becomes disconnected, what should a nurse do first? -Call the physician. -Apply a dry sterile dressing to the site. -Clamp the catheter. -Tell the client to take and hold a deep breath.

A: Clamp the catheter. Rationale: If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the physician, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.

A client with ascites is experiencing severe respiratory distress and refuses endotracheal intubation. What should be the nurse's first action? -Inform the physician of the client's decision. -Have the client sign a do-not-resuscitate (DNR) form. -Determine whether the family has been consulted. -Determine whether the client is competent to make the decision.

A: Determine whether the client is competent to make the decision. Rationale: Informed decision-making requires that the decision be voluntary, that the client have the capacity and competence to understand their decision, and that the client have adequate information on which to base the decision. In this instance, the nurse must determine whether the client is competent to refuse endotracheal intubation because severe respiratory distress leads to hypoxemia, which may impair the client's ability to make the decision. The nurse should inform the physician of the client's decision after determining the client's competency. A DNR form requires a physician's order, and the physician is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights guarantees the client autonomy to make decisions about their care plan, including the right to refuse recommended treatment. As an advocate, the nurse should support the client's decision, which may be in opposition to family members' opinions.

A nurse on a labor and birth unit goes to the cafeteria for lunch with colleagues. One colleague begins talking about a newer staff member and says, "I heard that she does not have any labor and birth nursing experience." Which is the nurse's most appropriate action? -Discuss the colleague's behavior in private. -Confront the colleague immediately to prevent causing additional harm. -Ignore the comment because it is not considered harmful. -Ask how the colleague knows this information.

A: Discuss the colleague's behavior in private. Rationale: This behavior is unprofessional and breaches client confidentiality as per the American Nurses Association (Canadian Nurses' Association) Code of Ethics. The nurse is obligated to approach the colleague and discuss inappropriate behaviors. Therefore, it is inappropriate to ignore the comment. Discussing this in private demonstrates professional conduct rather than confronting the colleague immediately. It is inappropriate to ask how the colleague knows this information because doing so would contribute to the unprofessional behavior.

On the first day after abdominal surgery, the nurse auscultates a client's abdomen for bowel sounds; there are none. What should the nurse do next? -Notify the health care provider (HCP). -Ask another nurse to validate the absence of bowel sounds. -Encourage the client to take more ice chips. -Document assessment findings in the client's medical record.

A: Document assessment findings in the client's medical record. Rationale: Bowel sounds are not present until the third or fourth postoperative day; the nurse should document the assessment findings. Too many ice chips may promote abdominal distention, especially if the client is not ambulating in the intermediate postoperative period.

A client with venous insufficiency reports swelling in the feet and ankles. What is the most appropriate intervention for the nurse to recommend? -Limit fluid intake after 8 pm. -Buy well-fitting walking shoes. -Elevate the feet several times a day. -Wear a pair of knee-high support hose.

A: Elevate the feet several times a day. Rationale: Elevating the feet will promote venous return and decrease foot and ankle edema. Limiting fluid intake is not recommended unless there are additional medical complications such as heart failure; limiting fluids after 8 pm can help with nocturia but time is irrelevant to edema prevention. Buying walking shoes will not necessarily decrease edema. Over-the-counter knee-high "support hose" are not the same as medical-grade graduated compression stockings, and there are some contraindications to compression that should first be ruled out. Therefore, the nurse should not recommend this intervention unless the elevation of legs fails to solve the edema, at which time the client should consult the health care provider about the use of medically approved compression stockings.

A college student comes to the campus health care center with reports of headache, malaise, and a sore throat that has worsened over the past 10 days. The nurse measures a temperature of 102.6° F (39.2° C) and finds an enlarged spleen and liver and exudative tonsillitis. Laboratory tests reveal a leukocyte count of 20,000/mm3, antibodies to Epstein-Barr virus, and abnormal liver function tests. What are the nurse's priority action(s)? -Administer antibiotics orally. -Transfer student to acute care setting. -Treat headache and hold food. -Encourage fluids and treat fever.

A: Encourage fluids and treat fever. Rationale: The client's clinical manifestations and laboratory test results suggest infectious mononucleosis. Although the WBC's are elevated, a virus is present so antibiotics would be ineffective. The client requires rest, fluids, and fever treatment. The client is not sick enough to require hospitalization.

A laboring client provides the nurse with the birth plan that she wishes to follow. The birth plan expresses that the client wishes for her partner to do the coaching through her contractions. What is the best way for the nurse to meet this family's needs during labor and birth? -Enter the birthing room as few times as possible to do the required assessments. -Enter the birthing room only when requested. -Stay in the room as much as possible because they will likely require support. -Contact the physician to discuss the birth plan.

A: Enter the birthing room as few times as possible to do the required assessments. Rationale: The birth plan is a vehicle for communicating to the healthcare providers the family's desires regarding the birth attendant; birth setting; support person; and activities during labor, birth, and the postpartum period. The nurse should collaborate with the couple to respect their plans and privacy while achieving the goals of safe childbirth. It is incorrect to contact the physician; the plan should be discussed directly with the couple to ensure understanding of their desires. It is critical that the nurse does enter the room to perform the required assessments, and not only when requested, to ensure safety of both mother and baby.

The nurse is serving on the hospital ethics committee that is considering the ethics of a proposal for the nursing staff to search the room of a client diagnosed with substance abuse while he is off the unit and without his knowledge. What should be considered concerning the relationship of ethical and legal standards of behavior? -Ethical standards are generally higher than those required by law. -Ethical standards are equal to those required by law. -Ethical standards bear no relationship to legal standards for behavior. -Ethical standards are irrelevant when the health of a client is at risk.

A: Ethical standards are generally higher than those required by law. Rationale: Some behavior that is legally allowed might not be considered ethically appropriate. Legal and ethical standards are often linked, such as in the commandment "Thou shalt not kill." Ethical standards are never irrelevant, though a client's safety or the safety of others may pose an ethical dilemma for health care personnel. Searching a client's room when he or she is not there is a violation of privacy. Room searches can be done with a HCP's prescription and generally are done with the client present.

The family members of a client with mild dementia are asking the nurse about permitting the elderly father to prepare an advance directive. Which information would be essential for the nurse to include in a discussion with this family? -Discuss how careful the family needs to be if they allow a person with mild dementia to develop an advance directive. -Facilitate a conversation with the family that addresses if this is the client's way of telling the family that the client wants to die. -Explain that the client may have some ideas and some ability to make certain decisions about what is wanted at end of life. -Suggest to the family that the client be evaluated psychiatrically to determine if the client should construct an advance directive.

A: Explain that the client may have some ideas and some ability to make certain decisions about what is wanted at end of life. Rationale: A client with mild dementia may have adequate cognitive ability to contribute to discussing and making end-of-life care decisions, as well as identifying the person to serve as the health care proxy decision maker. It is not necessary to have a complete psychiatric evaluation prior to preparing an advance directive, nor is it necessary to be cautious about encouraging the client to discuss end-of-life wishes. Discussions about advance directives are about having wants met and wishes fulfilled.

What position should the nurse use for the client with peripheral arterial disease (PAD) to enhance blood supply? -prone with head turned to one side -dorsal recumbent with legs separated -Fowler with lower extremities in neutral position -supine with lower extremities elevated

A: Fowler with lower extremities in neutral position Rationale: Arterial blood supply to a body part can be enhanced by positioning. For clients with PAD, blood flow to the lower extremities needs to be enhanced; therefore, the lower extremities should be kept in a neutral or dependent position. Fowler position is the head of the bed up with legs in neutral position. Prone with head turned to one side has the client on the abdomen and is not best to enhance blood supply. Dorsal recumbent with legs separated does not position the legs neutrally or dependent and would not increase blood supply. Supine with lower extremities elevated would not increase blood supply to the lower extremities and should be avoided.

A nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement? -Give the medication on an empty stomach. -Warn the client that they'll experience mouth dryness. -Give the medication before meals with a small amount of food. -Administer the medication for complaints of muscle weakness or difficulty swallowing.

A: Give the medication before meals with a small amount of food. Rationale: Because neostigmine's onset of action is 45 to 75 minutes, it should be administered at least 45 minutes before eating to improve chewing and swallowing. Taking neostigmine with a small amount of food rather than on a completely empty stomach reduces GI adverse effects. Adverse effects of the medication include increased salivation, bradycardia, sweating, nausea, and abdominal cramps. Neostigmine must be given at scheduled times to ensure consistent blood levels.

Which of the following should the nurse include in the teaching plan for the parents of a child who is receiving methylphenidate? -Give the medication at the same time every evening. -Have the child take two doses at the same time if the last dose was missed. -Give the single-dose form of the medication early in the day. -Allow concurrent use of any over-the-counter medications with this drug.

A: Give the single-dose form of the medication early in the day. Rationale: The single-dose form of methylphenidate should be taken 10 to 14 hours before bedtime to prevent problems with insomnia, which can occur when the daily or last dose of the medication is taken within 6 hours (for multiple dosing) or 10 to 14 hours (for single dosing) before bedtime. It is recommended that a missed dose be taken as soon as possible; the dose is skipped if it is not remembered until the next dose is due. Any other medication, including over-the-counter medications, should be discussed with the health care provider (HCP) before use to eliminate the risk of a possible drug interaction.

A 15-year-old with acute lymphocytic leukemia has been caught hiding her oral chemotherapy each morning. Which nursing intervention will improve compliance? -Have the child meet teenage survivors of cancer who were compliant with treatment. -Notify the physician to talk to the teenager and the family about compliance. -Give written and internet resources of information about the disease process and implications of noncompliance. -Discuss the noncompliance with the parents, child, and physician, setting limits and taking away privileges until the child complies.

A: Have the child meet teenage survivors of cancer who were compliant with treatment. Rationale: Have the teenager talk to other teenagers who are going through similar experiences. Talking to age-appropriate peers will make a bigger impact than trying to force the teenager to conform.

A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next? -Use the McDonald procedure to widen the pelvic opening. -Increase the rate of oxygen and intravenous fluids. -Instruct the client to use a pant-blow pattern of breathing. -Tell the client to push only when absolutely necessary.

A: Instruct the client to use a pant-blow pattern of breathing. Rationale: Pushing during the first stage of labor, when the urge is felt but the cervix is not completely dilated, may produce cervical swelling, making labor more difficult. The client should be encouraged to use a pant-blow (or blow-blow) pattern of breathing to help overcome the urge to push. The McDonald procedure is used for cervical cerclage for an incompetent cervix and is inappropriate here. Increasing the rate of oxygen and intravenous fluids will not alleviate the pressure that the client is feeling. The client should not push even if she feels the urge to do so because this may result in cervical edema at 7-cm dilation.

The toddler with nephrotic syndrome responds to treatment and is ready to go home. When helping the family plan for home care, the nurse should include which instruction in the teaching? -Administer pain medication as needed. -Keep the child away from others with an infection. -Notify the health care provider (HCP) if there is an increase in the child's urine output. -Administer acetaminophen daily.

A: Keep the child away from others with an infection. Rationale: A child recovering from nephrotic syndrome should be protected from infection. Therefore, the nurse would teach the parents to keep the child away from others with an infection. Because pain is not associated with this disorder, pain medication typically is not needed. The HCP should be notified if urine output decreases, not increases. In children recovering from nephrotic syndrome, there is no reason to administer acetaminophen daily.

The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate? -Have the client wear eyeglasses at all times. -Lightly tape the eyelid shut. -Instill artificial tears once every shift. -Clean the eyelid with a washcloth every shift.

A: Lightly tape the eyelid shut. Rationale: When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.

The nurse is monitoring a client, who is six hours post embolectomy, for an acute arterial occlusion of the left leg. When a Doppler ultrasound fails to detect a pedal pulse, the nurse notifies the surgeon who requests that the client be prepared for immediate surgery. The client refuses to consider additional surgery. What is the nurse's initial intervention? -Reinforce the risks of not having the surgery -Notify the provider immediately -Notify the nursing supervisor -Record the client's refusal in the nurses' notes

A: Notify the provider immediately Rationale: The nurse should notify the health care provider. The health care provider is responsible for providing information regarding the procedure, risks, benefits and expected outcomes. After notifying the provider, the nurse should document the situation and client response in the client's record.

At the beginning of the shift on the postpartum unit, a charge nurse notices that the licensed practical nurse (LPN) working with the charge nurse is acting inappropriately and smells of alcohol. When the charge nurse confronts the LPN, the LPN apologizes and promises never report to work in this condition again. Which step should the charge nurse take next? -Rearrange the nursing assignment so that the LPN performs paperwork for the rest of the shift. -Notify the shift supervisor and rearrange the client care assignment. -Assign the LPN to the nursery to sit and rock babies. -Tell the LPN this behavior is irresponsible and that it better not happen again.

A: Notify the shift supervisor and rearrange the client care assignment. Rationale: The charge nurse should notify the shift supervisor and rearrange the client care assignment. An impaired worker can't remain in the clinical area doing paperwork or taking care of neonates in the nursery. The LPN should be escorted from the area by the shift supervisor. Telling the LPN that this behavior is irresponsible and warning that the incident better not reoccur doesn't help the impaired worker. The impaired worker should receive counseling to overcome the problem.

The nurse is developing a teaching plan the client with viral hepatitis. What information should the nurse include in the plan? -Obtain adequate bed rest. -Increase fluid intake. -Take antibiotic therapy as ordered. -Drink 8 oz (240 mL) of an electrolyte solution every day.

A: Obtain adequate bed rest. Rationale: Treatment of hepatitis consists primarily of bed rest with bathroom privileges. Bed rest is maintained during the acute phase to reduce metabolic demands on the liver, thus increasing its blood supply and promoting liver cell regeneration. When activity is gradually resumed, the client should be taught to rest before becoming overly tired. Although adequate fluid intake is important, it is not necessary to force fluids to treat hepatitis. Antibiotics are not used to treat hepatitis. Electrolyte imbalances are not typical of hepatitis.

While reviewing a client's chart, the nurse notices that the client has myasthenia gravis. Which statement about neuromuscular blocking agents is true for a client with this condition? -The client may be less sensitive to the effects of a neuromuscular blocking agent. -Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage. -Pancuronium shouldn't be used; succinylcholine may be used in a lower dosage. -Pancuronium and succinylcholine both require cautious administration.

A: Pancuronium and succinylcholine both require cautious administration. Rationale: The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis because of the potential for prolonged recovery times. Such a client isn't less sensitive to the effects of a neuromuscular blocking agent. Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with myasthenia gravis.

A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that the blood pressure is 96/60 mm Hg, with a heart rate of 120 bpm. The client just vomited coffee-ground-like material. Based on these data what should the nurse do first? -Administer an antiemetic. -Prepare to insert a nasogastric (NG) tube. -Collect data regarding recent client stressors. -Place the client in a modified Trendelenburg position.

A: Prepare to insert a nasogastric (NG) tube. Rationale: The nurse should prepare to insert an NG tube. The data collected provide evidence that the client is experiencing an upper gastrointestinal bleed secondary to a peptic ulcer. The client will be placed on nothing-by-mouth status, and an NG tube will be inserted to provide gastric decompression and alleviate vomiting. Administering antiemetics is not a priority action for a client who is hypotensive and vomiting coffee-ground emesis. Assessment of client stressors is appropriate after emergency care has been provided and the client stabilized. A modified Trendelenburg position is inappropriate for clients who are vomiting.

A nurse is performing a neurologic assessment on an infant. When assessing for function of cranial nerve X (vagus), which technique is most appropriate to use? -Press a tongue blade on the posterior surface of the tongue. -Observe for spontaneous eye movement. -Lightly brush a cotton swab across the child's cheek. -Assess for smiling or forceful eye closing with crying.

A: Press a tongue blade on the posterior surface of the tongue. Rationale: Cranial nerve X measures swallowing and the gag reflex, and is tested by pressing a tongue blade on the posterior surface of the tongue. Cranial nerve III (oculomotor) is tested by observing for spontaneous eye movement. Cranial nerve V (trigeminal) receives sensation from the face and innervates the muscles of mastication. It is tested by gently tickling a child's face. Cranial nerve VII is responsible for facial expression and is tested by assessing for smiling and forceful eye closure with crying.

What instruction should the nurse give the client who underwent a laryngectomy and is now going home? -Perform mouth care every morning and evening. -Provide adequate humidity in the home. -Maintain a soft, bland diet. -Limit physical activity to shoulder and neck exercises.

A: Provide adequate humidity in the home. Rationale: Adequate humidity should be provided in the home to help keep secretions moist. A bedside humidifier is recommended. A high fluid intake is also important to liquefy secretions. Mouth care is important to prevent drying of mucous membranes and should be performed frequently throughout the day, especially before and after meals, to help stimulate appetite. The client may eat any food that can be chewed and swallowed comfortably. The client may resume physical activity as tolerated.

The nurse is planning with a client who has cancer to improve the client's independence in activities of daily living after radiation therapy. What should the nurse do? -Refer the client to a community support group after discharge from the rehabilitation unit. -Make certain that a family member is present for the rehabilitation sessions. -Provide positive reinforcement for skills achieved. -Inform the client of rehabilitation plans made by the rehabilitation team.

A: Provide positive reinforcement for skills achieved. Rationale: The positive reinforcement builds confidence and facilitates achievement of rehabilitation goals. Community support may or may not be applicable after discharge. Although family support is an important component of rehabilitation, reinforcing the skills the client has acquired is of greater importance when regaining independence. Rehabilitation plans should include the client, family, or both.

A nurse is caring for a client who has been diagnosed with somatic symptom disorder. The client attributes a cough to tuberculosis. A chest X-ray and skin test are negative for tuberculosis. The client begins to complain about the sudden onset of chest pain. How should the nurse react initially? -Express understanding of the client's fears of serious illness. -Encourage the client to discuss the fear of having a serious illness. -Report the client's complaint of chest pain to a physician. -Determine if the illness is fulfilling a psychological need for the client.

A: Report the client's complaint of chest pain to a physician. Rationale: Because of the risk of missing an actual medical problem, new symptoms reported by a client with somatic symptom disorder should be reported to the physician. Letting the client know the nurse understands the fears, encouraging the client to discuss the fears, and determining if the supposed illness is fulfilling a psychological need are appropriate after the nurse has determined that the client doesn't have a serious medical disorder.

A client was admitted with a diagnosis of schizophrenia and exhibiting behaviors of hostility, paranoia, and isolation. The student nurse discussed with the nurse what the most therapeutic approach to take with the client would be. Which would indicate to the nurse that the student understands the best approach? -Inform the client that they need to receive care and that you will assist them. -Greet the client by gently touching their arm and telling the client that they can trust you. -Respect the client's need for personal space and avoid physical contact with the client. -Tell the client that if they do not comply with the rules, you will inform the physician.

A: Respect the client's need for personal space and avoid physical contact with the client. Rationale: A newly-admitted client with a diagnosis of schizophrenia accompanied by paranoia needs to have a sense of trust before the nurse attempts to touch the client. Using statements of veiled threats will only increase the client's anxiety and lead to increased potential for hostility and anger.

What are important nursing care measures for a client with diabetes who is admitted with end-stage renal failure? -Prepare for temporary peritoneal dialysis or hemodialysis. -Restrict sodium and potassium and restrict fluids as ordered. -Provide a diet high in protein and restrict fluids as ordered. -Monitor for hypotension and maintain accurate intake and output records.

A: Restrict sodium and potassium and restrict fluids as ordered. Rationale: In renal failure, there is retention of sodium and potassium, so these are restricted. Important care measures will also include fluid restrictions. The client will require permanent dialysis, not temporary as with acute renal failure. The diet will be restricted in protein to decrease waste products. Hypertension is associated with chronic renal failure.

The nurse is providing discharge teaching for a client with rheumatic endocarditis but no valvular dysfunction. On which nursing diagnosis should the nurse focus her teaching? -Risk for infection -Chronic pain -Impaired gas exchange -Impaired memory

A: Risk for infection Rationale: Clients with endocarditis have a Risk for infection. The nurse should stress to the client that they will need to continue antibiotics for a minimum of 5 years and that they will need to take prophylactic antibiotics before invasive procedures for life. There is no indication that the client has Chronic painor Impaired memory. Because the client doesn't have valvular damage, Impaired gas exchangedoesn't apply.

A client with chronic back pain is admitted to the medical-surgical floor and is receiving multiple pain medications and an antidepressant for pain control. The physician's orders include a physical therapy consult for ambulation and back strengthening, magnetic resonance imaging (MRI) of the lumbar spine, and a computed tomography (CT) scan of the abdomen. How should the nurse schedule therapy and diagnostic tests? -Schedule the MRI of the lumbar spine first, then the physical therapy consult, and then the CT scan. -The physical therapy consult takes priority because the client's medications place them at risk for falls. -Schedule the client according to the other department's availability. -Schedule the CT scan of the abdomen first because the client's medications place them at risk for abdominal complications.

A: Schedule the MRI of the lumbar spine first, then the physical therapy consult, and then the CT scan. Rationale: The client was admitted for back pain; therefore, the MRI of the lumbar spine should take priority. Next, the nurse should schedule the physical therapy consult followed by the CT scan of the abdomen. The client has been tolerating the medications at home; therefore, the client isn't at an increased risk for falls. The client's needs should be placed before the needs of the other departments. The medications could place the client at risk for abdominal complications; however, the client was admitted for back pain, not abdominal pain, so the back pain takes priority.

The toddler with nephrotic syndrome exhibits generalized edema. Which measure should the nurse institute for this child with impaired skin integrity related to edema? -Ambulate every shift while awake. -Apply lotion on opposing skin surfaces. -Apply powder to skinfolds. -Separate opposing skin surfaces with soft cloth.

A: Separate opposing skin surfaces with soft cloth. Rationale: Placing soft cloth between opposing skin surfaces absorbs moisture and keeps the area dry, thus preventing any further breakdown. The child with nephrotic syndrome and severe edema is usually maintained on bed rest. Therefore, ambulation is not appropriate. Applying lotion or powder to edematous surfaces that touch increases moisture and can lead to maceration, causing further breakdown.

Which principle should a nurse consider when administering pain medication to a client? -Use opioid combination drugs or nonopioid analgesics only for severe pain. -I.V. pain medications may take as long as 2 hours to relieve pain. -Sustained-release oral formulations should be given around the clock, if possible, for control of chronic pain. -Morphine and hydromorphone shouldn't be used to treat severe pain.

A: Sustained-release oral formulations should be given around the clock, if possible, for control of chronic pain. Rationale: Administering sustained-release oral formulations around the clock provides better relief of chronic pain by keeping blood levels within therapeutic range. Opioid combination drugs and nonopioid medications are most effective in the treatment of mild to moderate pain. I.V. medications usually act within 1 hour of administration. Morphine and hydromorphone are drugs of choice for severe pain.

A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect child abuse? -The child cries uncontrollably throughout the examination. -The child pulls away from contact with the physician. -The child doesn't cry when the shoulder is examined. -The child doesn't make eye contact with the nurse.

A: The child doesn't cry when the shoulder is examined. Rationale: A characteristic behavior of abused children is lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse. Crying throughout the examination, pulling away from the physician, and not making eye contact with the nurse are normal behaviors in preschoolers.

Nurse researchers have proposed a study to examine the efficacy of a new wound care product. Which aspect of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? -The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. -The nurses have organized the study in such a way that the foreseeable risks and benefits are distributed as fairly as possible. -The nurses have given multiple opportunities for potential participants to ask questions and have been following the informed consent process systematically. -The nurses have completed a literature review that suggests the new treatment may result in decreased wound healing time.

A: The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. Rationale: The principle of nonmaleficence dictates that nurses avoid causing harm. In this study, this may appear in the form of taking measures to ensure that the intervention will not cause more harm than good. The principle of justice addresses the distribution of risks and benefits and the informed consent process demonstrates that autonomy is being protected. Preliminary indications of the therapeutic value of the intervention show a respect for the principle of beneficence.

A high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? -The student discusses conflicts over drug use. -The student accepts a referral to a substance abuse counselor. -The student agrees to inform the parents of the problem. -The student reports increased comfort with making choices.

A: The student accepts a referral to a substance abuse counselor. Rationale: All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor.

A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation? -Fetal development needs to be complete before testing. -The volume of amniotic fluid needed for testing will be available by 15 weeks. -Cells indicating hemophilia A are not produced until 15 weeks' gestation. -Performing an amniocentesis prior to 15 weeks' gestation carries a greater infection rate.

A: The volume of amniotic fluid needed for testing will be available by 15 weeks. Rationale: The volume of fluid needed for amniocentesis is 15 mL, and this is usually available at 15 weeks' gestation. Fetal development continues throughout the prenatal period. Cells necessary for testing for hemophilia A are available during the entire pregnancy but are not accessible by amniocentesis until 12 weeks' gestation. Amniocentesis carries a slight risk of infection regardless of when the procedure is performed.

With plans to breastfeed her neonate, a pregnant client with insulin-dependent diabetes asks the nurse about insulin needs during the postpartum period. Which statement about postpartal insulin requirements for breastfeeding mothers should the nurse include in the explanation? -They fall significantly in the immediate postpartum period. -They remain the same as during the labor process. -They usually increase in the immediate postpartum period. -They need constant adjustment during the first 24 hours.

A: They fall significantly in the immediate postpartum period. Rationale: Insulin needs fall significantly during the first 24 hours postpartum because the client has usually been on nothing-by-mouth status for a period of time during labor and the labor process has used maternal glycogen stores. If the client breastfeeds, lower blood glucose levels decrease the insulin requirements. With insulin resistance gone, the client commonly needs little or no insulin during the immediate postpartum period. Although the need for insulin decreases during the intrapartum period, the insulin requirements fall further during the first 24 hours postpartum. After the first 24 hours postpartum, insulin requirements may fluctuate markedly, needing adjustment during the next few days as the mother's body returns to a nonpregnant state.

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions? -They help prevent subcutaneous emphysema. -They help prevent pneumothorax. -They help prevent cardiac arrhythmias. -They help prevent pulmonary edema.

A: They help prevent cardiac arrhythmias. Rationale: ET suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. Hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. Subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isn't a complication associated with suctioning. Hyperventilation and hyperoxygenation can't prevent a pneumothorax because this condition itself indicates air in the pleural space. Pulmonary edema is associated with cardiac dysfunction, not ET suctioning.

The client has had a cataract removed. When explaining discharge instructions, what should the nurse tell the client to do? -Keep the head aligned straight. -Utilize bright lights in the home. -Use an eye shield at night. -Change the eye patch as needed.

A: Use an eye shield at night. Rationale: Using an eye shield at night prevents rubbing the eye. The head should be turned to the side to scan the entire visual field to compensate for impaired peripheral vision. Eye medications may initially cause sensitivity to bright light. The surgeon changes the eye patch on the second postoperative day.

The nurse is to administer IV fluids to an infant. Which safeguard would be most important for the nurse to use? -Administration of fluid at the slowest possible rate by infant weight -Use of a gravity infusion set -Use of a micro drop (mini drip) infusion set -Use of an infusion pump to regulate the flow rate

A: Use of an infusion pump to regulate the flow rate Rationale: Use of an infusion pump to regulate the flow rate is the appropriate safeguard, because infants and children are particularly vulnerable to I.V. fluid overload. Administering fluid at the slowest possible rate may not benefit the infant. Using a gravity infusion set or a micro drop infusion set will not protect against fluid overload when I.V. administration is too rapid.

A triage nurse is completing an initial assessment of several clients in the waiting room. Which client would the nurse see first? -a client who reports passing "some thick, red-tinged mucus when I urinated this morning" -a client who reports that her baby dropped lower into her pelvis, and who has to urinate more frequently -a client with uterine contractions who reports "they are getting stronger and closer now" -a client who is 12 days past her due date with cramping

A: a client with uterine contractions who reports "they are getting stronger and closer now" Rationale: True labor is defined as the onset of regular uterine contractions that increase in frequency, intensity, and duration. The passing of the mucous plug (may be thick and red tinged) implies softening and effacement of the cervix, which is a sign of impending labor (24-48 hours prior), not true labor. Lightening (the fetus settles or drops into the pelvic inlet) is another sign of impending labor and may occur up to 2 weeks prior to birth. The client who is past her due date is showing no signs of distress.

Which of the following situations does the nurse recognize as having the greatest risk for the fetus? -a fundal height of 27 cm at 32 weeks gestation -a fetal heart rate of 170 bpm with fetal movements -a breech lie -a gestational age of 37 weeks

A: a fundal height of 27 cm at 32 weeks gestation Rationale: Optimal fetal growth and development during pregnancy are assessed with fundal height measurement. Fundal height, measured in centimeters, should equal gestational weeks throughout the pregnancy (e.g., fundal height of 27 cm should occur at 27 weeks gestation). A fundal height of 27 cm at 32 weeks gestation is a very ominous finding that requires immediate attention and investigation. The fetal heart rate (FHR) range is 110-160 bpm but may fluctuate with fetal movement. It is considered tachycardia and at risk only if a FHR is greater than 160 bpm for at least 10 minutes. A breech lie may result in a cesarean section, which carries increased risk after childbirth. There is a possibility that the fetus will change the lie naturally prior to birth or an external cephalic version may be performed. A gestation of 37 completed weeks is considered term.

A nurse assessing a client with catatonia notes a lack of responsiveness and ridged posturing. What is the best nursing intervention? -administer 2 mg lorazepam intramuscular injection (IM) -assist the client to a more comfortable position -infuse .9 normal saline (NS) 100 mL/hr -assess the client's blood glucose level

A: administer 2 mg lorazepam intramuscular injection (IM) Rationale: A client with catatonia shows a lack of responsiveness to the environment. The client may move rapidly or slowly, often alternating between patterns of movement. In many cases, they pose and appear rigid. Benzodiazepines are the drugs of choice for catatonia. Clinically significant improvement typically begins to occur about 24 hours after starting benzodiazepines. Clients who are unresponsive or insufficiently responsive to benzodiazepines may require electroconvulsive therapy (ECT).

A nurse takes all of these actions when caring for a client with hypothyroidism. Which intervention is the priority? -administering liothyronine -administering acetaminophen for headache -increasing room temperature and providing blankets -assessing for periorbital edema

A: administering liothyronine Rationale: Liothyronine is triiodothyronine (T3) and is often administered to a client with hypothyroidism. This is the priority to increase thyroid hormone levels. The other interventions would be lower-level priorities.

The nurse is teaching a client who has been prescribed thiothixene. Which adverse reaction is most important for the nurse to discuss with this client? -akinesia -hypotension -sedation -weight gain

A: akinesia Rationale: Thiothixene is a high-potency agent with a high affinity for dopamine-2 receptors. This affinity increases the likelihood of akinesia, a form of extrapyramidal symptoms. Although thiothixene targets other neurotransmitters responsible for hypotension, sedation, and weight gain, its affinity to these receptors is weak, and more likely to occur with lower-potency psychotropics.

A nurse is assessing vital signs of a client who gave birth to her first child 4 hours ago. Which finding requires additional investigation? -a bounding pulse -an irregular pulse -tachycardia -bradycardia

A: an irregular pulse Rationale: An irregular pulse is never normal and requires investigation. During the client's first postpartum rest or sleep, which usually occurs 2 to 4 hours after birth, the heart rate typically decreases, possibly slowing to 50 beats/minute (bradycardia). This decrease probably results from supine positioning and such normal physiologic phenomena as the postpartum rise in stroke volume and a reduction in vascular bed size. Tachycardia and bounding pulse may result from pain, hormones, and excess fluid volume.

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client? -a private room down the hall from the nurses' station -an isolation room three doors from the nurses' station -a semiprivate room with a client who has viral meningitis -a two-bed room with a client who previously had bacterial meningitis

A: an isolation room three doors from the nurses' station Rationale: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.

The nurse is caring for a client with Reye syndrome who is receiving pancuronium bromide. What is the most important intervention for the nurse to include in the plan of care? -applying artificial tears as needed -providing regular tactile stimulation -performing active range-of-motion (ROM) exercises -placing the client in a supine position

A: applying artificial tears as needed Rationale: Pancuronium bromide suppresses the corneal reflex, making the eyes prone to irritation. Artificial tears prevent drying. Tactile stimulation isn't appropriate because it may elicit a pressure response. Active ROM exercises may cause an increase in pressure. The head of the bed should be elevated slightly, with the paralyzed client in a side-lying or semi-prone position to prevent aspiration and minimize intracranial pressure.

Which is the priority intervention for a preschool child with epiglottiditis and a deteriorating respiratory status? -administering oxygen by face mask -administering parenteral antibiotics -assisting with intubation -monitoring the electrocardiogram for arrhythmias

A: assisting with intubation Rationale: The most important intervention for a child with epiglottiditis is airway management because children are at high risk for developing abrupt airway obstruction. Therefore, intubation should be performed as soon as possible in a controlled environment. Children need supplemental oxygen, but most are so anxious that they will never allow a mask to stay in place. Provide humidified "blow-by" oxygen administered by the parent if possible. The child does need parenteral antibiotics; however, the priority is airway management. The most common rhythm in this client is sinus tachycardia related to compensation. However, monitoring for arrhythmias isn't a priority over airway management.

A client is admitted to an acute care facility with pneumonia. When auscultating heart sounds, the nurse notes a fixed split of the second heart sound (S2) — a pathological split that doesn't vary with respirations. A fixed S2 split is the hallmark of -right bundle-branch block. -left bundle-branch block. -atrial septal defect. -aortic stenosis.

A: atrial septal defect. Rationale: A fixed S2 split is the hallmark of atrial septal defect. This split, which is continuous and doesn't vary with respirations, results from prolonged emptying of the right ventricle. A right bundle-branch block causes a wide S2 split that's louder on inspiration than on expiration; this split results from delayed depolarization of the right ventricle and late pulmonic valve closure. Left bundle-branch block, aortic stenosis, and patent ductus arteriosus cause a paradoxical S2 split. Heard only on expiration, a paradoxical S2 split results from delayed aortic valve closure.

At the beginning of a shift, the nurse is assigned to care for four school-age children admitted that day due to an acute asthma exacerbation. Which children should the nurse assess first? -child with a respiratory rate of 24 breaths/minute and wheezing -child with an oxygen saturation of 95% and wheezing on auscultation -child with oxygen saturation of 93% and no wheezing on auscultation -child whose mother reports that the child sometimes forgets to take the inhalers

A: child with oxygen saturation of 93% and no wheezing on auscultation Rationale: No wheezing on auscultation is an indication that the child is not moving air in and out and is in respiratory distress when the oxygen saturation is 93%. A respiratory rate of 24 breaths/minute in an 8-year-old child is normal. An oxygen saturation of 95% and wheezing noted on auscultation is somewhat of a concern, possibly indicating that the child needs oxygen or needs to clear the airways. However, this finding is a lower priority than no wheezing on auscultation and an oxygen saturation of 93%. The child sometimes forgetting to take medication is a concern but an oxygen saturation level of 93% is a more immediate concern.

A client's chest tube accidentally disconnects from the drainage tube. The nurse should first: -notify the health care provider. -clamp the chest tube. -cover the chest tube with a sterile dressing. -reconnect the tube.

A: clamp the chest tube. Rationale: When a chest tube becomes disconnected, the nurse should take immediate steps to prevent air from entering the chest cavity, which may cause the lung to collapse. Therefore, when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. The nurse can then notify the health care provider.First priority must be given to clamping the chest tube.Covering the disconnected chest tube with a dressing does not prevent air from entering the chest cavity.Reconnecting the tube may allow air to enter the chest cavity.

A nurse is caring for several clients on an oncology unit. Which client should the nurse see first? -client who is on complete bed rest -client with a white blood cell count of 2000 µL -client receiving brachytherapy for prostate cancer -client who is 2 days postoperative following a hemicolectomy

A: client with a white blood cell count of 2000 µL Rationale: A white blood cell count of 2000 µL puts the client at risk for infection. The nurse would want to see this client first in order to reduce the transmission of bacteria and other organisms from working with other clients. The client on bed rest can wait and the other clients are stable.

An elderly client who is receiving steroids has secondary diabetes and chronic kidney disease (CKD) and takes insulin. The client has had episodes of hypoglycemia. The nurse should: -continue to monitor the client's blood glucose values. -contact the dietitian to request that one additional serving of protein be added to each meal. -restrict ambulation so there will be less of a chance for hypoglycemia. -keep an 240 ml bottle of orange juice at the bedside to use when the client becomes hypoglycemic.

A: continue to monitor the client's blood glucose values. Rationale: The nurse should continue to monitor glucose in the blood to prevent the client from continuing to experience hypoglycemia. One of the risk factors for hypoglycemia is decreased insulin clearance as with impaired kidney function and/or renal failure. Another risk factor for hypoglycemia is increased glucose utilization when there is too much activity or exercise without enough food.Protein is digested slower than carbohydrate, but with chronic kidney disease (CKD) it is more difficult for the kidneys to rid the body of metabolic waste products.

A client with a history of cystitis is admitted to the hospital with a diagnosis of pyelonephritis. The nurse should assess the client for which symptom? -suprapubic pain -dysuria -urine retention -costovertebral tenderness

A: costovertebral tenderness Rationale: Costovertebral tenderness occurs on the side of the affected kidney in pyelonephritis. Dysuria, suprapubic pain, and urine retention may occur in pyelonephritis but do not specifically support a diagnosis of pyelonephritis. Dysuria, suprapubic pain, and urine retention are symptoms of cystitis, which can lead to pyelonephritis if not treated.

A laissez-faire nurse-manager takes which action? -completes the vacation schedule without staff input -delegates responsibility for -evaluating the effectiveness of new equipment to the staff members who use that equipment -identifies possible solutions to staffing problems and asks staff members for their opinions about each one -delegates to staff responsibility for selecting a new nursing care delivery system (model)

A: delegates to staff responsibility for selecting a new nursing care delivery system (model) Rationale: Delegating a process that will affect all aspects of a nursing area shows a lack of accountability characteristic of a laissez-faire manager. Making critical decisions without staff input is characteristic of an autocratic manager. Delegating evaluation to staff who are intimately involved in a project is appropriate and characteristic of a democratic manager. Identifying potential solutions to a problem and asking staff members for their opinions of the solutions is characteristic of a participative manager.

A client recovering from a drug overdose is interacting with the nurse and recounting her exploits at numerous parties she has attended. Which action is most therapeutic? -allowing the client to continue with her stories -telling the client you have heard the stories before -questioning the client further about her exploits -directing the conversation to realistic concerns

A: directing the conversation to realistic concerns Rationale: The nurse directs the conversation to realistic concerns or issues to decrease denial and focus on rebuilding a substance-free life. Allowing the client to continue with the stories or questioning the client further about her exploits reinforces the denial. Telling the client you have heard the stories before is nondirective. Additionally, these actions do nothing to help the client focus on rebuilding a substance-free life.

A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the nurse should explain that the reason for holding a cane on the uninvolved side is to -prevent leaning. -distribute weight away from the involved side. -maintain stride length. -prevent edema.

A: distribute weight away from the involved side. Rationale: Holding a cane on the uninvolved side distributes weight away from the involved side. Holding the cane close to the body prevents leaning. Using a cane won't maintain stride length or prevent edema.

The mother of an infant with a cleft lip asks when the repair will be scheduled. What is the nurse's best response? -at birth -during the first 6 months of life -after 6 months of age -at 1 year of age

A: during the first 6 months of life Rationale: Cleft lips are typically repaired during the first 6 months of life. This allows the child to form a better seal around the nipple of a bottle for feeding and strengthens muscles needed for speech. If the surgery is delayed until after 6 months, the child may have possible dental issues and problems with sucking. The repair is not done at birth because the infant must first gain weight to safely undergo surgery. The palate should be closed by 18 months to protect the formation of tooth buds and allow the infant to develop more normal speech patterns.

A nurse is caring for a client admitted to the inpatient psychiatric unit. When is it mostimportant to introduce information about the end of the nurse-client relationship? -during the orientation phase -as the goals of the relationship are reached -at least one or two sessions before the last meeting -when the client can tolerate it

A: during the orientation phase Rationale: Preparation for ending the nurse-client relationship should begin during the orientation phase, when realistic limits of the relationship are established. Termination should also be discussed as goals are achieved and the relationship nears an end. Although the nurse should remind the client when only one or two sessions remain, the nurse must not wait until then to prepare the client for termination. The client's ability to tolerate the end of a relationship shouldn't dictate its timing. Because many clients have had negative experiences when ending relationships, the nurse may use termination of the nurse-client relationship to prepare the client for positive termination experiences with others.

The nurse in the labor and birth area receives a telephone call from the emergency department announcing that a multigravid client in active labor is being transferred to the labor area. The client has had no prenatal care. When the client arrives by stretcher, she says, "I think the baby is coming ... Help!" The fetal skull is crowning. The nurse should obtain which information first? -estimated date of birth -amniotic fluid status -gravida and parity -prenatal history

A: estimated date of birth Rationale: A priority assessment for the nurse to make is to determine the estimated date of childbirth or probable gestational age of the fetus. If the gestation is less than 37 weeks, the neonatal team should be called to begin resuscitative efforts if needed. Amniotic fluid status is not important at this point, because if the fetal skull is crowning, birth is imminent. Determination of gravida and parity is part of the normal nursing history, but the priority is the status of the fetus and safe birth. Prenatal history is part of the nursing assessment, but this information is not especially relevant until the fetus is safely born and has been given immediate care.

A client with a spinal cord injury says they are having difficulty recognizing the symptoms of a urinary tract infection (UTI). Which assessment finding is an early symptom of UTI in a client with a spinal cord injury? -lower back pain -burning sensation on urination -frequency of urination -fever and change in urine clarity

A: fever and change in urine clarity Rationale: Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

A client with a history of medication noncompliance is receiving outpatient treatment for schizophrenia. The physician is most likely to order which medication for this client? -chlorpromazine -imipramine -lithium carbonate -fluphenazine decanoate

A: fluphenazine decanoate Rationale: Fluphenazine decanoate is a long-acting antipsychotic agent administered by injection. Because it has a 4-week duration of action, it's commonly ordered for outpatients with a history of medication noncompliance. Chlorpromazine, also an antipsychotic agent, must be administered daily to maintain adequate plasma levels, which necessitates compliance with the dosage schedule. Imipramine, a tricyclic antidepressant, and lithium carbonate, a mood stabilizer, are rarely used to treat clients with chronic schizophrenia.

A client is admitted in early active labor at 39 weeks' gestation with intact membranes. When assessing the fetal heart rate, the nurse locates the heart sounds above the client's umbilicus at midline. The nurse should further confirm that the fetus is lying in which position? -cephalic -frank breech -face -transverse

A: frank breech Rationale: When the fetus is in a breech position, the fetal heart rate most often is located above the umbilicus because the fetal heart is near the top of the mother's uterus. The heart of a fetus in the cephalic position is typically located on either the left or the right side of the client's uterus. Also, because the fetal heart typically is located in the lower portion of the mother's uterus, the sounds would be heard below the umbilicus. With a face presentation, fetal heart sounds are typically located on either the left or the right side of the client's uterus; in addition, because the fetal heart typically is located in the lower portion of the mother's uterus, the sounds would be heard below the umbilicus. When the fetus is in a transverse position, the fetal heart sounds typically would be located below the umbilicus and in the midline.

A severe winter storm has prevented most staff members from getting to work on a busy medical-surgical unit. One registered nurse, two licensed practical nurses, and three nursing assistants have been able to get to work. A nurse-manager must decide which nursing care delivery system (model) (NCDS) should be implemented for the best possible client care during this staffing crisis. The nurse-manager directs the staff to implement which NCDS (NCDM)? -team nursing -primary nursing -functional nursing -case management

A: functional nursing Rationale: Functional nursing best uses the skills of all staff in a timely manner during this crisis. This delivery system (model) requires the fewest staff and delegates tasks to those who can best perform them. Team nursing doesn't allow for the best use of a limited number of staff who must care for a large number of clients. Primary nursing and case management require more registered nurses than are currently available.

An 11-year-old child contracted severe acute respiratory syndrome (SARS) when traveling abroad with the parents. The nurse knows to put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear? -gloves -gown and gloves -gown, gloves, and mask -gown, gloves, mask, and eye goggles or eye shield

A: gown, gloves, mask, and eye goggles or eye shield Rationale: The transmission of SARS isn't fully understood. Therefore, all modes of transmission must be considered possible, including airborne, droplet, and direct contact with the virus. For protection from contracting SARS, any healthcare worker providing care for a person with SARS should wear a gown, gloves, mask, and eye goggles or an eye shield.

A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for complications? -gravida 2 para 2002, cesarean birth, incision site intact, hemoglobin level 9.8 g/dl -gravida 2 para 2011, cesarean birth, incision site intact, pulse 84 beats/minute -gravida 1 para 2001, vaginal delivery, midline episiotomy, temperature of 99.8° F (37.7° C) -gravida 1 para 2001, vaginal delivery, membranes ruptured 10 hours before birth

A: gravida 2 para 2002, cesarean birth, incision site intact, hemoglobin level 9.8 g/dl Rationale: Women who have anemia during pregnancy (defined as a hemoglobin less than 10 g/dl) may experience more complications such as poor wound healing and inability to tolerate activity. An intact incision site and a pulse of 84 beats/minute after a cesarean birth and a temperature of 99.8° F (37.7° C) after a vaginal delivery with episiotomy are findings within normal limits. Dehydration can cause a slightly elevated temperature. Although women whose membranes are ruptured more than 24 hours before birth are more prone to developing chorioamnionitis, the client with anemia is at greater risk for complications.

A client is to receive epoetin injections. What laboratory value should the nurse assess before giving the injection? -hematocrit -partial thromboplastin time -hemoglobin concentration -prothrombin time

A: hematocrit Rationale: Epoetin is a recombinant DNA form of erythropoietin, which stimulates the production of red blood cells and therefore causes the hematocrit to rise. The partial thromboplastin time, hemoglobin level, and prothrombin time are not monitored for this drug.

What should the nurse assess the client for during the early phase of burn care? -hypernatremia -hyponatremia -metabolic alkalosis -hyperkalemia

A: hyperkalemia Rationale: Immediately after a burn, excessive potassium from cell destruction is released into the extracellular fluid. Hyponatremia is a common electrolyte imbalance in the burn client that occurs within the first week after being burned. Metabolic acidosis usually occurs as a result of the loss of sodium bicarbonate.

During the initial assessment of a child admitted to the pediatric unit with osteomyelitis of the left tibia, when assessing the area over the tibia, which is an expected finding? -diffuse tenderness -decreased pain -increased warmth -localized edema

A: increased warmth Rationale: Findings associated with osteomyelitis commonly include pain over the area, increased warmth, localized tenderness, and diffuse swelling over the involved bone. The area over the affected bone is red.

The nurse is teaching a postmenopausal client about strategies to prevent the development of osteoporosis. On which topic should the nurse focus as primary prevention for the disorder? -participating in cardiovascular -exercises regularly -taking regular estrogen replacement therapy -increasing calcium and vitamin D in the diet -maintaining a body mass index of less than 20

A: increasing calcium and vitamin D in the diet Rationale: Primary prevention of osteoporosis includes maintaining optimal calcium and vitamin D intake. Although estrogen replacement can reduce the risk for osteoporosis, it can increase the risk for certain cancers and should therefore not be recommended as first-line prevention. Cardiovascular exercise will directly help in the prevention of osteoporosis only if it involves weight-bearing activity, such as walking or jogging. A lower body mass index (weight under 125 pounds for women of average height) is a risk factor for developing osteoporosis rather than preventing it.

During the morning assessment, a nurse notes that a client is awake, alert, and has severe dyspnea; respirations are 34 breaths/minute and labored. Oxygen saturation is 79% on 3 L of oxygen. The nurse notes that the client's chart includes a living will. When considering best practice, the nurse should -follow the living will order and stop all treatments. -increase the oxygen flow rate to 4 L, but avoid initiating other interventions. -call the client's family and ask what they think is best. -initiate potentially life-prolonging treatment unless the client refuses.

A: initiate potentially life-prolonging treatment unless the client refuses. Rationale: A living will doesn't go into effect unless the client is unable to make his own decisions. The nurse should give all appropriate care while also maintaining the client's right to refuse treatment. Increasing the oxygen flow rate might be an appropriate response, but it isn't the best and only action at this time. The family isn't responsible for determining care at this time.

A client suspects the end of life is near. However, others talk about only pleasant matters and maintain a persistently cheerful façade. The nurse plans care for this client by recognizing that these behaviors will most likely cause the client to experience which feeling? -relieved -isolation -hope -independence

A: isolation Rationale: Clients tend to experience isolation and loneliness when those around them are trying to hide or mask the truth. They are then left to face the realities of death alone. Clients do not experience relief or hopefulness when others are falsely cheerful. Independence is promoted by offering realistic choices about care at the end of life.

A client diagnosed today with a deep vein thrombosis in the right leg. The nurse should instruct the client to: -ambulate twice a shift. -do active leg exercises hourly with both legs. -keep the right leg elevated above heart level. -assess the edema of the right leg every 4 hours.

A: keep the right leg elevated above heart level. Rationale: The extremity should be kept elevated with heat applied to treat the inflammation and pain.To decrease chances of dislodging a thrombus, the client is typically kept on bed rest during the initial stages of treatment until therapeutic levels of anticoagulation are achieved.The client may exercise the unaffected leg but not the one with the deep vein thrombosis.Assessing the edema of the right leg is an essential activity, but it is the responsibility of the nurse to perform this task.

A physician has ordered a wet-to-damp dressing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to: -prevent the spread of the infection. -debride the wound. -keep the wound moist. -reduce pain.

A: keep the wound moist Rationale: Wet-to-damp dressings keep the wound bed moist, which helps promote the growth of granulation tissue. Because dead tissue adheres to a dry dressing, wet-to-dry dressings are used for debriding wounds. Wet-to-damp dressings do not prevent the spread of infection. Although these dressings provide a soothing, cool feeling, they don't relieve pain.

When developing a care plan for a hospitalized adolescent with acute lymphoblastic leukemia, the nurse considers psychosocial needs. Which activity is best suited to help this adolescent cope with a prolonged illness? -playing board games with friends throughout the weekend -keeping a journal or artistic scrapbook of experiences and thoughts -engaging in video calling with friends throughout the day -creating a puppet show for young, hospitalized children

A: keeping a journal or artistic scrapbook of experiences and thoughts Rationale: According to Erikson, the primary psychosocial task during adolescence is to establish a personal identity while overcoming role or identity confusion. The adolescent attempts to establish a group identity by seeking acceptance and approval from peers, and strives to attain a personal identity by becoming more independent from his or her family. An activity that best helps the adolescent cope by maintaining his or her identity is creating a journal or scrapbook of memories and frustrations. Becoming industrious is the developmental task of the school-age child; achieving intimacy is the task of the young adult; and developing initiative is the task of the preschooler. Board games, creating a puppet show, and writing letters are good activities for this adolescent, but are not the best option for assisting with coping and meeting needs for personal identity. Additionally, collaborative activites are not always a good option for a client with immunosuppression such as occurs in leukemias. Activities may also add to the fatigue the client is already experiencing.

Which circumstance would exempt the nurse from professional negligence following an error in drug administration to a client? -not knowing the drug was contraindicated for this client -lack of harm to the client as a result of the errant drug administration -confirmation by a coworker that the dosage was correct -dosage inaccurately dispensed by the pharmacy

A: lack of harm to the client as a result of the errant drug administration Rationale: lack of harm to the client as a result of the errant drug administration

A client is receiving methotrexate, 12 g/m2 I.V., to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells? -probenecid -cytarabine -thioguanine -leucovorin (citrovorum factor or -folinic acid)

A: leucovorin (citrovorum factor or folinic acid) Rationale: Leucovorin is administered with methotrexate to protect normal cells, which methotrexate could destroy if given alone. Probenecid should be avoided in clients receiving methotrexate because it reduces renal elimination of methotrexate, increasing the risk of methotrexate toxicity. Cytarabine and thioguanine aren't used to treat osteogenic carcinoma.

A client has severe arterial occlusive disease and gangrene of the left great toe. Which finding is expected? -edema around the ankle -loss of hair on the lower leg -thin, soft toenails -warmth in the foot

A: loss of hair on the lower leg Rationale: The client with severe arterial occlusive disease and gangrene of the left great toe would have lost the hair on the leg due to decreased circulation to the skin. Edema around the ankle and lower leg would indicate venous insufficiency of the lower extremity. Thin, soft toenails (i.e., not thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the extremity. Typically, the foot would be cool to cold if a severe arterial occlusion were present.

Following a transsphenoidal hypophysectomy, a client has a cerebrospinal fluid leak. The nurse should prepare the client for which treatment of the leak? -packing the nose with pressure dressings -returning the client to surgery to close the leak -maintaining bed rest with the head of the bed elevated to 30 degrees -administering high-dose corticosteroid therapy

A: maintaining bed rest with the head of the bed elevated to 30 degrees Rationale: If CSF leakage is suspected or confirmed, the client is treated initially with bed rest with the head of the bed elevated to decrease pressure on the graft site. Most leaks heal spontaneously, but occasionally surgical repair of the site in the sella turcica is needed. Repacking the nose will not heal the leak at the graft site in the dura. The client will not be returned to surgery immediately because most leaks heal spontaneously. High-dose corticosteroid therapy is not effective in healing a CSF leak.

A coworker confides in the nurse that she had been a lifelong friend of a client who committed suicide. The coworker states: "We just saw each other last week. I can't believe she tried to kill herself. She told me she wanted to give me her expensive necklace because our friendship meant so much to her. She seemed really happy and content. I knew she had been feeling down the last few months. I should've known that something was wrong; I should've asked her about suicide." The nurse determines the coworker is most likely experiencing which condition? -secondary traumatic stress -a boundary violation -compassion fatigue -moral distress

A: moral distress Rationale: Moral distress occurs when one is unable to act because of internal or external constraints. The nurse is not able to change the way she interacted with her friend the last time she saw her and is feeling anguish. Secondary traumatic stress is distress that is a result of hearing first-hand traumatic experiences of another. A boundary violation is behavior by a professional that have violated the limits of a professional-client relationship. Compassion fatigue is disengagement on the part of the care-giving professional.

After an exploratory laparotomy, a client develops a subhepatic abscess. After the abscess is incised and the drainage cultured, the infecting organism is identified as Bacteroides fragilis. The physician orders clindamycin, 300 mg I.V. every 6 hours. Before administering the antibiotic, the nurse reviews the client's medication history because clindamycin may enhance the action of -neuromuscular blocking agents. -antiarrhythmic agents. -anticonvulsant agents. -beta-adrenergic blocking agents.

A: neuromuscular blocking agents. Rationale: Clindamycin may enhance the action of neuromuscular blocking agents by blocking neuromuscular transmission. Clindamycin isn't known to interact with antiarrhythmics, anticonvulsants, or beta-adrenergic blocking agents.

A client who has had a lumbar laminectomy with a spinal fusion is sitting in a chair. Which is the correct position for this client's feet? -on the floor with the feet flat -on a low footstool -in any comfortable position with legs uncrossed -on a high footstool so the feet are level with the chair seat

A: on the floor with the feet flat Rationale: A client who has had back surgery should place his feet flat on the floor to avoid strain on the incision. Placing the feet on a low or high footstool or in any other position of comfort with the legs uncrossed increases the pressure on the suture line and increases the inflammation around the involved nerve root, thereby increasing the risk of possible rerupture of the disc site.

The health care provider prescribes raloxifene hydrochloride for a 60-year-old woman. The drug is effective if the client does not develop: -hot flashes. -osteoporosis. -hyperglycemia. -migraine headaches.

A: osteoporosis. Rationale: Raloxifene hydrochloride, an estrogen receptor modulator, increases bone mineral density without stimulating the endometrium. The drug is useful in preventing osteoporosis in postmenopausal women. This drug is contraindicated for women who smoke cigarettes or who have a history of venous thrombosis.Raloxifene does not prevent hot flashes or hyperglycemia.One of its adverse effects is increased headaches.

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately? -absent cough and gag reflexes -blood-tinged secretions -oxygen saturation of 90% -respiratory rate of 13 breaths/min

A: oxygen saturation of 90% Rationale: The nurse should respond immediately to an oxygen saturation (SaO2) of 90%. Normal SaO2 ranges from 95% to 100%. Therefore, an SaO2 of 90% indicates inadequate oxygenation, an adverse effect of moderate sedation. The nurse should respond by attempting to arouse the client, assisting the client with deep breathing, and administering a higher dose of oxygen. Cough and gag reflexes are typically absent after administration of anesthetics required for bronchoscopy, and they usually return about 2 hours after the procedure. Blood-tinged secretions are common for several hours after bronchoscopy, especially if a biopsy was obtained. A respiratory rate of 13 breaths/minute is within normal limits.

A nurse is caring for a client who is recovering from an illness requiring prolonged bed rest. Based on the nursing documentation above, which procedures would the nurse implement next? -performing active range-of-motion exercises of the legs -performing isometric exercises of the legs -providing assistance walking the client to the bathroom -performing passive range-of-motion exercises of the legs

A: performing active range-of-motion exercises of the legs Rationale: Active range-of-motion exercises involve moving the client's joints through their full range of motion; they require some muscle strength and endurance. The client should have received passive range-of-motion exercises because admission to maintain joint flexibility and should have been taught isometric exercises to build strength and endurance for transfers and ambulation. Walking to the bathroom would be unsafe without the ability to first dangle the legs over the bedside and transfer from bed to chair.

The nurse is caring for an infant with pyloric stenosis. Which manifestation requires priority attention? -loss of appetite -explosive diarrhea -projectile vomiting -coffee ground emesis

A: projectile vomiting Rationale: The obstruction doesn't allow food to pass through the pyloris to the duodenum. When the stomach becomes full, the infant forcefully vomits for pressure relief. Chronic hunger is commonly seen. There's no diarrhea because food doesn't pass the stomach. Coffee ground emesis is a result of partially digested blood in the stomach, and not an expected finding with pyloric stenosis.

A client with a cocaine dependency is irritable, anxious, highly sensitive to stimuli, and overreacting to clients and staff on the unit. Which action is most therapeutic for this client? -secluding and restraining the client as needed -telling the client to stay in his room until he can control himself -providing the client with frequent "time-outs" -confronting the client about his behaviors

A: providing the client with frequent "time-outs" Rationale: Providing frequent "time-outs" when the client is highly anxious, sensitive, irritable, and over reactive is needed to calm the client and reduce the possibility of escalating behaviors and violence. Secluding and restraining the client is not appropriate and would only be used if the client was threatening others and other alternative actions had been unsuccessful. Telling the client to stay in his room until he can control himself is unrealistic and futile because the client cannot eliminate behaviors induced by chemicals. Confronting the client about his behaviors would most likely lead to aggression and possibly violent behavior.

The mother of a toddler diagnosed with iron deficiency anemia asks what foods she should give her child. The nurse should evaluate the teaching as successful when the mother later reports that she feeds the toddler which foods? -milk, carrots, and beef -raisins, chicken, and spinach -beef, lettuce, and juice -eggs, cheese, and milk

A: raisins, chicken, and spinach Rationale: Good sources of dietary iron include red meats, poultry, green leafy vegetables, and dried fruits such as raisins. Milk products are poor sources of iron. Carrots are high in vitamin A.

Twenty-four hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for -removal of the transplanted kidney. -high-dose I.V. cyclosporine therapy. -bone marrow transplant. -intra-abdominal instillation of methylprednisolone sodium succinate.

A: removal of the transplanted kidney. Rationale: Hyperacute rejection isn't treatable; the only way to stop this reaction is to remove the transplanted organ or tissue. Although cyclosporine is used to treat acute transplant rejection, it doesn't halt hyperacute rejection. Bone marrow transplant isn't effective against hyperacute rejection of a kidney transplant. Methylprednisolone sodium succinate may be given I.V. to treat acute organ rejection, but it's ineffective against hyperacute rejection.

A parent asks the nurse what types of activities the 3-year-old child should be able to do at this age. What is the nurse's best response? -ride a tricycle -lace shoelaces -throw ball overhand -jump rope

A: ride a tricycle Rationale: The nurse should expect the child to ride a tricycle because at age 3 gross motor development and refinement in eye-hand coordination enable a child to perform such an action. The fine motor skills required to lace shoelaces and the gross motor skills required for throwing a ball overhanded and jumping rope develop around age 4.

With a diagnosis of right rib fracture and closed pneumothorax, the client should be placed in which position? -modified Trendelenburg's position with the lower extremities elevated -reverse Trendelenburg's position with the head down -left side-lying position with the head elevated 15 to 30 degrees -semi- to high-Fowler's position, tilted toward the right side

A: semi- to high-Fowler's position, tilted toward the right side Rationale: Pneumothorax will cause a client to feel extremely short of breath. Semi- or high Fowler's position will facilitate ventilation by the unaffected lung. Positioning the client toward the affected side does not compromise the remaining, functional lung. Positioning the client on the unaffected side—in this case, in the left side-lying position—compromises the remaining, functional lung and should be avoided.A modified Trendelenburg's position places additional pressure on the chest and inhibits ventilation.Reverse Trendelenburg places additional pressure on the chest and inhibits ventilation.

The nurse is performing an assessment on a client after the client's third electroconvulsive therapy (ECT). Which finding should the nurse anticipate most frequently? -a cardiac arrhythmia -a prolonged seizure -a headache -short-term memory loss

A: short-term memory loss Rationale: Short-term memory loss is the most common adverse effect of ECT. In many cases, the memory does not return. ECT does not affect the heart. A seizure is not an adverse effect; rather, it is intentionally induced. Brain damage caused by ECT has not been substantiated. A headache is common but not the most frequent effect.

Which is the most appropriate diet for a client during the acute phase of myocardial infarction (MI)? -liquids as desired -small, easily digested meals -three regular meals per day -nothing by mouth

A: small, easily digested meals Rationale: Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.

A client sustains a minor fracture to the left wrist. For which type of immobilization device should the nurse prepare teaching for this client? -cast -splint -brace -traction

A: splint Rationale: For a simple and stable fracture, a splint is used. This device is faster and easier to apply, is noncircumferential, will not compromise circulation, and can be easily removed to inspect the injury site. A cast is indicated for a more complicated fracture. A brace is used for long-term stabilization. Traction is used to align the bones of lower extremities and would not be indicated for a minor fracture of the wrist.

A primigravid client in the second stage of labor feels the urge to push. The client has had no analgesia or anesthesia. Anatomically, what would be the best position for the client to assume? -dorsal recumbent -lithotomy -hands and knees -squatting

A: squatting Rationale: Anatomically, the best position for the client to assume is the squatting position because this enhances pelvic diameters and allows gravity to assist in the expulsion stage of labor. This position also provides for natural pressure anesthesia as the fetal presenting part presses on the stretched perineum. If the client is extremely fatigued from a lengthy labor process, she may prefer the dorsal recumbent position. However, this position is not considered the best position anatomically. The lithotomy position may be ineffective and uncomfortable for a client who is ready to push. The hands and knees position may help to alleviate some back pain. However, this position can cause discomfort to the arms and wrists and is tiring over a long period of time.

What position should the nurse use for the client with venous insufficiency to enhance blood supply? -prone with head turned to one side -Fowler with lower extremities in neutral position -dorsal recumbent with legs separated -supine with lower extremities elevated

A: supine with lower extremities elevated Rationale: For clients with venous insufficiency, blood return to the heart needs to be enhanced; therefore, the nurse should position them in a position with lower extremities elevated. Prone with head turned to one side and Fowler with lower extremities in neutral position does not elevate the extremities and, therefore, does not increase blood supply. Dorsal recumbent with legs separated is used for special situations, not to enhance blood supply in venous insufficiency.

An unemployed client without health insurance has not filled their prescription. Which assessment finding indicates that this client is not taking their levothyroxine as prescribed? -diarrhea -rapid heart rate -warm, dry, flushed skin -temperature of 94° F (34.4° C)

A: temperature of 94° F (34.4° C) Rationale: Levothyroxine is prescribed for hypothyroidism, which causes a hypodynamic state. Failure to maintain levothyroxine therapy can lead to a low body temperature as well as slowing all metabolic processes. The other assessments indicate a hypermetabolic state, which could be symptomatic of an increase in thyroid hormones

A nurse is preparing for the discharge of a client who has been hospitalized for schizophrenia. The client's spouse expresses concern over whether the client will continue to take daily ordered medication. The nurse should inform the spouse that: -the concern is valid, but the client is an adult and has the right to make decisions. -the spouse can easily mix the medication in food if the client stops taking it. -the client can be given a long-acting medication that is administered every 1 to 4 weeks. -the client knows the medication must be taken as ordered to avoid future hospitalizations.

A: the client can be given a long-acting medication that is administered every 1 to 4 weeks. Rationale: Long-acting psychotropic drugs can be administered by depot injection every 1 to 4 weeks. These agents are useful for noncompliant clients because the client receives the injection at the outpatient clinic. A client has the right to refuse medication, but this issue isn't the focus of discussion at this time. Medication should never be hidden in food or drink to trick the client into taking it; in addition to destroying the client's trust, doing so would place the client at risk for overmedication or undermedication because the amount administered is hard to determine. It would be unrealistic to assume the client knows medication must be taken to avoid future hospitalizations.

Following an incisional approach to an abdominal hysterectomy, the nurse should assess the client for: -thrombophlebitis. -ascites. -peripheral edema. -hypostatic pneumonia.

A: thrombophlebitis Rationale: Clients who have had major pelvic surgery are especially at risk for developing thrombophlebitis postoperatively. Extensive manipulation of the pelvic organs and removal of lymph glands can lead to edema, stasis, and circulatory congestion.Ascites, peripheral edema, and hypostatic pneumonia are not complications that would be specifically anticipated after pelvic surgery.

A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the health care provider (HCP) before having which procedure? -blood drawn -an IV line inserted -tooth extraction -an X-ray examination

A: tooth extraction Rationale: The client with a synthetic graft may need to be treated with prophylactic antibiotics before undergoing major dental work and should notify the HCP before any such procedure. Prophylactic antibiotic treatment reduces the danger of systemic infection caused by bacteria from the oral cavity. Venous access for drawing blood, IV line insertion, and X-rays do not contribute to the risk of infection.

Following an eclamptic seizure, the nurse should assess the client for which complication? -polyuria -facial flushing -hypotension -uterine contractions

A: uterine contractions Rationale: After an eclamptic seizure, the client commonly falls into a deep sleep or coma. The nurse must continually monitor the client for signs of impending labor because the client will not be able to verbalize that contractions are occurring. Oliguria is more common than polyuria after an eclamptic seizure. Facial flushing is not common unless it is caused by a reaction to a medication. Typically, the client remains hypertensive unless medications such as magnesium sulfate are administered.

Emergency restraints or seclusion may be implemented without a physician's order under which condition? -when a licensed practitioner will do a face-to-face assessment within 1 hour -never -if a voluntary client wants to leave against medical advice -when a child is acting out

A: when a licensed practitioner will do a face-to-face assessment within 1 hour Rationale: In an emergency, a client who is a threat to self or others may be restrained without an order. If restraints are initiated without an order the client must be assessed within 1 hour of application by a licensed, independent practitioner. Voluntary clients have the right to leave against medical advice. A minor should be treated the same way as an adult regarding restraints.

While caring for a multigravid client in early labor in a birthing center, which food would be best if the client requests a snack? -yogurt -cereal with milk -vegetable soup -peanut butter cookies

A: yogurt Rationale: In some birth settings, intravenous therapy is not used with low-risk clients. Thus, clients in early labor are encouraged to eat healthy snacks and drink fluids to avoid dehydration. Yogurt, which is an excellent source of calcium and riboflavin, is soft and easily digested. During pregnancy, gastric emptying time is delayed. In most hospital settings, clients are allowed only ice chips or clear liquids.Cereal with milk and vegetable soup, although nutritious, could cause aspiration if nausea and vomiting occur because these foods take longer to digest than yogurt.Peanut butter cookies are not as nutritious as yogurt for the client in labor because yogurt is rich in calcium. Although cookies are a source of carbohydrate, they could cause aspiration.

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation? -abundance of scalp hair -thin, wasted appearance -descended testicles -numerous scrotal rugae

Answer: thin, wasted appearance Rationale: The premature neonate characteristically exhibits a thin, wasted appearance.The premature neonate commonly exhibits a scarcity of scalp hair.In the premature male neonate, testicles are typically high in the inguinal canal and absence of rugae on the scrotum is typical.