NCLEX 1

The nurse develops a brochure on health promotion. Which example of primary prevention health promotion does the nurse include in the brochure? 1. attending a stress management class 2. performing a testicular examination 3. having a blood test for diabetes 4. taking an analgesic for a HA

1 Primary prevention aimed at health promotion includes activities that may prevent the disease from developing These activities include health education programs, immunizations, and physical and nutritional fitness activities Performing a testicular examination, which assists w/early identification of disease, is a form of secondary prevention health promotion

A new nurse makes staff assignments for the first time. After completing assignments, the nurse is called to a meeting. When returning to the unit, the new nurse finds extensive assignment changes were made. Which response by the new nurse is *best*? 1. I noticed the assignments were changed. did something happen while I was gone? 2. why did you change the assignments? I was asked to make them today 3. changing the assignments makes me appear incompetent. Next time, please ask first 4. I would appreciate it if you would not make changes in the assignments I make

1 Seeking information in a non-accusatory way allows staff members to discuss the situation so that the nurse can learn from the changes made

A client who is receiving isoniazid, rifampin, and ethambutol asks the nurse why the HCP has prescribed three medications. Which response should the nurse provide? 1. the combination of medication prevents the development of resistant organisms 2. the combination of medication kills the bacteria more rapidly 3. the combination of medication reduces the duration of time you take the medication 4. the combination of medication reduces the risk of developing SE from the medication

1 TB is an infectious disease transmitted by droplet infection via airborne route To prevent resistant strains, two or three medications are usually administered concurrently

The nurse prepares to assess an adolescent during a visit to the clinic for a sports physical examination. Which developmentally appropriate intervention does the nurse include w/an adolescent? 1. allow time for questions w/o the parent in the room 2. expose the entire body to allow for a quick examination 3. allow adolescent females to keep their bra on during the examination 4. remain in the examination room while the adolescent undresses

1 The nurse allows time for questions w/o the parent present in the room This intervention gives the adolescent an opportunity to ask sensitive questions that they might not feel comfortable asking in front of a parent The nurse asks the adolescent female to remove the bra so the nurse can assess for scoliosis and examine the breasts

The nurse performs a home visit for a client dx w/Alzheimer disease. Which observation is *most* concerning to the nurse? 1. the client spends most of the day in bed 2. the home appears cluttered 3. the daughter attends her children's school activities 4. the son-in-law helps w/the client's care

1 The nurse needs to determine the reason that the client is not getting up and moving around Physical activity is important to prevent skin breakdown, respiratory tract infections, and to support client mobility While the clutter is a potential issue if it obstructs walking and poses a fall risk, it is more important for the nurse to address the current actual client issue of spending most of the day in bed

The nurse provides care for a client dx w/TB. The nurse notices surgical masks are available in the negative pressure isolation anteroom. Which action does the nurse take before entering the room? *select all that apply* 1. wear an N95 mask 2. wear a mask w/a face shield 3. wear a surgical mask 4. wear a personal protective gown 5. wear sterile gloves

1 When caring for a client dx w/TB, appropriate respiratory protection consists of an N95 mask or a powered air-purifying respirator (PAPR) These devices are designed to protect the nurse from exposure to aerosolized droplets w/in the environment Personal protective gowns are used for clients requiring contact isolation (C. diff); they are not needed when caring for a client in airborne precautions

The professional development educator teaches novice nurses about the causes of systemic inflammatory response syndrome (SIRS). Which types of injury will the nurse include in the teaching? *select all that apply* 1. burn injuries 2. crush injuries 3. major surgeries 4. bowel ischemia 5. viral infection

1, 2, 3, 4 Burn injuries, crush injuries, major surgeries, and bowel ischemia cause mechanical tissue trauma, a trigger for SIRS Viral infection causes microbial invasion, not mechanical trauma

A client receives hydromorphone upon arrival to the post-anesthesia care unit (PACU). Forty minutes later, the client develops respiratory depression. The nurse discovers the client received hydromorphone before transferring to the PACU. Which action does the nurse take when addressing this medication administration error? *select all that apply* 1. report the incident to the nurse manager 2. notify the HCP 3. delete the medication administration entry in the EHR 4. complete an incident report per facility protocol 5. report the OR nurse for not relaying details of all medications administered when giving report

1, 2, 4 Medication errors should be promptly reported via the vertical chain of command; the nurse manager should be notified in this situation The HCP should be notified of the medication error and updated on the client's condition Institutions have established reporting processes that should be followed to ensure compliance w/facility protocol; in this situation, institutions have HCP complete an incident or occurrence report when medication administration errors occur

The nurse provides care for a client w/an AV fistula. Which intervention will assist the nurse in determining patency of the AV fistula? *select all that apply* 1. auscultate to detect a bruit 2. palpate pulses distal to site 3. assess the site for tenderness 4. observe capillary refill in fingers distal to site 5. check for altered sensation

1, 2, 4, 5 Auscultation, w/a stethoscope, will assist in detecting a bruit, or swishing sound, which confirms arterial and venous blood flow and patency Assessment of patency includes circulation checks, such as palpating the pulses distal to the AV fistula Capillary refill in fingers distal to the AV fistula assesses for circulation and patency In addition to peripheral pulses and capillary refill, circulation checks include assessing for altered sensation, as well as coolness or pallor in the limb w/the AV fistula Assessment of the AV fistula for tenderness is associated with s/s of infection, along w/redness, swelling, or purulent drainage

The nurse reviews a list of clients waiting to be seen in the ED. Which client does the nurse select to be seen *immediately*? *select all that apply* 1. experiencing a tingling sensation in the face and arm 2. reporting chest heaviness 3. experiencing redness on the lower legs for the past week 4. reporting a needlestick while administering a medication to a client 5. reporting drowsiness after taking cyclobenzaprine 6. experiencing HA, fever, and neck stiffness

1, 2, 4, 6 Face and arm tingling could indicate a stroke; the client requires immediate evaluation Chest heaviness requires an immediate ECG and lab tests to rule in or r/o a MI Receiving a needlestick may require post-exposure prophylaxis if the client is high risk or known to have an infectious disease HA, fever, and neck stiffness are manifestations of meningitis; the client needs to be assessed immediately Redness on the lower legs for a week could indicate cellulitis; the client may require antibiotics; this is not an emergency since it has been going on for a week; this client can be seen later

The nurse instructs a client prescribed hydralazine as tx for HTN. Which client statements indicate to the nurse that the teaching is effective? *select all that apply* 1. I will take my hydralazine w/my breakfast 2. I will call my HCP before taking ibuprofen 3. I need to have my blood drawn twice a week 4. I will feel hungry while on this medication 5. I will sit on the edge of my bed for 2 minutes before I get out of bed

1, 2, 5 Hydralazine should be taken w/food to increase bioavailability of the medication OTC medications should be avoided when taking hydralazine unless otherwise directed by the HCP Orthostatic hypotension is a possible adverse effect of hydralazine; the client should be instructed to sit on the edge of the bed prior to standing to prevent this effect

A client dx w/a severe sprain of the right ankle must avoid all weight-bearing on the right foot. Which demonstration by the client indicates proper use of the crutches? *select all that apply* 1. elbows are flexed 20-30 degrees 2. touches down w/the right foot 3. ensures rubber tips are on both crutches 4. bears weight on the armpits 5. keeps crutches 14-16 inches out to side

1, 3 Crutches should be measured for client's height; when measured correctly, elbows should be flexed 20-30 degrees Rubber tip placement on crutches ensures equipment safety

The nurse provides education about influenza tx and prevention at a local health fair. Which statement from a participant demonstrates *correct* understanding of oseltamivir? *select all that apply* 1. I will begin taking the medication as soon as I experience flu symptoms 2. the capsules must be swallowed whole and never opened 3. if the medication upsets my stomach, I can take it w/food 4. children younger than 12 years should not take this medication 5. after I complete the medication, I will not need a yearly flu shot 6. I should not take this medication if I am allergic to eggs

1, 3 To lessen the severity of influenza symptoms, influenza sufferers should take oseltamivir as soon as symptoms appear Oseltamivir may cause stomach upset, and taking it w/food should decrease this adverse effect Capsules may be opened and mixed w/flavoring if needed Children as young as 1 year of age may take oseltamivir There is no contraindication for taking oseltamivir in persons allergic to eggs

A HCP would like to give the nurse a verbal telephone prescription for a client. Which action does the nurse take to properly receive the prescription? *select all that apply* 1. clarify the client's name 2. explain that verbal prescriptions are only accepted in emergency situations 3. transcribe the prescription into the client's medical record as soon as possible 4. read back the prescription and get confirmation from the HCP 5. have another nurse also listen as the HCP gives the verbal prescription 6. record the prescription as "Pending until written prescription provided"

1, 3, 4 The HCP and nurse should clarify the name, dx, and other identifying data about the client to ensure both are speaking about the same client Verbal or telephone prescriptions should be transcribed into the client's medical record as soon as feasible Verbal or telephone prescriptions must be told back to the HCP to ensure accuracy

The nurse prepares assignments r/t nutrition for the evening shift. Which client can be assigned to the UAP? *select all that apply* 1. the weak client dx w/HIV and pneumonia 2. the client dx w/a CNS teratoma 3. the client dx w/RA and who is allergic to fish 4. the client post brain aneurysm and who requires assistance w/feeding 5. the client dx w/epilepsy and who is alert and oriented

1, 3, 5 The UAP can provides direct client care to someone w/standard, unchanging procedures; the client dx w/HIV and pneumonia requires standard, unchanging procedures The client dx w/RA and who is allergic to fish requires standard, unchanging procedures Someone w/a stable seizure disorder can be taken care of by a UAP The UAP does not have knowledge, skills, and abilities for unpredictable situations caused by a closed aneurysm

An adolescent client presents to the clinic for a follow-up after a recent dx of substance use disorder (SUD). Which client statement indicates to the nurse that SUD education was effective? *select all that apply* 1. it is very normal if I relapse. I will try again if it happens and will reach out for help 2. I'll need a prescription for naloxone to have on hand in case I go into w/drawal 3. I am going to just stop using this week and gain the trust of my parents again 4. I can reduce my cravings and triggers by getting involved in extracurricular school activities 5. the best and only sure way to recovery is through wilderness training 6. I started using e-cigarettes w/a fruity flavor as a deterrent to using hard drugs

1, 4 This statement is correct and is helpful for the client to realize that in case of relapse there is support available to help the client get back on track; SUD is not cured by "will power" and a relapse should not be viewed as a lack of will power; strength comes in reaching out for assistance and help from professionals and trusted resources It is proven that alternative, productive, and healthy activities can help detour and redirect the energies typically spent in using and misusing drugs; encouraging adolescents to form healthy relationships w/others is a helpful tool in recovery

The nurse has educated a client dx w/esophageal cancer who will be having an implanted port for chemotherapy and possible total parenteral nutrition (TPN). Which statement made by the client indicates that teaching is successful? *select all that apply* 1. I will have less risk of infection this way 2. I will learn how to flush the port daily 3. I won't be able to do my morning swimming 4. my port will only be accessed when needed 5. I will remind HCP that I have a port

1, 4, 5 One advantage of implanted central venous access ports is that they demonstrate less risk of infection as they are not continuously accessed The port may be accessed for blood draws, chemotherapy txs, and administration of TPN if needed W/the port in place, there will not be a need for repeated venous punctures

The nurse provides care for a client in active labor. The client's birth plan includes avoidance of all pharmacologic pain measures. Which intervention does the nurse implement to improve comfort during contractions? 1. place the client in a supine position 2. use hydrotherapy 3. tell client to hold breath during contraction and then "blow all the pain out" 4. maintain bed rest

2 Sitting or standing in the shower or submerging in a bathtub allows warm water to relieve muscle tension, which aids the labor process

The nurse provides care for a client dx w/chronic kidney disease who has increasing edema and SOB. Which action by the nurse is *most* important before giving prescribed oral atenolol? 1. ask the client about diuretic use at home 2. check the client's pulse and BP 3. tell the client to call for help if dizzy or faint 4. allow only a few sips of water w/the medication

2 The actions of atenolol, a beta blocker, include slowing the HR and decreasing the BP

The nurse on the behavioral health unit negotiates a behavior modification contract w/an adolescent w/anorexia nervosa. The nurse determines further teaching is necessary when the client makes which statement? 1. exercise is not allowed until I reach my target weight 2. the faster I gain weight, the faster I will return to school 3. I will eat at each meal time because it's my only option 4. I know someone will watch me during eating and after I eat

2 The client needs slow, steady weight gain of no more than 2 lb per week, because rapid weight gain can put undue stress on the heart, which already has diminished output from poor nutrition Eating is the only option now that the pt is hospitalized

A client experiences frequent bouts of constipation. The nurse has taught the client strategies for avoiding constipation. Which response by the client indicates a need for further teaching? 1. I should not ignore the urge to pass a BM 2. I usually drink 2-3 glasses of water per day 3. exercising three to five times a week is good for me 4. I am going to cut back on my cheese and egg intake

2 The client should increase fluid intake to 8-12 glasses per day, if not contraindicated, to avoid constipation

The nurse provides care for several clients in a mental health care setting. Which situation requires the nurse's *immediate* attention? 1. client w/bipolar disorder walks into the day room wearing only underwear and begins dancing 2. client w/depression says, "my plan is complete, and I'm ready to go for it" 3. client recovering from substance abuse reports harassment by another client 4. client w/schizophrenia says that it's "God's will" that the "evil TV" be destroyed

2 The client w/depression who says a plan is complete and plans to implement it is at high risk for committing suicide This client needs immediate follow-up and attention

The charge nurse observes a new nurse in the medical unit who is transferring a client dx w/multiple sclerosis from the bed to a wheelchair. Which action by the new nurse will require the charge nurse to intervene? 1. assisting the client to the edge of the bed 2. placing the wheelchair on the affected side 3. bends the knees when lowering the client to the wheelchair 4. straightens the client's shoulders and hips before transport

2 The nurse should place the wheelchair on the client's unaffected side because this supports weight and provides greater stability compared to the affected side

A new client reports, "I can't shake off feeling uneasy! I just have too much going on right now!" After a few minutes, the client starts pacing, hyperventilating, and is unable to follow the nurse's instructions. Which action does the nurse take? *select all that apply* 1. talk continually to the client 2. stay w/the client 3. instruct the client to lie down and rest 4. tell the client that everything is under control 5. educate the client about ways to manage stress 6. isolate the client until symptoms resolve

2 Unmanaged stress can lead to symptoms of anxiety If the client cannot cope w/the stress, the anxiety can escalate from mild, moderate, severe, and panic A client who is in the panic level of anxiety or experiencing a panic attack has a decreased perceptual field, cannot solve problems, has a disorganized personality, and is a danger to the self and others The nurse should stay w/the client to prevent the client from harming self and others, speaking in short and soft sentences and providing a therapeutic environment

The nurse teaches a client dx w/multiple rib fractures on pulmonary hygiene. Which statement by the client indicates that further teaching is necessary? *select all that apply* 1. I can use a pillow to hold over my abdomen while coughing to reduce discomfort 2. I should exhale deeply into the incentive spirometer 10 times an hour during the day 3. I don't want to ask the HCP for pain medicine because they will think I am an addict 4. it is important for me to drink water so that I can cough up secretions effectively 5. when using my incentive spirometer, I sit on the edge of the bed so that my lungs can expand 6. I will call for assistance when I am ready to go for a walk in the hall

2, 3 This statement indicates that further teaching is needed; correct use of the incentive spirometer consists of deep inhalation into the mouthpiece to expand the lungs Pain management is key to allow the client to effectively perform coughing, deep breathing, and other components of pulmonary hygiene; the client should understand that asking for pain medication does not indicate weakness or addiction 4: hydration is an important component of pulmonary health to aid in effective expectoration by thinning secretions 5: the client should be positioned for optimal lung expansion prior to using the incentive spirometer

An older adult client is admitted to the hospital. During the health hx, the client reports that her sleep patterns have changed w/age. Which explanation does the nurse include when discussing sleep changes that occur due to the aging process? *select all that apply* 1. rapid eye movement *REM) sleep increases in older adults 2. total sleep time is usually shorter in the older adult 3. stage IV sleep is substantially decreased 4. physical problems and medications can affect sleep 5. older adults have more difficulty falling asleep

2, 3, 4, 5 Sleep time decreases as adults age; the nurse should include this explanation when discussing sleep changes that occur due to the aging process Older adults may experience no stage IV (deep) sleep, or significantly less amounts of it; the nurse should include this explanation when discussing sleep changes that occur due to the aging process Physical problems, disease processes, nocturia, and medications may all have an impact on the inability to sleep soundly; the nurse should include this explanation when discussing sleep changes that occur due to the aging process Older adults tend to have difficulty falling asleep; the nurse should include this explanation when discussing sleep changes that occur due to the aging process

A client newly admitted to a long-term facility reports that it is a long walk from the bed to the activity room. Which finding prompts the nurse to assess if an assistive device might be appropriate for this client? *select all that apply* 1. the client is overweight and does not enjoy physical activity 2. the client ambulates w/a one-person assist 3. the client has full weight-bearing status 4. the client has had a recent fall 5. the client takes a medication that has sedating properties

2, 4 The fact that the client has been ambulating w/assistance suggests the need for further assessment; the client may benefit from the use of an assistive device 4: this is concerning and necessitates further assessment An assistive device would not address this concern; if the sedating medication is causing ambulation or alertness issues, this should be discussed w/the HCP

The nurse provides care for a client dx w/impaired vision. Which interventions will the nurse implement to meet the client's needs? *select all that apply* 1. keep the voice even throughout conversations 2. explain the sounds in the environment 3. decrease background noise before speaking 4. stay in the client's field of vision 5. identify self by name and staff position

2, 4, 5 Explaining environmental sounds is appropriate for this client Remaining in the client's filed of vision helps the client best see the nurse Stating name, position, and intent will help the client recognize the person providing care

The charge nurse assists a new nurse in learning client care management and delegation. The charge nurse counsels the new nurse when which action is observed? *select all that apply* 1. the new nurse asks the charge nurse to assist w/the insertion of an IV catheter after two failed attempts 2. the new nurse asks the UAP to obtain the blood glucose on a client newly dx w/DM who was just admitted to the unit 3. the new nurse asks the UAP to perform a complete bed bath on a bedbound client w/a tracheostomy 4. the new nurse asks the UAP to obtain VS on a client who just returned from a cardiac catheterization 5. the new nurse asks the UAP to assist a newly admitted client w/myasthenia gravis w/the first meal

2, 4, 5 This client is both newly dx w/DM and is a new admit; the new nurse should obtain the initial blood glucose, for there is a high likelihood of an abnormal result that requires immediate tx; the charge nurse needs to counsel this new nurse on tasks that are appropriate to delegate The client just returned from an invasive procedure, and obtaining VS are part of the assessment after a cardiac catheterization; this task should not be delegated This client may be unstable and require additional assessment by the nurse, including a swallow assessment

A client w/a newly placed tracheostomy and a dx of active TB is admitted to the unit. When orienting the client to the unit, it is *most* important for the nurse to include which information? 1. the importance of adhering to the prescribed diet 2. the use of the phone and the direct number to the nurses' station 3. the location and use of the call light 4. the importance of covering the tracheostomy site when leaving the room

3 A client w/a newly placed tracheostomy is unable to communicate via speech or call for help if something is needed Because of the dx of active TB, the client will be placed in a negative airflow room to prevent the spread of infection to other clients The best way for the client to get help or assistance when needed is to use the call light

The nurse provides care for an older adult client w/a hx of DM and stroke w/left-sided deficit who was admitted to the hospital after falling at home. While assessing the client, the nurse observes the client is underweight, incontinent of urine, and too weak to transfer or move in bed independently. Which action does the nurse take *first*? 1. reposition the client immediately onto the affected side 2. instruct the UAP to reposition the client every 2 hours 3. complete skin assessment and document any reddened or pressure areas thoroughly 4. massage reddened area on client's right heel to promote circulation

3 Advanced age, DM, malnutrition, immobility, and incontinence are all risk factors for impaired skin integrity The nurse should complete the skin assessment and document thoroughly first, so that any existing skin breakdown can be treated and a plan of care established Based on the complete skin assessment completed by the nurse, the frequency of repositioning can be determined

The spouse of a client dx w/a phobia is concerned by the client's sudden fear of elevators. The spouse asks the nurse what to do when the client becomes frightened. Which action does the nurse encourage the spouse to take *first*? 1. ride the elevator w/the client 2. encourage the client to get into the elevator 3. allow the client to avoid the elevator 4. encourage the client to discuss the fear

3 By allowing the client to avoid the elevator, the spouse will not increase the client's apprehension and anger This maintains a better relationship 4: while appropriate, it is more important to allow the client to avoid the elevator; phobia is not rational and responds best to systematic desensitization

The triage nurse prioritizes clients for evaluation. Which client does the nurse determine should be seen *first*? 1. the client receiving dialysis and who missed a tx the day before and reports swelling in the feet and ankles 2. the adolescent client w/a leg laceration from a fall down five steps and who reports pain of 4 on a 1-10 numeric scale 3. the client w/a hx of chronic alcohol use and who reports tremors, confusion, and feeling like the heart is racing 4. the woman at 8 weeks' gestation and who reports vaginal spotting that has occurred off and on for the past several days

3 Chronic alcohol use is the most common cause of hypomagnesemia (<1.5), which may result in cardiac arrest The manifestations include increased neuromuscular irritability, tremors, tetany, and seizures The client's symptoms put the client at an actual risk

The nurse provides care for a client who is recovering from DKA. The nurse teaches the client strategies to prevent recurrence of the condition. Which preventative strategy is appropriate for the nurse include in the teaching plan? 1. eat six small meals per day 2. maintain appropriate follow-up care 3. monitor blood glucose levels frequently 4. test urine for ketone levels

3 Following DKA, there is a great need to check blood glucose levels frequently Catching an increase in glucose levels early will enable tx to be started to prevent the development of DKA

The nurse provides care for a client who has undergone gastric surgery for peptic ulcer disease (PUD). Two hours after eating, the client reports feeling weak and shaky. The nurse observes that the client's skin is cool and clammy. Which assessment is a *priority* for the nurse to complete? 1. bleeding 2. BP 3. blood glucose 4. urine output

3 Immediately after eating, the client's blood glucose rises and excessive insulin may be secreted in response About 2 hours after eating, a client is at risk for hypoglycemia This client is experiencing symptoms of hypoglycemia (clammy skin, feeling weak, shaky), so obtaining a blood glucose is the priority assessment

The nurse provides care for a client who experienced a severe eye injury r/t an acid splash. The nurse administers proparacaine hydrochloride before each eye examination. Which action is *most* important for the nurse to take? 1. instruct the client about the action of the medication 2. measure the client's intraocular pressure 3. instruct the client not to touch the eye 4. inform the client that the numbing effect will last 15 minutes

3 Rubbing or touching the eye when the eye is anesthetized may cause corneal damage Instructing the client not to touch the eye ensures client safety and is the highest priority Intraocular pressure is used to test for glaucoma; this is not a relevant assessment at this time

The nurse provides care for a client recently dx w/DM. The nurse instructs the client about foot care. Which client statement indicates to the nurse the need for further teaching? 1. I will file my nails 2. I am going to use a mirror to check my feet 3. I enjoy walking barefoot around the house 4. I will increase the time that I wear new shoes each day

3 The client needs to avoid walking barefoot because it could cause injury, whether walking inside or outside the home Injury may result in an infection Neurological impairment is likely as a result of the diabetes, which may result in a decreased sensation, making a client unaware of an injury

The nurse teaches a client about measures to combat seasonal affective disorder. Which statement by the client indicates to the nurse that teaching was effective? 1. I will make sure to get eyeglasses that have UV filters 2. I will sit w/in 3 feet of artificial light for 30 minutes a day 3. I will continue phototherapy until spring 4. I will only use phototherapy during daytime hours

3 The client w/seasonal affective disorder should use phototherapy beginning in October and continue use until spring Phototherapy, a technique used to suppress melatonin by stimulating light receptors in the eyes, should be used 2-6 hours a day; during this time, the client should sit w/in 3 feet of the artificial light

A client is brought to the ED by friends who state, "Our friend has been hanging w/the wrong crowd. We are worried about drug use." The nurse notes that the client stares blankly and has an unsteady gait, stiff muscles, and eyes that are moving rapidly side to side and up and down. Which manifestation(s) is/are *most* important for the nurse to anticipate? 1. torticollis 2. hypotension, hypothermia, bradycardia 3. aggression 4. n/v, abdominal cramping

3 The symptoms of blank stare, rigid muscles, ataxia, and nystagmus that are both vertical and horizontal indicate probable PCP intoxication Aggression in all forms is another symptoms that manifests w/PCP use This can take the form of assault, belligerence, impulsiveness, or suicidality, and it is very often bizarre in nature It often occurs in unpredictable outbursts This manifestation impacts safety This is the most important clinical manifestation for the nurse to monitor for when providing care for this client While torticollis is a clinical manifestation associated w/PCP use, this finding will not require an immediate intervention from the nurse; this is not the most important manifestation for the nurse to anticipate

The nurse provides teaching to a client being discharged w/newly prescribed home O2. Which client statement indicates additional teaching is needed w/regards to home safety? 1. I should keep the O2 unit and tubing away from open flames 2. I should clean the O2 tubing weekly or as advised by the medical supply company 3. I should request that family and friends not visit 4. I should post the 'No Smoking. O2 in Use.' sing in my front window

3 Visitors should not be limited just because the client is using O2 They should be educated on safety issues such as not smoking and avoiding visiting if they are sick

A parent brings a 10 month old child to the health clinic. The parent asks the nurse when the child will be ready to begin toilet training. Which response by the nurse is accurate? 1. your child is ready now 2. your child will be ready in 2 months 3. your child should be ready in another 8-12 months 4. your child will tell you when your child is ready

3 Voluntary control over sphincters is achieved at 18-24 months Parents may recognize a child's readiness; a toddler may be curious about a parent's toilet habits, but is unlikely to reliably indicate their own readiness

The nurse prepares to assess a client w/right-sided HF. Which symptom will the nurse expect to observe? 1. increased respiration w/exertion 2. cough producing large amount of thick, yellow mucus 3. peripheral edema and anorexia 4. twitching of extremities

3 Right-sided HF is manifested by congestion of the venous system, resulting in peripheral edema There is congestion of the gastric veins, resulting in anorexia and eventual development of ascites

A newborn weighing 3250 gm is prescribed IV digoxin 0.025 mg/kg in three divided doses over 24 hours. The medication available is 100 mcg/mL. Which amount of medication in mL will the nurse administer for one dose?

0.27 mL

A client's cardiac monitor shows a new onset of a. fib w/a ventricular rate of 90 bpm. Which actions will the nurse implement when providing care for the client? *select all that apply* 1. perform rapid defibrillation 2. measure VS 3. assess for associated s/s 4. notify the HCP 5. administer amiodarone

2, 3, 4 The nurse should measure the client's VS to determine whether the client is hemodynamically stable and tolerating the arrhythmia The nurse should assess the client to determine whether associated s/s are present The nurse should notify the HCP of the change in the client's condition

The nurse assesses a client who is prescribed lithium. Which finding indicates to the nurse that the client is experiencing early toxicity? 1. restlessness, shuffling gait, involuntary muscle movements 2. ataxia, confusion, seizures 3. n/v/d 4. elevated WBC count, fever, orthostatic hypotension

3 Early signs of lithium toxicity include n/v/d

The nurse provides care for a client dx w/prerenal acute kidney injury. The nurse recognizes that which cause likely led to this dx? 1. acute tubular necrosis 2. glomerular injury 3. ureteral obstruction 4. hypovolemia

4 The nurse needs to recognize that decreased cardiac output or hypovolemia is the cause of prerenal acute kidney injury

The nurse reviews ABG lab work for a client dx w/DKA. Which lab values would be consistent w/this dx? 1. pH 7.34, PaCO2 46, HCO3 25 2. pH 7.48, PaCO2 33, HCO3 25 3. pH 7.5, HCO3 29 4. pH 7.25, HCO3 17

4 This reflects a metabolic acidosis, seen w/DKA Metabolic acidosis is a disorder that reduces the serum HCO3 concentration and pH Normal pH is 7.35-7.45, and normal HCO3 is 22-26

A client will receive regular insulin 36 units/hr by IV drip. The IV solution contains 100 units of regular insulin in 250 mL of0.9% sodium chloride. How many mL per hour does the nurse set the IV pump to infuse?

90 mL/hr

The nurse observes a student nurse assess neonates in the nursery. Which student nurse action requires intervention by the nurse? 1. documenting a negative red light reflex in a neonate who is two days old 2. testing the tonic neck reflex by lying the neonate supine and turning the head to one side 3. testing the rooting reflex by stroking the corner of the neonate's mouth 4. documenting a positive Babinski reflex in a neonate who is one day old

1 A negative (absent) red light reflex indicates a severe neurological deficit, possibly caused by increased ICP It must be evaluated immediately

A client who had abdominal surgery 4 months ago experiences bloating, vomiting, cramping, and abdominal pain. Which does the nurse suspect as the cause of the client's symptoms? 1. adhesions 2. influenza 3. contractures 4. evisceration

1 An adhesion is a band of scar tissue that forms between organs after a surgical procedure and can cause the symptoms of an intestinal obstruction

The community health nurse reviews recent lab tests for the caseload. Which client should the nurse see *first* based on the lab results? 1. client w/granular casts found in the urinalysis 2. client w/urine specific gravity of 1.025 3. client w/BUN of 16 4. client w/serum creatinine of 1.0

1 Granular casts indicate kidney disease and this client should be seen first

After abdominal surgery, the client reports abdominal gas pain. Which action is appropriate for the nurse to take? 1. offer the client fresh fruits and vegetables 2. ambulate the client frequently 3. teach the client how to splint the abdomen during activity 4. position the client on the left side

2 Ambulation promotes the return of peristalsis and facilitates the expulsion of flatus, reducing gas pains

The nurse observes an UAP provide care for clients. Which observation by the nurse requires an *intervention*? 1. a small pillow is placed under the thighs of a client dx w/SOB, and the HOB is elevated 60 degrees 2. a pillow is placed under the head and neck of a client who is lying on the right side after a liver biopsy 3. a client dx w/hemiplegia lies prone w/the lower legs placed on a pillow 4. a client dx w/a sacral pressure injury lies on the left side w/the right leg extended and resting on the mattress

4 This action is to be avoided by having the upper leg mildly flexed and resting on a pillow from groin to feet A potential trouble area of the side-lying position is hip joints that are internally rotated, adducted, and unsupported Two common potential trouble areas of the prone position are plantar flexion of the feet (foot drop) and pressure points on the toes; a pillow under the lower leg allows for dorsiflexion of the client's ankle and foot and keeps pressure off the toes

The nurse provides care for clients in an outpt psychiatric unit. The parent of a client dx w/antisocial personality disorder says to the nurse, "My child seems much better, and seems to be growing up and willing to accept more responsibility." Which response by the nurse is *best*? 1. I am so glad that your child is cured 2. you should be careful; people w/antisocial tendencies do not change 3. make sure that your child continues to take the medication 4. tell me about the responsibilities your child has accepted

4 This is an open-ended statement that directly addresses the parent's statement and provides the nurse w/the opportunity to further assess the situation Clients w/antisocial personality disorder are often manipulative and untrustworthy They usually move from situation to situation in an opportunistic fashion The nurse should assess the client's behavior and ensure that the parent does not give the child responsibilities that could pose a risk to others (the parent should not delegate financial responsibilities)

The nurse completes a surgical hand scrub before each procedure. In which order, starting w/the first step, does the nurse implement the surgical hand scrub?

First: remove all jewelry for thorough skin cleaning; items such as rings present a serious infection risk and cannot be cleaned thoroughly enough to be considered safe Second: turn on the water using knee or foot controls to eliminate recontamination of hands Third: remove debris from under finger nails; artificial nails are not permitted Fourth: apply the antimicrobial scrub agent to the hands and forearms w/a soft sponge, and then scrub for 3-5 minutes using gentle friction to reduce contaminants Fifth: rinse the hands and forearms, holding the hands above the forearms to prevent water from running back onto cleaned hands

The nurse accidentally provides a client w/carvedilol 300 mg by mouth instead of clopidogrel 300 mg by mouth. In which order will the nurse complete actions because of this medication error?

First: since the client is at risk for a fall because of a potential drop in BP, the nurse will instruct the client to stay in bed Second: the nurse will place the client on continuous BP monitoring to assess for a possible hypotensive crisis Third: the nurse will report the error to the HCP who may prescribe medications to counteract the effects of the beta blocker that was accidentally provided to the client Fourth: the nurse will assess urine output; since cardiogenic shock is a potential complication from an overdose of this medication, a drop in urine output will be a late sign

The nurse plans care for clients waiting to be seen in the outpt clinic. Which client does the nurse identify to be seen *first*? 1. an infant w/lethargy and refusing breastfeeding for 8 hours 2. a toddler reporting elbow pain w/an obvious deformity 3. a preschool-age client who is flushed and an elevated temperature 4. a school-age client w/two episodes of vomiting and a sore throat

1 Not taking fluids or food for 8 hours increases the infant's risk for dehydration and acidosis The infant's rate of fluid exchange is significantly higher than an adult's an the metabolism rate is nearly twice that of an adult Because the kidneys are not mature at this age, the infant cannot adequately concentrate urine to conserve water

Which action does the nurse take to utilize milieu therapy when providing care to clients in a psychiatric inpt setting? 1. provide a consistent set of activities and responsibilities for each client 2. ask the family to bring in items from home in order to recreate the home environment 3. use therapeutic communication w/other staff members to foster community 4. set consistent limits on client behaviors

1 In milieu therapy, all aspects of the environment are utilized as instruments of growth for the client's benefit Clients are encouraged to take responsibility for various tasks and to participate in activities that allow them to develop healthy social behaviors Milieu therapy is primarily intended to treat behavior and personality disorders Recreating the home environment may be detrimental to the client, as it may trigger problematic behaviors that the client was exhibiting in the home environment; the goal of milieu therapy is to provide an environment in which new patterns of behavior can be developed

The nurse provides care for a client dx w/mild preeclampsia. Which assessment data, identified by the nurse, supports this dx? *select all that apply* 1. BP of 150/96 2. urine output of 460 mL in a 24 hour period 3. platelet count of 110,000 4. 4+ proteinuria 5. ALT level 30

1, 5 The criteria for mild preeclampsia include BP > or = to 140/90 but < or = to 160/110 Liver enzymes remain normal w/mild preeclampsia; elevated liver enzymes are seen w/severe preeclampsia (HELLP syndrome); the normal ALT level is 10-40 2: an adequate urine output is seen w/mild preeclampsia; oliguria (< or = to 30 mL/hr) is seen w/severe preeclampsia 4: > or = to 1+ proteinuria is seen w/mild preeclampsia; > or = to 3 + proteinuria is seen w/severe preeclampsia

The nurse provides care for an infant client dx w/constipation. The client's abdominal x-ray reveals a large amount of stool in the colon. Which steps does the nurse take to give the infant an enema?

1. always gather and prepare all supplies prior to beginning a procedure 2. standard precautions are required 3. this is the safest position for the infant; bending the knees allows room in the rectum for the enema solution 4. lubricating the tubing allows for ease and comfort of insertion 5. the infant's rectum is shorter than the child's or adult's rectum; this length of insertion is sufficient for appropriate placement of the enema solution 6. instilling the enema solution at a rate of no more than 100 mL per minute ensures comfort and safety; *note*: an isotonic solution is used in children because plain water can cause rapid fluid shifts and fluid volume overload

A client requires blood glucose testing to determine insulin dosing before the next meal. The nurse plans to delegate blood glucose monitoring to an UAP.

1. the nurse must assess the UAP's ability to safely perform the blood glucose monitoring, before delegation of the task to the UAP 2. once the nurse knows the UAP has the skills and knowledge to perform blood glucose monitoring, the task can be delegated 3. the UAP should don nonsterile gloves before obtaining the blood glucose sample because there is a potential for exposure to the client's blood 4. the UAP should then obtain the sample and apply it to the test strip 5. after obtaining the blood glucose reading, the UAP should report the value to the nurse 6. once the UAP has completed the task and reported the results, the nurse can administer insulin to the client based on blood glucose level obtained by the UAP

A young adult college student arrives at the student health center. The young adult is crying hysterically and states, "I was raped last night." Which intervention is *most* appropriate? 1. report the incident to the local police 2. reassure the client of being in a safe place 3. tell the client to expect difficulty sleeping 4. call the client's friend

2 A client who has been sexually assaulted is in crisis, may fear for their life, and must be reassured of safety 1: while this may be appropriate for legal purposes, it is not the first intervention

A client w/HF and T1DM is found unresponsive. Which action will the nurse take *first*? 1. open four packets of sugar and empty them on the client's tongue 2. call for help 3. begin chest compressions 4. administer glucagon SQ, as prescribed

2 After establishing unresponsiveness, the nurse should call for help, check for breathing, and assess for a pulse The nurse needs to further assess the client instead of assuming that hypoglycemia is the cause of unresponsiveness; after determining that hypoglycemia is the cause, the nurse should administer glucagon by SQ or IM, as prescribed

The nurse instructs the parents of toddlers about safety precautions for their children's eyes, ears, and noses. Which statement does the nurse include? 1. teach the child to blow the nose by alternating occluding nares 2. cotton-tipped applicators are used only on the outer ear 3. getting a foreign object out of the ear is done using irrigation 4. if you need to give ear drops, make sure the solution is cold

2 Applicators are not safe for the inner ear because they can force earwax further in and block the canal 1: this is an incorrect action; blowing w/one nostril closed can push foreign material into the eustachian tube or otherwise damage the inner canal

An older adult client w/a necrotic left foot is scheduled for a below-the-knee amputation. The client states to the nurse, "I have changed my mind and do not want this procedure." Which response by the nurse is appropriate? 1. I understand you may be scared, but this is a routine surgery and you have nothing to worry about 2. It is your right to refuse tx, and I will inform the HCP immediately 3. it is too late to cancel the procedure. the OR has already been reserved 4. I'm sorry, but because you have already signed the consent, you cannot refuse the surgery

2 It is important that the nurse shows respect and recognizes the client's right to refuse tx or care Informing the HCP immediately once the client decides to refuse the procedure and respecting that choice is the most appropriate response

The nurse administers medication on the pediatric unit. Which is the *first* action by the nurse? 1. validate the prescription w/the medical record after the medication has been administered 2. verify the client by looking at the armband before administering the medication 3. contact the pharmacist to find out about possible adverse reactions 4. administer the medication mixed in the client's formula

2 Medication errors often occur because of improper identification The nurse should remember the rights of medication administration

During a team huddle, the nursing staff discusses the plan of care for a client dx w/a stroke. To which nursing problem does staff assign *priority*? 1. altered thought processes 2. powerlessness 3. inefficient swallowing 4. potential for injury

3 Inefficient swallowing takes priority over problems caused by other levels of needs Problems that interfere w/a client's physiological needs take priority over safety and security, love and belonging, esteem and self-esteem, and self-actualization

The nurse provides care to a client at 15 weeks' gestation who has a non-immune rubella titer. Which action will the nurse take *next*? 1. suggest that the client have a rubella vaccine at this visit 2. tell the client to avoid any contact w/young children 3. explain that immunization will occur after delivery 4. plan to immunize the client during the third trimester

3 Non-immune women are vaccinated during the postpartum period so that they will be immune before becoming pregnant again This vaccination is not given during pregnancy, because it is a live attenuated (weakened) form of the virus

The nurse provides care for clients on the psychiatric unit. The nurse identifies which comment by a client as indicative of a dissociative disorder? 1. I keep having recurring nightmares 2. I have a HA and my stomach has bothered me for a week 3. I always check the door locks three times before I leave home 4. I do not know who I am or where I live

4 Dissociative disorders are characterized by either a sudden or gradual disruption in the integrative functions of identity, memory, or consciousness The disruption may be transient or become a well established pattern The development of a dissociative disorder is often associated w/exposure to a traumatic event

The nurse changes a large abdominal wound dressing w/two Penrose drains in place. Which information does the nurse *most* correctly document regarding this dressing change? 1. condition of surrounding tissue, time used to change the dressing, type of dressing used 2. client's tolerance of the procedure, client position in bed, amount of wound drainage 3. client's response to the dressing change, status of Penrose drains, type of drainage from Penrose drains 4. time dressing was changed, description of the wound, color and amount of drainage from Penrose drains

4 Good documentation is legible, accurate, timely, thorough, well organized, and concise, containing essential information regarding the dressing change The time is essential to all documentation A description of the wound gives other care givers information about the wound's status The color and amount of drainage directly address the wound's status, whether it is healing, becoming infected, or other status

The adult child of a client w/Alzheimer disease asks if the prescribed medication will improve dementia. Which response by the nurse is appropriate? 1. it will help the client live independently once more 2. it is used to stop the progression of Alzheimer disease, but will not cure it 3. it will help provide a steady improvement in memory, but not in problem solving 4. it will not improve dementia, but can help control symptoms

4 Medication for Alzheimer disease is used to control emotional outbursts and other behavior responses

The nurse provides care for a client who sustained a severe burn. The client is scheduled for an autograft to be placed on the left lower extremity. Which intervention is *most* appropriate for the nurse to include in the client's postoperative care plan? 1. place the client in the prone position 2. keep the grafted extremity covered w/a blanket 3. maintain the grafted extremity in a flat position 4. elevate and immobilize the grafted extremity

4 This is the best position for clients w/autografts on lower extremities to allow the graft to adhere and attach to the wound bed Elevation of the extremity minimizes edema It is usually maintained for 3-7 days, depending on the HCP preference 2: the friction of a blanket can disrupt the graft

A client who gave birth an hour ago lets the nurse know that five relatives have arrived to visit but have been told by reception that only two visitors are allowed per client. Also, it is after visiting hours. The client requests that the relatives be allowed to participate in a short cultural ceremony naming the baby, as it is customary in the client's culture to name the baby as quickly after birth as possible. Which response by the nurse is *best*? 1. the unit can allow two visitors now. unfortunately, your other relatives will have to wait till visiting hours tomorrow 2. we can transport you down to the family visiting room to meet your relatives there 3. I can advocate for you on your behalf. your relatives may not realize you are overtired from giving birth 4. I will speak to the nurse in charge about allowing an exception

4 This response demonstrates advocacy on behalf of the client, as well as an effort to validate the client's cultural needs

A client receiving palliative care discusses end-of-life wishes w/the nurse. Which client statement *most* concerns the nurse? 1. w/my power of attorney for health care in place, I feel secure that someone can make health decisions for me when I am unable to do so 2. now that I have completed my living will, the HCP will be aware I don't want a tracheostomy performed 3. since an organ and tissue donation clause was included in my advance directive, maybe my organs can be put to good use after I die 4. now that I have designated my health care proxy, I don't have to worry about my mortgage being paid on time

4 This statement by the client would concern the nurse as it is inaccurate A health care proxy is not authorized to make financial decisions for the client The client may be thinking about a durable power of attorney for finances, which is a person who has been authorized to conduct financial transactions on behalf of an incapacitated client

The nurse teaches a group of parents about using relaxation and distraction techniques to manage pain for young children. Which parent statement indicates a need for further teaching? 1. I will cuddle my infant while softly singing 2. I will gently stroke my toddler's back 3. I will read my toddler's favorite stories 4. I will try progressive muscle relaxation w/my infant

4 This statement would require additional teaching by the nurse Infants and toddlers are not at a cognitive level to follow the directions required for progressive muscle relaxation In progressive muscle relaxation, the client is instructed to tense a group of muscles while inhaling and relax them while exhaling