NCLEX Comprehensive Exam

A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply.

*Tachycardia *Diminished peripheral pulses

A client with type 1 diabetes mellitus is instructed by the health care provider to obtain glucagon hydrochloride for emergency home use. The nurse provides information to the client's wife about the medication. Which statement by the client's wife indicates that she understands the information?

"I need to give this if he has signs of low blood sugar and goes into a coma."

A nurse, providing information to a client who has just been diagnosed with diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply.

*Hunger *Weakness *Blurred vision

As a nurse prepares to administer medications to an assigned client, the client asks, "Why don't you just leave me alone?" What is the best response by the nurse?

"I can see that you're upset. Would you like to talk about it?"

A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse?

"I don't think anyone can save the world from the terrorists by himself."

A nurse provides skin care instructions to a client with acne vulgaris. Which statement by the client indicates a need for further instruction?

"I should use oil-based cosmetics."

A client with post-traumatic stress disorder tells the nurse that he has stopped taking his prescribed medication because he didn't like how the medication was making him feel. Which of the following initial responses by the nurse is appropriate?

"Tell me more about how the medication was making you feel." Rationale: The correct response acknowledges the client's feelings and opens the channel of communication between the nurse and client. "That's all right. I'd stop, too, if it made me feel funny," indicating approval, is a nontherapeutic response and is therefore inappropriate. "Did you let your doctor know that you stopped taking the medication?" may be an appropriate question at some point during the conversation, but it is not the most appropriate initial question. "It doesn't make sense to stop the medication. I don't know why you took it upon yourself to do that" demeans the client.

A nurse is teaching a client with left-side weakness how to walk with the use of a quad-cane. The nurse ensures that:

30-degree flexion of the client's elbow is maintained when the client is holding the cane

A nurse is caring for a client who sustained burn injuries on the anterior lower legs and anterior thorax. What percentage of the client's body, according to the Rule of Nines, has been affected?

36%

A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note?

A blood pressure higher than the normal range

The nurse is the first responder at the scene of a bus crash. After a quick assessment of the victims, which one does the nurse care for first?

A victim with an open fracture of the arm that is bleeding profusely

A Tensilon test is performed on a client with suspected myasthenia gravis. Which finding constitutes a positive result?

An increase in muscle strength

A nurse prepares to administer digoxin to a client with heart failure. Which vital sign must be checked before the medication is administered?

Apical pulse

A client with emphysema is receiving theophylline (Theo-24). While providing dietary instructions, the nurse tells the client that it is acceptable to consume:

Apple juice

A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate?

Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain

(Video) The nurse is performing a sterile change of an abdominal dressing. Once the dressing has been removed and discarded in a waterproof bag, which action should the nurse take next?

Assessing the wound

A client is receiving an intravenous infusion of alteplase. For which adverse effect of the medication does the nurse monitor the client most closely?

Bleeding

An intravenous dose of adenosine is prescribed for a client to treat Wolff-Parkinson-White syndrome. Which piece of equipment does the nurse make a priority of obtaining before administering the medication?

Cardiac monitor

A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg position, on the left side. What action does the nurse take next?

Clamping the intravenous catheter

An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which finding does the nurse expect to note?

Complaints of inability to close the eye on the affected side

A mother calls the emergency department and tells the nurse that her 3-year-old child drank ammonia from a bottle while the mother was cleaning house. The nurse tells the mother to immediately:

Encourage the child to drink water or milk in small amounts

Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate?

Every morning before breakfast, with a full glass of water

A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test:

Helps predict the risk for the development of chronic complications of diabetes mellitus

A client with suspected HIV infection has positive results on enzyme-linked immunosorbent assay (ELISA) and Western blot tests. The plasma HIV RNA level is assessed, and the result is reported as 8000 copies/mL. The nurse interprets the results of the HIV RNA test as indicating that the client:

Is at low risk for AIDS

A nurse is transcribing a health care provider's prescription for oral prednisone 5 mg/day that was written in the chart of a client with type 2 diabetes mellitus who is already taking an oral hypoglycemic medication. The nurse contacts the health care provider to ask about the prescription because:

Prednisone can increase the blood glucose level

A client diagnosed with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would first:

Raise the head of the client's bed

A nurse is caring for a client who has had a stroke and is experiencing hemianopsia. Which measure does the nurse take in the care of the client?

Teaching the client to move the head from side to side (scan) when eating

A nurse is providing home care instructions to a client diagnosed with coronary artery disease (CAD) who will be discharged home and will be taking 1 aspirin daily. The nurse tells the client:

That ringing in the ears is a sign of toxicity

A nurse is providing information about the storage of insulin to a client who will be self-administering regular insulin. The nurse tells the client:

That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity

A nurse is assessing a client who is experiencing chest pain. Which observation indicates to the nurse that the pain is most likely a result of angina?

The pain is relieved by rest and nitroglycerin.

A client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid daily in a divided dose. At the health care provider's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. The nurse tells the client that:

The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage

Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the health care provider with the procedure, expect to note?

Thick and opaque Rationale: Empyema is the accumulation of pus in the pleural space. Empyema fluid is thick, opaque, exudative, and intensely foul-smelling. Clear and yellow, white and odorless, and clear and foul-smelling are incorrect descriptions of the fluid that occurs in this disorder.

A child with growth hormone deficiency will be receiving somatropin. The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring?

Thyroid-stimulating hormone (TSH)

Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. The nurse most appropriately tells the client:

To contact the health care provider

A nurse is preparing the room of a client in skeletal traction who will be admitted to the nursing unit. Which item for use by the client does the nurse identify as the most important?

Trapeze bar

A nurse is caring for a client who has undergone transsphenoidal hypophysectomy to remove a microadenoma of the pituitary gland. Which finding would be of greatest concern to the nurse?

Urinary specific gravity is low

A nurse provides dietary instructions about foods that will promote healing to a client diagnosed with osteoporosis who has sustained a fracture. The nurse tells the client that it is best to consume foods that are high in:

Vitamin C

The nurse, auscultating the breath sounds of a client, hears (these sounds.) What are they?

Wheezes

A nurse is reviewing the laboratory results of a female client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy?

White blood cell count of 2.5 × 103/μL (2.5 × 109/L) Rationale: The normal white blood cell count ranges from 4.0-11.0 × 103/μL (4.0-11.0 × 109/L). A white blood cell count of 2.5 × 103/μL (2.5 × 109/L)is low and puts the client at risk for infection. All of the other values are within normal limits. The normal sodium level is 135-145 mEq/L (135-145 mmol/L).. The normal hemoglobin level for a male ranges from 13.2-17.3 g/dL (132-173 g/L). The normal BUN concentration ranges from 6-20 mg/dL (2.1-7.1 mmol/L).

A client with acute gouty arthritis is being started on medication therapy with indomethacin.The nurse, providing medication instructions, and tells the client to take the medication:

With food

A nurse transcribing the prescriptions of a client admitted to the nursing unit notes that metformin daily has been prescribed. The nurse makes a note in the client's medication record that the medication should be administered:

With the morning meal

A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the appropriate way for the nurse to document this occurrence in the client's record?

Writing down the client's words and placing them in quotation marks

A nurse provides information about smoking-cessation measures to a client diagnosed with coronary artery disease (CAD). Which statement by the client indicates a need for further information?

"I should drink a cup (235 ml) of coffee if I feel the urge to smoke."

A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication?

"Are you having any difficulty hearing?" Rationale: Gentamicin sulfate is an aminoglycoside. It inhibits bacterial protein synthesis and has a bactericidal effect. Serious adverse reactions to aminoglycosides include ototoxicity and nephrotoxicity. The nurse must assess the client for changes in hearing, balance, and urine output. The remaining assessment questions are not associated with the adverse effects of this medication.

A nurse is performing an assessment of a client with Ménière disease. Which question does the nurse ask to elicit data about the manifestations of this disease?

"Do you have episodes of dizziness?"

A client with diabetes mellitus calls the clinic nurse and reports that she has been vomiting during the night and now has diarrhea. Which question does the nurse make a priority of asking the client?

"Have you tested your blood glucose?"

Tolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus has not been controlled with diet and exercise alone. The nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction?

"I can have a beer or glass of wine as long as I stay within my daily dietary restrictions."

A nurse has given a client with viral hepatitis instructions about home care. Which statement by the client indicates to the nurse that the client needs further teaching?

"I need to eat three meals a day with foods high in protein, fat, and carbs."

A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction?

"I need to keep any unopened bottles of insulin in the freezer."

A client has been scheduled for an electronystagmography (ENG), and the nurse provides instructions to the client about the test. Which statement by the client tells the nurse that the client understands the instructions?

"I need to not drink coffee before the test."

A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being discharged from the hospital. Which statement by the client indicates a need for further instruction?

"I need to participate in aerobic and weightlifting exercise three times a week."

A nurse provides information to a client with chronic obstructive pulmonary disease (COPD) about methods of alleviating shortness of breath while the client is eating. Which statement by the client indicates a need for further instruction?

"I should eat three meals a day, and the biggest meal should be at suppertime."

A nurse provides information about activity and exercise to the wife of a client with Parkinson's disease. Which statement by the spouse indicates a need for further instruction?

"I should encourage him to keep his hands hanging at his side when he walks."

Oral candidiasis (thrush) develops in a client infected with HIV, and the nurse provides instruction to the client about measures to relieve the discomfort. Which statement by the client indicates a need for further instruction?

"I should put ice in my drinks to help soothe the discomfort."

A nurse assigns a unlicensed assistive personnel (UAP) to care for a client who is hearing impaired and provides instructions to the UAP about the effective methods for communicating with the client. Which statement by the UAP indicates that further instruction is needed?

"I should raise the volume of my voice and stand on the client's affected side when I'm talking to him."

A nurse is teaching a client with angina pectoris who is being discharged from the hospital about managing chest pain at home. Which statement by the client indicates a need for further teaching?

"If I get chest pain, I should put 3 nitroglycerin tablets under my tongue and then go to the emergency department if that doesn't work."

A nurse has provided nutrition instructions to a mother of an infant. Which statement by the mother indicates to the nurse that the mother requires further instruction?

"It's best to use cow's milk, as long as it's whole milk and not skim."

A client diagnosed with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation?

"Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?"

A nurse provides instructions to a client who has been prescribed lithium carbonate for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply.

*"I need to avoid salt in my diet." *"It's fine to take any over-the-counter medication with the lithium." *"Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."

A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply.

*Beer *Yogurt *Pickled herring

A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the client, identifies posttrauma syndrome as a concern and identifies a client outcome that states, "The client will cope effectively with thoughts and feelings of the event." Which nursing interventions will assist the client in achieving this outcome? Select all that apply.

*Being honest, nonjudgmental, and empathetic *Assessing the immediate post-traumatic reaction *Encouraging the client to keep a journal focused on the trauma *Asking the client about the use of alcohol and drugs before and since the event

A client diagnosed with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply.

*Drink copious amounts of fluid and void frequently *Avoid contact with any individual who has signs or symptoms of a cold

A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply.

*Drooling *Excessive oral secretions

A nurse provides information to a client diagnosed with peripheral vascular disease about ways to limit the disease's progression. Which measures does the nurse tell the client to take? Select all that apply.

*Engaging in exercise such as walking on a daily basis *Washing the feet daily with a mild soap and drying them well

An emergency department nurse is caring for a client in hypovolemic shock, a result of external hemorrhage caused by a gunshot wound. Which nursing interventions should the nurse take? Select all that apply.

*Ensuring that direct pressure is applied to the external hemorrhage site *Ensuring a patent airway and supplying oxygen to the client as prescribed *Inserting an intravenous (IV) catheter and administering fluids as prescribed

A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply.

*Fatigue *Low-grade fever

A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record?

*Fever *Vasculitis *Abdominal pain Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory disorder of the connective tissue that can cause the failure of major organs and body systems. Manifestations include fever, fatigue, anorexia, weight loss, vasculitis, discoid lesions, and abdominal pain. Erythema, usually in a butterfly pattern (hence the nickname "butterfly rash"), appears over the cheeks and bridge of the nose. Other manifestations include nephritis, pericarditis, the Raynaud phenomenon, pleural effusions, joint inflammation, and myositis.

A community health nurse is preparing a poster for a health fair that will include information about the ways to prevent ear infection or ear trauma. Which prevention measures does the nurse include on the poster? Select all that apply.

*Keep the volume of headphones at the lowest setting. *Avoid environmental conditions involving rapid changes in air pressure. *Clean the external ear and canal daily in the shower or while washing the hair.

Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply.

*Keeping the room slightly darkened *Monitoring the client for changes in alertness or mental status *Restricting visits to close family members and significant others and keeping visits short

An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which characteristic of the disorder does the nurse expect the client to exhibit? Select all that apply.

*Nausea *Eye pain *Vomiting *Headache

An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply.

*Skin tenting *Flat neck veins *Weak peripheral pulses

A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which risk factors does the nurse include in the pamphlet? Select all that apply.

*Smoking *High alcohol intake *White or Asian ethnicity

A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply.

*Spinach *Legumes *Whole grains

A nurse is preparing medication instructions for a client who will be taking a daily oral dose of digoxin 0.25 mg in the treatment of heart failure (HF). Which instructions should the nurse include on the list? Select all that apply.

*Take your pulse before taking each dose. *Take the digoxin at the same time each day. *Notify the physician if you experience loss of appetite, muscle weakness, or visual disturbances.

A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after sustaining a cervical fracture. Which instructions should the nurse include? Select all that apply.

*Use a straw to drink. *Use caution when leaning forward or backward. *Do not drive, because full range of vision is impaired with the device.

A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which recommendations does the nurse include on the poster? Select all that apply.

*Wear a hat, opaque clothing, and sunglasses when out in the sun. *Seek medical advice if you find a skin lesion. Rationale: Measures to prevent skin cancer include avoiding sun exposure between 10 a.m. and 4 p.m.; using sunscreen with a high SPF; wearing a hat, opaque clothing, and sunglasses when out in the sun; and examining the body every month for possibly cancerous or precancerous lesions. The client should also seek medical advice if any changes in a skin lesion are noted.

A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expects see documented in the infant's medical record? Select all that apply.

*Weight loss *Projectile vomiting *Distended upper abdomen

A nurse is preparing to provide information to a client who has been found to have stable angina. The nurse plans to tell the client that this type of angina:

Is often managed medically with medications such as calcium channel blockers and beta-blocking medications

A nurse preparing to administer digoxin to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.0 ng/mL (2.6 nmol/L). On the basis of this result, the nurse would:

Contact the health care provider

Ciprofloxacin hydrochloride is prescribed to a client with a urinary tract infection. The nurse, providing instruction about the medication, tells the client that it is best to take the medication:

2 hours after meals

A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client?

28 mm Hg

Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of:

3 minutes Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten seconds and 30 seconds are brief periods. Thirty minutes is a lengthy period.

A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must:

Contact the physician if the skin appears yellow

A registered nurse is planning client assisgnments for the day. There is a licensed practical nurse and a unlicensed assistive personned (UAP) on the team. Which client is the appropriate choice for the UAP?

A client with rheumatoid arthritis who needs assistance with feeding and ambulation

A school nurse observing a child diagnosed with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation?

Contacting the child's physician to report the findings

A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented?

Flulike pulmonary symptoms

The mother of a newborn found to have a congenital diaphragmatic hernia asks the nurse to explain the diagnosis. The nurse tells the mother that in this condition:

Abdominal contents herniate through an opening of the diaphragm

A nurse is providing morning care to a client who has undergone surgery to repair a fractured left hip. Which item is most important for the nurse to use in turning the client from side to side to change the bed linens?

Abduction device

A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen. Which medication does the nurse prepare, anticipating that it will be prescribed to treat the child?

Acetylcysteine

NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should:

Administer the antihypertensive with a small sip of water Rationale: General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac medications, antihypertensive agents, or histamine (H2) blockers, which should be administered several hours before treatment with a small sip of water. Withholding the antihypertensive and administering it at bedtime and withholding the antihypertensive and resuming administration on the day after the ECT are incorrect actions, because antihypertensives must be administered on time; otherwise, the risk for rebound hypertension exists. The nurse would not administer a medication by way of a route that has not been prescribed.

Fluticasone propionate and albuterol, administered by inhalation twice daily, are prescribed for a client with asthma. The nurse, providing information to the client about administration of the medication, tells the client to use the:

Albuterol several minutes before inhaling the fluticasone propionate

A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify?

Anxiety Rationale: Anxiety is a vague, uneasy feeling of apprehension. Some related factors include a threat or perceived threat to physical or emotional integrity or self-concept, changes in function in one's role, and threats to or changes in socioeconomic status. The client experiencing powerlessness expresses feelings of having no control over a situation or outcome. Disruption of thought processes involves disturbance of cognitive abilities or thought. Inability to maintain health is being incapable of seeking out help needed to maintain health.

Testing of the plasma theophylline level in a client who is receiving a continuous intravenous infusion of theophylline reveals a level of 20 mcg/mL (111 umol/L). The nurse interprets this result as:

At the top of the therapeutic range

A client with myasthenia gravis who has been taking pyridostigmine bromide for the treatment of the disorder comes to the emergency department complaining of severe muscle weakness, and cholinergic crisis is diagnosed. Which medication does the nurse prepare for immediate use in treating the crisis?

Atropine sulfate

A nurse is assessing a client who has been taking amantadine hydrochloride for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication?

Bilateral lung wheezes Rationale: Amantadine hydrochloride is an antiparkinson agent that potentiates the action of dopamine in the central nervous system (CNS). The medication is used to treat rigidity and akinesia. Insomnia and orthostatic hypotension are side effects of the medication. Adverse effects include congestive heart failure (evidenced by bilateral lung wheezes), leukopenia, neutropenia, hyperexcitability, convulsions, and ventricular dysrhythmias.

A nurse is monitoring a client with pheochromocytoma who is receiving an intravenous (IV) infusion of phentolamine. Which vital sign does the nurse monitor most closely during the infusion?

Blood pressure

A nurse is providing dietary instructions to the mother of a child with celiac disease. The nurse tells the mother that it is acceptable to give the child:

Boiled Rice

A nurse reviews the results of a total serum calcium determination in a client with chronic kidney disease. The results indicate a level of 12.0 mg/dL (3 mmol/L). In light of this result, which finding does the nurse expect to note during assessment?

Bounding, full peripheral pulses

Vasopressin (Pitressin) is prescribed to a client with diabetes insipidus. For which sign, indicative of an adverse effect of the medication, does the nurse monitor the client?

Chest pain

A client with a medical history of diabetes mellitus is found to have sarcoidosis, and oral prednisone is prescribed. The nurse provides instructions to the client about the medication and tells the client to:

Closely monitor the blood glucose level

Oral prednisone 5 mg/day has been prescribed for a client with a chronic respiratory disorder, and the nurse provides instructions to the client about the medication. The nurse tells the client to:

Call the health care provider if a fever, sore throat, or muscle aches develop

The nurse notes the presence of drainage on the mustache dressing of a client who has undergone transsphenoidal hypophysectomy. The initial nursing action is to:

Check the drainage for glucose

A nurse taking the vital signs of a client immediately after she has delivered a newborn notes that the client's heart rate is 110 beats/min. The nurse would first:

Check the uterus and amount of lochia discharge

(Video) The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution?

Checking for gastric residual volume and assessing tube placement

Methylergonovine is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication?

Checking the client's blood pressure

A nurse in a health care provider's office is talking to a client who underwent mastectomy of the right breast 2 weeks ago. The client says to the nurse, "I hate looking at this incision. I feel that I'm not even myself anymore." The nurse interprets this statement to mean that the client is experiencing which problem?

Distorted body image

A nurse caring for a client 24 hours after a radical neck dissection notes the presence of serosanguineous drainage in the portable wound suction device attached to the surgical site. On the basis of this finding, the nurse should:

Document the findings

The blood serum level of imipramine is determined in a client who is being treated for depression. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should:

Document the laboratory result in the client's record Rationale: Imipramine is a tricyclic antidepressant that is often used to treat depression. The therapeutic blood serum level is between 225 and 300 ng/mL, so the nurse would simply document the laboratory result in the client's record. Asking the laboratory to recheck the level and withholding the next dose of the imipramine and contacting the health care provider are unnecessary.

Cyclobenzaprine is prescribed to a client with multiple sclerosis for the treatment of muscle spasms. For which common side effect of this medication does the nurse monitor the client?

Drowsiness

A nurse provides information to a client who will be undergoing endoscopic retrograde cholangiopancreatography (ERCP). The nurse tells the client that:

Dye may be injected during the procedure to permit visualization of the pancreatic and biliary ducts

A nurse in a health care provider's office is reviewing the medical record of a child with a diagnosis of lactose intolerance. Which finding does the nurse expect to see documented in the child's record?

Episodes of cramping abdominal pain and excessive flatus

A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately:

Get into the shower and rinse the skin for at least 15 minutes

A nurse is providing information to a client with diabetes insipidus who will be taking desmopressin acetate by way of the nasal route. For which occurrence does the nurse tell the client to contact the health care provider?

Headache and nausea

A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" The nurse responds by telling the client that:

Her hair may fall out but will regrow after the chemotherapy is discontinued

A nurse has provided information about exercise to a client with a diagnosis of degenerative joint disease (osteoarthritis). Which type of exercise does the nurse tell the client to avoid?

High-impact exercise

A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially:

Identify the client's treatment goals

A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his own insulin but has difficulty seeing and accurately preparing doses. The nurse places the medication in the client's refrigerator with the syringes:

In a vertical position with the needles pointing up

Oral prednisone 10 mg/day is prescribed for a client with an acute exacerbation of rheumatoid arthritis. The nurse, providing information to the client about the medication, tells the client that it is best to take it:

In the morning, before 9:00 a.m.

A nurse provides instructions to a client who will be taking levothyroxine for hypothyroidism. The nurse tells the client that it is best to take the medication:

In the morning, before breakfast

A laxative has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to:

Increase fluid intake

A client diagnosed with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. The nurse tells the client to:

Increase intake of high-fiber foods

A nurse is monitoring a child with intussusception for signs of peritonitis. For which finding, indicative of this complication, does the nurse notify the health care provider?

Increased heart rate

Laboratory studies are performed on a client diagnosed with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease?

Increased white blood cell (WBC) count

A client diagnosed with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B. Which parameter does the nurse check to detect the most common adverse effect of this medication?

Intake and output

Desmopressin (DDAVP) is prescribed to a client with diabetes insipidus. Which parameter does the nurse tell the client that it is important to monitor while taking the medication?

Intake and output

A nurse is caring for a client who is immobilized in skeletal traction after sustaining a leg fracture in a motor vehicle crash. The nurse notes that the client is restless, and the client complains of being bored. Which problem does the nurse identify on the basis of this information?

Lack of adequate diversional activity

A pediatric nurse is caring for a hospitalized toddler. Which activity does the nurse deem the most appropriate for the toddler?

Large building blocks

A nurse is monitoring a client who was brought to the emergency department in an unresponsive state and is now being treated for hyperglycemic nonketotic syndrome (HNS). Which finding indicates to the nurse that fluid replacement is inadequate?

Level of consciousness remains unchanged

Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the health care provider's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the health care provider to confirm the prescription for warfarin sodium because:

Levothyroxine amplifies the effect of warfarin sodium

A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium at home. The nurse teaches the client about the medication and tells the client to:

Lie down to administer the subcutaneous injection

Alprazolam (Xanax) is prescribed for a client to treat an anxiety disorder. Which side effect does the nurse warn the client of?

Lightheadedness

Although previously well controlled with glyburide, a client's fasting blood glucose has been running 180 to 200 mg/dL (10 to 11.1 mmol/L). On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia?

Lithium carbonate (Lithobid)

Captopril (Capoten) is prescribed for a hospitalized client with heart failure. Which action is a priority once the nurse has administered the first dose?

Maintaining the client on bed rest for 3 hours

A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed because the health care provider suspects iron-deficiency anemia. Which finding indicative of this type of anemia does the nurse expect to find on reviewing the laboratory results?

Microcytic red blood cells (RBCs)

A nurse is assessing a client with hepatitis for signs of jaundice. Which area does the nurse check, knowing that it will provide the best data regarding the presence of jaundice?

Mucous membranes

An emergency department nurse is monitoring a client who sustained a severe inhalation burn injury during a fire in which the client was trapped in an enclosed space. The nurse auscultates the client's trachea and notes that the previously heard wheezing sounds have disappeared. The nurse most appropriately:

Notifies the emergency department health care provider

A client is found to have iron-deficiency anemia, and ferrous sulfate is prescribed. The nurse tells the client that it is best to take the medication with:

Orange juice

A nurse admitting a newborn to the nursery notes that the health care provider has documented that the newborn has a gastroschisis. The nurse performs an assessment, expecting to note that the viscera are:

Outside the abdominal cavity, not covered with a sac

A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client's bedside?

Oxygen cannula and flowmeter

A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse prepares the room for the child and places a sign at the child's bedside that tells staff to avoid:

Palpating the abdomen

A client is found to have hypoxemic respiratory failure. Which finding does the nurse expect to note on review of the results of the client's arterial blood gas analysis?

Pao2 of 49 mm Hg, Paco2 of 32 mm Hg

A nurse is caring for a client who has had a cast applied to the left leg and is at risk for acute compartment syndrome. For which early sign of this complication does the nurse monitor the client?

Paresthesia

The wife of a client diagnosed with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL (3.3 mmol/L) and that her husband is awake but groggy. The nurse tells the client's wife to immediately:

Place some honey in her husband's mouth, between his gums and cheek

A nurse discovers that a client receiving heparin sodium by way of continuous intravenous (IV) infusion has removed the IV tubing from the infusion pump to change his hospital gown. After assessing the client and placing the tubing back in the infusion pump, which medication does the nurse check for in the medication room in case a heparin overdose has occurred?

Protamine sulfate

While being seen by a health care provider, a client reports persistent fever, malaise, and night sweats. On physical examination, the health care provider palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies?

Reed-Sternberg cells on biopsy of a lymph node

A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take from the medication supply room for intravenous (IV) administration?

Regular (Humulin R)

The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which intended effect of the medication does the nurse monitor the client?

Relief of anxiety

A nurse reviews arterial blood gas values and notes a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse interprets these values as indicative of:

Respiratory alkalosis (uncompensated)

A nurse is performing an assessment of a client being admitted to the hospital with a diagnosis of multiple sclerosis. The client tells the nurse that she took baclofen (Lioresal) for the past 9 months but completely stopped the medication 2 days ago because it was making her feel weak. On the basis of this information, the nurse notes in the plan of care that the client should be monitored most closely for:

Seizure activity

A nurse is reviewing the laboratory results of a client in the emergency department with diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to note?

Serum bicarbonate of 12 mEq/L (12 mmol/L)

Propylthiouracil has been prescribed for a client with Graves disease, and the nurse provides instructions to the client about the medication. For which occurrence does the nurse tell the client to contact the health care provider?

Sore throat

Calcium carbonate is prescribed for a client with mild hypocalcemia. What food does the nurse instruct the client to avoid consuming while taking this medication?

Spinach

A client with a history of angina pectoris tells the nurse that the chest pain usually occurs with moderate to prolonged exertion and is generally relieved by nitroglycerin or rest. Which type of angina does the nurse recognize in the client's description?

Stable

A nurse is monitoring a client with bronchogenic carcinoma for signs of superior vena cava syndrome. For which early sign of this oncological emergency does the nurse assess the client?

Stokes sign

A hospitalized client scheduled for surgery is told by the health care provider that she is extremely anemic and will need a blood transfusion. The client, a Jehovah's Witness, tells the nurse that she is refusing the transfusion. What is the most appropriate initial nursing action?

Supporting the client's decision to refuse the transfusion

A client with multiple sclerosis has been started on baclofen for muscle spasms. The client calls the health care provider's office 1 week after beginning the medication and tells the nurse that she feels extremely drowsy. The nurse most appropriately tells the client:

That drowsiness usually diminishes with continued therapy

A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of postoperative complications. Which finding would be a matter of concern for the nurse as an indication of hypocalcemia?

The client complains of a tingling sensation around the mouth.

A client has a physician's appointment to get a prescription for sildenafil (Viagra). The nurse obtains the health history from the client. Which finding indicates that the medication is contraindicated?

The client takes isosorbide dinitrate (Isordil)

Levothyroxine is prescribed to a client with hypothyroidism. One week after beginning the medication, the client calls the health care provider's office and tells the nurse that the medication has not helped. The nurse most appropriately tells the client that:

The full therapeutic effect may take 4 weeks

A client diagnosed with tuberculosis will be taking pyrazinamide, and the nurse provides instructions about the adverse effects of the medication. For which occurrence does the nurse tell the client to contact the health care provider?

Yellow skin

A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction?

"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." Rationale: An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. No special preparation is necessary before a GI series, except that NPO status must be maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction.

A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction?

"I need to contact my surgeon immediately if I feel any numbness in my genital area." Rationale: After radical vulvectomy, the client is instructed to wear support hose for 6 months and to elevate the legs frequently. The client should avoid straining during defecation and should be told that alteration in the direction of urine flow may occur. The client may resume sexual activity in 4 to 6 weeks; the nurse should discuss the possible need for lubrication and position changes during coitus. Genital numbness may be present, but it is not necessary to notify the surgeon immediately if numbness occurs.

A hospitalized female client demonstrating mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse?

"Don't say that. If you can't control yourself, we'll help you." Rationale: The nurse should respond using a firm, calm approach, providing the client with clear expectations. The correct option is the only one that involves a firm, calm approach and offers the client help if she needs it. The other three statements challenge the client.

A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder?

"Have you ever worked in a mine?" Rationale: Silicosis is a chronic fibrotic disease of the lungs caused by the inhalation of free crystalline silica dust over a long period. Mining and quarrying are each associated with a high incidence of silicosis. Hazardous exposure to silica dust also occurs in foundry work, tunneling, sandblasting, pottery-making, stone masonry, and the manufacture of glass, tile, and bricks. The finely ground silica used in soaps, polishes, and filters also presents a risk. The assessment questions noted in the other options are unrelated to the cause of silicosis.

Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information?

"I need to stop the medication and call my doctor if I have severe diarrhea." Rationale: Colchicine is classified as an antigout agent. It interferes with the capacity of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should maintain a high fluid intake (eight to ten 8-oz [235 ml] glasses of fluid per day) while taking the medication. The client is instructed to report a rash, sore throat, fever, unusual bruising or bleeding, weakness, tiredness, or numbness. A burning sensation in the throat or skin, severe diarrhea, and abdominal pain are signs of overdose.

A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse?

"Let's talk about the information that you need to determine your risk of contracting HIV." Rationale: HIV is a concern of rape victims. Such concern should always be addressed, and the victim should be given the information needed to evaluate his or her risk. Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in the emergency department or during follow-up, once the results of a pregnancy test have been obtained. However, stating, "You're more likely to get pregnant than to contract HIV" avoids the client's concern. Similarly, "HIV is rarely an issue in rape victims" and "Every rape victim is concerned about HIV" are generalized responses that avoid the client's concern.

A client who recently underwent coronary artery bypass graft surgery comes to the health care provider's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic?

"Tell me more about what you're feeling." Rationale: When a client expresses feelings of depression, it is extremely important for the nurse to further explore these feelings with the client. In stating, "This is a normal response after this type of surgery" the nurse provides false reassurance and avoids addressing the client's feelings. "It will take time, but, I promise you, you will get over the depression" is also a false reassurance, and it does not encourage the expression of feelings. "Every client who has this surgery feels the same way for about a month" is a generalization that avoids the client's feelings.

A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, "I don't think I'll be able to do these feedings by myself." Which response by the nurse is appropriate?

"Tell me more about your concerns regarding the tube feedings." Rationale: A client often has fears about leaving the secure environment of the healthcare facility, where he or she is cared for. This client fears that he will not be able to care for himself at home by administering himself the tube feedings. An open statement such as "Tell me more about..." often elicits valuable information about the client and the client's concerns. The remaining nursing responses are incorrect because they are nontherapeutic statements that do not address the client's expressed concern.

A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta?

"The placenta maintains the body temperature of my baby." Rationale: Many of the immunoglobulin G (IgG) class of antibodies are passed from mother to fetus through the placenta. Glucose, fatty acids, vitamins, and electrolytes pass readily across the placenta; glucose is the major source of energy for fetal growth and metabolic activities. The placenta provides an exchange of nutrients and waste products between the mother and fetus. Oxygen and carbon dioxide pass through the placental membrane by way of simple diffusion. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus.

A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information?

"Wearing the brace is really important in curing the scoliosis." Rationale: Scoliosis is a lateral curvature of the spine. Bracing is not curative of scoliosis but may slow the progression of the curvature to allow skeletal growth and maturation. A brace needs to be worn 18 to 23 hours a day, but it may be removed at night for sleep if this is prescribed. To be more cosmetically acceptable, a brace is usually worn under loose-fitting clothing. Back exercises are important in maintaining and strengthening the abdominal and spinal muscles. The child's skin must be meticulously monitored for signs of breakdown.

A nurse is providing morning care to a client in end-stage kidney disease. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic?

"What are your feelings right now?" Rationale: Asking, "What are your feelings right now?" encourages the client to identify his or her emotions or feelings, which is a therapeutic communication technique. In stating, "Why don't you feel like washing up?" the nurse is requesting an explanation of feelings and behaviors for which the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. "You aren't talking today. Cat got your tongue?" is a nontherapeutic cliché. The statement "You need to get yourself cleaned up. You have company coming today" is demanding, demeaning to the client, and non-therapeutic.

A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast?

(Anatomy with the appearance and dimpled texture of an orange peel.) Rationale: Peau d'orange (French for "orange peel") is the term used to describe skin dimpling, resembling the skin of an orange, at the location of a breast mass. This change, along with increased vascularity, nipple retraction, or ulceration, may indicate advanced disease. Erythema, or reddening, of the breast indicates inflammation such as that resulting from cellulitis or a breast abscess. Paget's disease is a rare type of breast cancer that is manifested as a red, scaly nipple; discharge; crusting lasting more than a few weeks. In nipple retraction, the nipple is pointed or pulled in an abnormal direction. It is suggestive of malignancy.

A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through:

A lower abdominal incision Rationale: A lower abdominal incision is used in suprapubic or retropubic prostatectomy. An upper abdominal incision is not used to remove the prostate. An incision between the scrotum and anus is made when a perineal prostatectomy is performed. Transurethral resection is performed through the urethra; an instrument called a resectoscope is used to cut the tissue by means of a high-frequency current.

A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which observation indicates to the nurse that placental separation has occurred?

A sudden gush of dark blood from the introitus Rationale: Placental separation occurs when the placenta separates from the uterus. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and a change in uterine shape from discoid to globular. The client may experience vaginal fullness but sudden sharp vaginal pain is not usual. Test-Taking Strategy: Use the process of elimination and focus on the subject, placental separation. Try visualizing this physiological process as a means of finding the correct option. Review the signs of placental separation if you had difficulty with this question.

An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client?

Administering 100% oxygen Rationale: A client with carbon monoxide poisoning is treated with inhalation of 100% oxygen to shorten the half-life of carbon monoxide to around an hour. Hyperbaric oxygen may be required to reduce the half-life to minutes by forcing the carbon monoxide off the hemoglobin molecule. Because the poisoning occurred as a result of a suicide attempt, a crisis counselor should be consulted, but this is not the priority. Suicide precautions should be instituted once emergency interventions have been completed and the client has been admitted to the hospital. The diagnosis is confirmed with a measurement of the carboxyhemoglobin level in the client's blood. Obtaining a blood specimen in which measure the carboxyhemoglobin level is a priority; however, the nurse would immediately administer 100% oxygen to the client.

A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time?

Anxiety Rationale: Anxiety is vague uneasiness or discomfort that warns of trouble and enables an individual to approach and deal with the threat. Fluid volume loss indicates a hypovolemic state, whereas fluid volume overload indicates a hypervolemic state. Premature grief is a state in which an individual grieves before an actual loss. There is no information in the question to indicate that fluid volume loss, fluid volume overload, or premature grief are factors for concern.

A nurse on the evening shift checks a health care provider's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the health care provider's answering service and is told that the health care provider is off for the night and will be available in the morning. The nurse should:

Ask the answering service to contact the on-call health care provider Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a health care provider's prescription may be in error is responsible for clarifying the prescription before carrying it out. Therefore the nurse would not administer the medication; instead, the nurse would withhold the medication until the dose can be clarified. The nurse would not wait until the next morning to obtain clarification. It is premature to call the nursing supervisor.

An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is:

Asking the ED health care provider to check the client Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be absent or diminished with the PVCs themselves because the decreased stroke volume of the premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause widened QRS complexes, it is essential that the nurse determine whether the premature beats are resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or femoral artery while observing the monitor for widened complexes or by auscultating for apical heart sounds. In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore the nurse would not tell the client that the PVCs are expected. Although the nurse will continue to monitor the client and document the findings, these are not the most appropriate actions of those provided. The most appropriate action would be to ask the ED health care provider to check the client.

A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse?

Assessing the client for organic causes of loss of arm movement Rationale: The priority is ruling out any neurological disorders. After it has been determined that there is no physiological basis for the problem, further psychiatric evaluation can be done. Encouraging the client to move his arms and performing active and passive ROM exercises have no beneficial effect in this situation. In fact, either option could be harmful if there is a physiological basis for the client's problem.

A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (PaO2) of less than 60 mm Hg (7.95 kPa). On the basis of the ABG result, the nurse prepares to:

Assist in intubating the client and beginning mechanical ventilation Rationale: A client who sustains smoke inhalation is immediately treated with 100% humidified oxygen, delivered by way of face mask. Endotracheal intubation with mechanical ventilation is needed if the client exhibits respiratory stridor, crowing, or dyspnea, all of which indicate airway obstruction. Normal arterial oxygenation is 80-100 mm Hg (10.6-13.33 kPa). An arterial oxygenation (Pao2) of less than 60 mm Hg (7.95 kPa) is an indication for intubation and mechanical ventilation.

A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which substance does the nurse ensure is readily available?

Calcium gluconate Rationale: Magnesium sulfate, which has anticonvulsant properties, is used for a client with preeclampsia to help prevent seizures (eclampsia). It also causes central nervous system depression, however, so toxicity is a concern. Calcium gluconate should be available at the bedside of a client receiving an intravenous infusion of magnesium sulfate to reverse magnesium toxicity and prevent respiratory arrest if the serum magnesium level becomes too high. Vitamin K is the antidote for warfarin sodium (Coumadin). Protamine sulfate is the antidote for heparin. Potassium chloride is used to treat potassium deficiency.

A nurse has assisted a health care provider in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to:

Call the radiography department to obtain a chest x-ray Rationale: One major complication associated with central venous catheter placement is pneumothorax, which may result from accidental puncture of the lung. After the catheter has been placed but before it is used for infusions, its placement must be checked with an x-ray. Hanging the prescribed bag of PN and starting the infusion at the prescribed rate and infusing normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency are all incorrect because they could result in the infusion of solution into a lung if a pneumothorax is present. Although the nurse may obtain a blood glucose measurement to serve as a baseline, this action is not the priority.

A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should:

Check for the presence of a gag reflex Rationale: In preparation for EGD, the client's throat is usually sprayed with an anesthetic to dampen the gag reflex and permit the introduction of the endoscope used to visualize the gastrointestinal structures. After EGD, the nurse places the highest priority on assessing the client for the return of the gag reflex. No food or oral fluids are given to the client until the gag reflex is fully intact.Vital signs are checked frequently, but this action is not associated with giving the client oral fluids. The client may be asked to use throat lozenges or a saline gargle to relieve a sore throat after the test, but neither action is related to giving the client oral fluids; additionally, neither action would be taken until the gag reflex had been detected again. Bowel sounds are not affected by this test.

Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication?

Checking the client's blood pressure Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client's blood pressure immediately before administering each dose. Checking the client's peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation.

A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which menu selection by the client tells the nurse that the client understands the instructions?

Cheeseburger Rationale: The client with COPD is encouraged to eat a high-calorie, high-protein diet and to choose foods that are easy to chew and do not promote gas formation. Dry foods stimulate coughing, and foods such as milk and chocolate may increase the thickness of saliva and other secretions. The nurse advises the client to avoid these foods, as well as caffeinated beverages, which promote diuresis, contributing to dehydration, and may increase nervousness.

A nurse is monitoring a client receiving terbutaline by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is:

Contacting the health care provider Rationale: Terbutaline may be used to stop preterm labor. It stimulates beta-adrenergic receptors of the sympathetic nervous system, resulting in bronchodilation and inhibition of uterine muscle activity. The nurse monitors the client for adverse effects and notifies the health care provider if the maternal heart rate is faster than 110 beats/min, respiration is faster than 24 breaths/min, systolic blood pressure is less than 90 mm Hg, the fetal heart rate is faster than 160 beats/min, or the client complains of chest pain or dyspnea. Increasing the rate of infusion and continuing to monitor the client and are inappropriate and delay necessary interventions. Although the nurse would document the findings, the most appropriate action in this scenario is to contact the health care provider.

A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which action should be the nurse's priority?

Contacting the health care provider Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis and warrants notifying the health care provider. A large amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen in cases of postterm gestation or placental insufficiency. Checking the fluid for protein is not associated with the data in the question. Although the nurse would continue to monitor the client and the FHR and would document the findings, contacting the health care provider is the priority.

A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with:

Conversion disorder Rationale: It is most important to establish a trusting relationship, which will indicate to the client that the client is important. After a therapeutic relationship has been established, other interventions may be carried out. The nurse would perform a physical assessment, but this would not be the first intervention. The client should be informed of the nursing unit's rules, but, again, this is not the first intervention. Telling the client that he or she will have to participate in self-care is inappropriate. The client with bipolar disorder requiring hospitalization is likely to need assistance with care.

A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk?

Count wet diapers to be sure that the infant is having at least six to 10 each day Rationale: The mother should be taught to count wet and soiled diapers to help determine whether the infant is receiving enough milk. Generally an infant should have at least 6 to 10 wet diapers (after the first 2 days of life) and at least 4 stools each day. The mother may also assess the swallowing and nutritive suckling of the infant, but this would not provide the best indication of adequate milk intake. Counting the number of times that the infant swallows during a feeding is an inadequate indicator of milk intake. The mother is not usually encouraged to weigh the infant at home, because this focuses too much attention on weight gain. Infants generally gain approximately 15 to 30 g (0.5 to 1 oz) each day after the early months of life. Pumping the breasts, placing the milk in a bottle, measuring the amount, and then bottle-feeding the infant constitute an assessment of the mother's bottle-feeding technique.

A nurse is providing instructions to a client with glaucoma who will be using acetazolamide daily. Which finding, an adverse effect, does the nurse instruct the client to report to the health care provider?

Dark urine Rationale: Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity may occur, manifesting as dark urine and stools, lower back pain, jaundice, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression may also occur as an adverse effect. Nausea, urinary frequency, and decreased appetite are side effects of the medication.

A client diagnosed with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally:

Decrease Rationale: Insulin needs generally decrease during the first trimester of pregnancy because the secretion of placental hormones antagonistic to insulin remains low. An increase in insulin need, lack of change in insulin need, and doubling of insulin need are all incorrect.

A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority?

Decreased fluid volume Rationale: Sickle cell disease is a genetic disorder that is manifested as chronic anemia, pain, disability, organ damage, increased risk for infection, and early death. In this disorder the red blood cells assume a sickle shape, become rigid, and clump together. Dehydration can precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and the fetus, including interruption of blood flow to the respiratory system and placenta. Decreased fluid volume is the priority concern in this situation, followed by decreased nutrition. Inability to tolerate activity and inability to cope compete for third priority, depending on the client's specific symptoms at the time.

A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride . On the basis of this information, the nurse determines that the client most likely has a history of:

Depression Rationale: Nefazodone hydrochloride is an antidepressant used as maintenance therapy to prevent relapse of an acute depression. Diabetes mellitus, hypethyroidism, and coronary artery disease are not treated with this medication.

A nurse in a health care provider's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to:

Document the findings Rationale: Involution is the progressive descent of the uterus into the pelvic cavity after delivery. Twenty-four hours after birth, descent of the fundus begins at a rate of approximately 1 fingerbreadth, or approximately 1 cm, per day. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. Asking the health care provider to see the client immediately, having another nurse check for the uterine fundus, and placing the client in the supine position for 5 minutes and rechecking the abdomen are all incorrect and unnecessary actions in light of the assessment finding.

A client who is taking lithium carbonate complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should:

Document the findings Rationale: Lithium carbonate is a mood stabilizer that is used to treat manic-depressive illness. Side effects include polyuria, mild thirst, and mild nausea, and therefore the nurse would simply document the findings. Because the client's complaints are side effects, not toxic effects, contacting the health care provider, instituting seizure precautions, and having a specimen drawn immediately for a serum lithium determination are all unnecessary. Vomiting, diarrhea, muscle weakness, tremors, drowsiness, and ataxia are signs of toxicity and if these occur the health care provider needs to be notified.

A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:

Document the findings Rationale: The scale for rating deep tendon reflexes is as follows: 0 = absent; 1+ = present, hypoactive; 2+ = normal; 3+ = hyperactive; 4+ = hyperactive with clonus. Deep tendon reflexes should be 1+ or 2+. Reflexes that are brisker than average and hyperactive reflexes (3+ to 4+) suggest preeclampsia and must be reported to the health care provider. It is not necessary to contact the health care provider, because the finding is normal. Likewise, rechecking the client's reflexes after ambulation and performing active and passive ROM exercises incorrect and unnecessary actions.

A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which action should the nurse take as a result of this observation?

Documenting the finding Rationale: The nurse sees evidence of accelerations. Accelerations are transient increases in the fetal heart rate that often accompany contractions and are normally caused by fetal movement. Accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Repositioning the mother, notifying the nurse-midwife, and taking the mother's vital signs are all unnecessary actions.

Chlorpromazine has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client?

Drowsiness Rationale: Chlorpromazine is an antipsychotic, antiemetic, antianxiety, and antineuralgia adjunct. Common side effects of chlorpromazine include drowsiness, blurred vision, hypotension, defective color vision, impaired night vision, dizziness, decreased sweating, constipation, dry mouth, and nasal congestion. Headache, photophobia, and urinary frequency are not specific side effects of this medication.

A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is:

Encouraging the client to deep-breathe, cough, and use an incentive spirometer Rationale: Care after abdominal hysterectomy includes maintenance of a patent airway, promotion of circulation and oxygenation, promotion of comfort, monitoring of output and drainage, promotion of elimination, and discharge teaching with regard to medications and therapeutic regimens. The priority is the maintenance of a patent airway and promotion of oxygenation and circulation. Monitoring the client for signs of returning peristalis, instructing her in dietary habits to prevent constipation, and encouraging her to talk about the effects of her surgery are also components of care after this surgery but are of lower priority than encouraging the client to deep-breathe, cough, and use an incentive spirometer.

A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase. For which adverse effect of the medication does the nurse monitor the client?

Epistaxis Rationale: Reteplase is a thrombolytic medication that promotes the fibrinolytic mechanism (i.e., conversion of plasminogen to plasmin, which destroys the fibrin in the blood clot). The thrombus, or blood clot, disintegrates when a thrombolytic medication is administered within 4 hours of an AMI. Necrosis resulting from blockage of the artery is prevented or minimized, and hospitalization may be shortened. Bleeding, a major adverse effect of thrombolytic therapy, may be superficial or internal and may be spontaneous. Epigastric pain, vomiting, and diarrhea are not adverse effects of this therapy.

A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first?

Establish a trusting nurse-client relationship Rationale: It is most important to establish a trusting relationship, which will indicate to the client that the client is important. After a therapeutic relationship has been established, other interventions may be carried out. The nurse would perform a physical assessment, but this would not be the first intervention. The client should be informed of the nursing unit's rules, but, again, this is not the first intervention. Telling the client that he or she will have to participate in self-care is inappropriate. The client with bipolar disorder requiring hospitalization is likely to need assistance with care.

A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" The nurse interprets the client's initial reaction as:

Fear Rationale: Fear is a response to a threat that is consciously recognized as a danger. In this situation, the client's reaction is one of fear, and the client verbalizes the object of fear (dying). There is no evidence of denial, acceptance, or preoccupation with self in the client's statement.

A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin . Which finding, indicating an adverse reaction to the medication, does the nurse monitor the client?

Fever Rationale: Levofloxacin is an antibiotic of the fluoroquinolone class. Pseudomembranous colitis is an adverse reaction associated with the use of this medication. It is characterized by severe abdominal pain or cramps, severe watery diarrhea, and fever. Dizziness, flatulence, and drowsiness are side effects of the medication.

A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube?

Fowler's Position Rationale: A nasogastric tube is inserted through the nose and into the stomach for the purpose of gastric decompression or feeding the client. The client is placed in the Fowler position before insertion of the tube to promote comfort and easy insertion. A flat position may be used for clients who are hypotensive. In the reverse Trendelenburg position, the entire bed frame is tilted with the foot of the bed down and may be used to promote gastric emptying or prevent esophageal reflux. A trendelenburg position is one in which the entire bed frame is tilted with the head of the bed down and may be used for postural drainage or to facilitate venous return in clients with poor peripheral perfusion

A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves:

Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening Rationale: The technique of systematic desensitization involves gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening with the goal of defusing the phobia. Having the client perform a healthy coping behavior is the description of modeling. Performing ritualistic or compulsive behaviors is a behavior characteristic of clients with obsessive-compulsive disorder. Having the client perform a ritualistic or compulsive behavior may not be therapeutic; additionally, it is not associated with systematic desensitization. Providing a high degree of exposure to a stimulus that the client finds undesirable is the technique known as flooding.

A client with cervical cancer is undergoing chemotherapy with cisplatin. For which adverse effect of cisplatin will the nurse assess the client?

Hearing loss Rationale: Cisplatin is a platinum-based agent used to treat various types of cancer. One adverse effect of cisplatin is ototoxicity, and the nurse would monitor the client for tinnitus and hearing loss. Nausea occurs with the use of several chemotherapeutic agents and is not necessarily an adverse effect. Cyclophosphamide causes hemorrhagic cystitis, evidenced by bloody urine. Doxorubicin (Adriamycin) causes cardiotoxicity.

A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be:

Helping the woman empty her bladder Rationale: In the postpartum period, the fundus should be firmly contracted and at or near the level of the umbilicus. If the uterus is found to be higher than the expected level or shifted from the midline position (usually to the right), the bladder may be distended. The location of the fundus should be rechecked after the woman has emptied her bladder. If the fundus is difficult to locate or is boggy (soft), the nurse stimulates the uterine muscle to contract by gently massaging the uterus. Encouraging the woman to walk is inappropriate at this time. The nurse would document fundal position, consistency, and height and any other interventions taken (e.g., uterine massage) after the woman has emptied her bladder.

A client diagnosed with advanced chronic kidney disease (CKD) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use:

Herbs and spices Rationale: Most clients with CKD retain sodium. The client with CKD is instructed not to add salt at the table or during food preparation. Herbs and spices may be used as an alternative to salt to enhance the flavor of food. The client with advanced CKD is instructed to limit potassium intake. The client is also instructed to avoid salt substitutes, many of which are composed of potassium chloride, if oliguria is present. Processed foods are discouraged because they are high in sodium.

A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which behavior is a characteristic of the disorder?

Hypersensitivity to negative evaluation Rationale: Avoidant personality disorder is a psychiatric condition in which a person feels extremely shy, inadequate, and sensitive to rejection. Other characteristics of avoidant personality disorder include excessive anxiety in social situations and hypersensitivity to negative evaluation. Neediness is a characteristic of dependent personality disorder. Perfectionism and preoccupation with details are characteristics of obsessive-compulsive disorder.

A client with myasthenia gravis is taking neostigmine bromide. The nurse determines that the client is gaining a therapeutic effect from the medication after noting:

Improved swallowing function Rationale: Neostigmine bromide, a cholinergic medication that prevents the destruction of acetylcholine, is used to treat myanthenia gravis. The nurse would monitor the client for a therapeutic response, which includes increased muscle strength, an easing of fatigue, and improved chewing and swallowing function. Bradycardia, increased heart rate, and decreased blood pressure are signs of an adverse reaction to the medication.

A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:

In about 6 weeks, when the vaginal vault is satisfactorily healed Rationale: After abdominal hysterectomy, the client is instructed to avoid sexual intercourse until the vaginal vault is satisfactorily healed. This takes about 6 weeks. A woman who has undergone this procedure must adjust to changes in the nature of pelvic sensations and stimuli during sexual intercourse; however, this is not related to when sexual intercourse may be resumed. The client will not have menstrual periods after abdominal hysterectomy.

A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2017. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is:

July 2, 2018 Rationale: Accurate use of Nagele's rule requires that the woman have a regular 28-day menstrual cycle. To calculate the EDD with the use of this rule, the nurse would subtract 3 months from the date of the first day of her LMP, add 7 days, and then adjust the year. First day of the LMP, September 25, 2017; subtract 3 months, June 25, 2017; add 7 days, July 2, 2017; add 1 year, July 2, 2018.

A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Wterm-67hich intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement?

Maintaining cuff pressure Rationale: Necrosis of the tracheal wall caused by the cuff of an endotracheal tube can lead to the development of an opening between the posterior trachea and esophagus, a complication known as tracheoesophageal fistula. The fistula allows air to escape into the stomach, resulting in abdominal distention. It also leads to the aspiration of gastric contents. To prevent this complication, the nurse must maintain cuff pressure, monitor the amount of air needed for cuff inflation, and help the client progress to a deflated cuff or cuffless tube as soon as possible as prescribed by the health care provider. Suctioning should be performed only as needed; frequent suctioning can cause mucosal damage. Maintenance of mechanical ventilation settings ensures that the client is adequately oxygenated, but this intervention is not a measure for the prevention of tracheoesophageal fistula. Alternating the use of a cuffed tube and a cuffless tube on a daily basis is incorrect, because the endotracheal tube would not be removed and replaced on a daily basis.

Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse?

Multiple sexual partners Rationale: Risk factors for cervical cancer include multiple sexual partners, a history of human papillomavirus infection, first sexual intercourse before the age of 16, cigarette smoking, environmental tobacco smoke exposure, and use of oral contraceptives for more than 5 years. Nulliparity, early menarche, and the use of hormone-replacement therapy are risk factors for ovarian rather than cervical cancer.

Phenelzine sulfate is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the health care provider immediately if she experiences:

Neck stiffness or soreness Rationale: Phenelzine sulfate, a monoamine oxidase inhibitor (MAOI), is an antidepressant and is used to treat depression. Hypertensive crisis, an adverse effect of this medication, is characterized by hypertension, frontally radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. The client is taught to be alert to any occipital headache radiating frontally and neck stiffness or soreness, which could be the first signs of a hypertensive crisis. Dry mouth and restlessness are common side effects of the medication.

A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which action should the nurse take next?

Notifying the healthcare provider Rationale: A client in traction who complains of severe pain may require realignment or may have traction weights that are too heavy. The nurse realigns the client and, if this is ineffective in relieving the pain, notifies the health care provider. Severe leg pain, once traction has been established, indicates a problem. Provision of pin care is not related to the problem as described. The client should be medicated after an attempt has been made to determine and treat the cause; the cause of the severe pain should be investigated first. The nurse should never remove the weights from the traction without a specific prescription to do so.

Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which occurrence does the nurse tell the client to report to the health care provider if she experiences them while taking the medication?

Numbness and tingling of the fingers or toes Rationale: Ergotamine is an antimigraine medication. Prolonged administration or an excessive dosage may produce ergotamine poisoning (ergotism). Symptoms include nausea, vomiting, weakness in the legs, pain in the limb muscles, and numbness and tingling of the fingers and toes. The client is instructed to report these symptoms to the health care provider if they occur. Cough, fatigue, lethargy, and dizziness are side effects not adverse effects of the medication.

A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. Which anxiety disorder does the nurse associate this client's symptoms?

Obsessive-compulsive disorder Rationale: Obsessive-compulsive disorder is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing anxiety; or by a combination of such thoughts (obsessions) and behaviors (compulsions). The client is inflexible and rigid, and is highly critical of self and others. The characteristics of dependent personality disorder include neediness and self-sacrificing and submissive behaviors. The client with avoidant personality disorder is extremely shy, feels inadequate, and is sensitive to rejection. Agoraphobia is the fear of open spaces.

A client diagnosed with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs?

Offering high-calorie and high-protein foods and fluids frequently throughout the day Rationale: The client should be offered high-calorie and high-protein foods and fluids frequently throughout the day. Small, frequent snacks are more easily tolerated than large plates of food when the client is anorexic. The client should be offered choices of foods and fluids he or she likes, because the client is more likely to consume foods he or she has selected. The client should be weighed weekly, not daily. Weight gain may not be noted daily, which may cause the client to view the interventions to improve nutritional status as useless.

A client diagnosed with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which response by the nurse is therapeutic?

Perhaps you could attend and talk to the other clients and see what they're drawing and painting." Rationale: The correct response encourages the client to socialize and deflects the client's attention from the issue of drawing and painting. "Why don't you really want to attend?" challenges the client. "This is what your health care provider has prescribed for you as part of the treatment plan" ignores the client's rights. "OK, let's have you attend music therapy. You can sing there. How does that sound?" does not address the client's concern.

A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the health care provider's instructions, understanding that the gait was selected after assessment of the client's:

Physical and functional abilities Rationale: A crutch gait is selected after an assessment of the client's physical and functional abilities and the disease or injury that resulted in the need for crutches. Assessing the client's uneasiness about using crutches, feelings about being mobility restricted, and understanding of the need for increased mobility are also important considerations, but assessment of the client's physical and functional abilities is most important in ensuring safety in ambulation.

A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that:

Pitting edema is present Rationale: Edema in the lower extremities reflects pooling of blood, which results in a shift of intravascular fluid into the interstitial spaces. Dehydration is not likely to cause pitting edema. When pressure exerted with a finger or thumb leaves a persistent depression, the client is said to have "pitting edema." Therefore the other options identify incorrect interpretations.

A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse

Place small pieces of tape over the rough edges of the cast Rationale: If a client with a cast experiences skin irritation from the edges of the cast, the nurse should petal (place small pieces of tape over) the rough edges of the cast to minimize the irritation. Bivalving is performed if the limb swells occurs and the cast becomes too tight. Using a nail file to smooth the rough edges could cause pieces of the cast to fall into the cast, possibly resulting in the disruption of skin integrity. It is not necessary to contact the health care provider, and there is no reason to reapply the cast.

A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the health care provider, which does the nurse specify as the first action in the event of shock?

Placing the client in a lateral position with the bed flat Rationale: If the client exhibits signs of hypovolemic shock, the nurse would contact the health care provider. The nurse would monitor fetal status closely and take action to minimize the effects of hypovolemic shock and promote tissue oxygenation. The client would be placed in a lateral position, with the head of the bed flat to increase cardiac return and thus increase circulation and oxygenation of the placenta and other vital organs. After positioning the client, the nurse would insert IV lines in accordance with the health care provider's prescriptions and hospital protocols so that blood and replacement fluids may be administered. Quick preparation of the client for cesarean delivery may be necessary, but obtaining informed consent for the procedure is not the first action. Urine output is monitored to ensure an output of at least 30 mL/hr but, again, this is not the first action.

A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client?

Positive result on d-dimer study Rationale: DIC is a life-threatening defect in coagulation. As plasma factors are consumed, the circulating blood becomes deficient in clotting factors and unable to clot. Even as anticoagulation is occurring, inappropriate coagulation is also taking place in the microcirculation, and tiny clots form in the smallest blood vessels, blocking blood flow to the organs and causing ischemia. Laboratory studies help establish a diagnosis. The fibrinogen value and platelet count are usually decreased, prothrombin and activated partial thromboplastin times may be prolonged, and levels of fibrin degradation products (the most sensitive measurement) are increased. The d-dimer study is used to confirm the presence of fibrin split products; a positive result is indicative of DIC.

A client diagnosed with chronic kidney disease who requires dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem?

Powerlessness Rationale: Powerlessness is present when a client believes that he or she has no control over the situation or that his or her actions will not affect an outcome in any significant way. Anxiety is a vague uneasy feeling of apprehension. Some factors in anxiety include a threat or perceived threat to physical or emotional integrity or self-concept, changes in role function, and a threat to or change in socioeconomic status. Ineffective coping is present when the client exhibits impaired adaptive abilities or behaviors in meeting the demands or roles expected. Disturbed body image is diagnosed when there is an alteration in the way the client perceives his or her own body image.

A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care?

Projecting blame, possibly becoming hostile Rationale: A client with paranoid personality disorder projects blame, is suspicious of others, and may become hostile or violent. The client also experiences cognitive or perceptual distortions. A client who is inflexible and rigid and is highly critical of self and others is showing signs of obsessive-compulsive disorder. Being self-sacrificing and submissive is a characteristic of a client with dependent personality disorder.

A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which diagnosis, if noted on the client's record, would indicate a need to contact the health care provider who is scheduled to perform the ECT?

Recent stroke Rationale: Several conditions pose risks in the client scheduled for ECT. Among them are recent myocardial infarction or stroke and cerebrovascular malformations or intracranial lesions. Hypothyroidism, glaucoma, and peripheral vascular disease are not contraindications to this treatment.

A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would:

Recheck the temperature in 4 hours Rationale: A temperature of 100.4° F (38° C) is common during the 24 hours after childbirth and may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for more than 24 hours or exceeds 100.4° F (38° C), infection is a possibility, and the fever is reported. The nurse would recheck the temperature in 4 hours. There is no reason to restrict place the client to strict bedrest or to notify the health care provider. Although the client would be encouraged to breastfeed her newborn, this action is unrelated to the client's temperature.

A postpartum nurse provides information about normal and abnormal characteristics of lochia to a client who has delivered a healthy newborn. Which finding does the nurse tell the client to report to the health care provider?

Reddish lochia on postpartum day 8 Rationale: Lochia is the postdelivery vaginal discharge from the uterus consisting of blood from the vessels of the placental site and debris from the deciduas. Rubra is the bright-red lochial discharge that appears from delivery day to day 3. Serosa is the brownish-pink lochial discharge that appears on days 4 to 10. Alba is the white lochial discharge that appears on days 10 to 14. Reddish lochia on postpartum day 8 is an abnormal finding and would be reported to the health care provider.

After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client?

Replacement of the uterus through the vagina into a normal position Rationale: If uterine inversion is suspected, the nurse immediately prepares the client for replacement of the uterus through the vagina. If this is not possible or effective, laparotomy with replacement is performed. Hysterectomy may be required. Intravenous lines are established to allow rapid fluid and blood replacement. A tocolytic medication or general anesthesia is usually needed to relax the uterus enough to replace it. Once the uterus has been replaced and the placenta removed, oxytocin is given to induce uterine contraction and control blood loss. To help prevent trapping of the inverted fundus in the cervix, oxytocin is not given until the uterus has been repositioned. An indwelling catheter is often inserted to aid monitoring of fluid balance and keep the bladder empty so that the uterus can contract fully, but this is not the action that would be taken immediately.

A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is:

Sardines Rationale: Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Foods high in calcium include milk and milk products, dark-green leafy vegetables, tofu and other soy products, sardines, and hard water. Corn, cocoa, and peaches do not contain appreciable amounts of calcium.

Ferrous sulfate is prescribed for a client. The nurse tells the client that it is best to take the medication with:

Scrambled eggs Rationale: Ferrous sulfate is an iron product. Absorption of iron is promoted when the supplement is taken with orange juice or another food source of vitamin C or ascorbic acid. Calcium and phosphorus in milk decrease iron absorption. Water has no effect on the absorption of vitamin C. Telling the client to take the medication with any meal of the day does not guarantee that the iron will be taken with a food source of vitamin C or ascorbic acid. Additionally, it is best to take the iron supplement between meals with a drink high in ascorbic acid.

A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which finding would the nurse expect to note on assessment of the client?

Soft, relaxed, nontender uterus Rationale: Partial placenta previa is incomplete coverage of the internal os by the placenta. One characteristic of placenta previa is painless vaginal bleeding. The abdominal assessment would reveal a soft, relaxed, nontender uterus with normal tone. Vaginal bleeding and uterine pain and tenderness accompany placental abruption, especially with a central abruption and blood trapped behind the placenta. In placental abruption, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium, resulting in uterine irritability. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax.

A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client?

Spontaneous bruising Rationale: Missed abortion is the term used to describe when a fetus dies during the first half of pregnancy but is retained in the uterus. When the fetus dies, the early symptoms of pregnancy (e.g., nausea, breast tenderness, urinary frequency) disappear. The uterus stops growing and begins to shrink. Red or brownish vaginal bleeding may or may not occur. A major complication of a missed abortion is disseminated intravascular coagulation (DIC). Bleeding at the sites of intravenous needle insertion or laboratory blood draws, nosebleeds, and spontaneous bruising may be early indicators of DIC; they should be reported and require further evaluation.

A client has been given a prescription for lovastatin. Which food does the nurse instruct the client to limit consumption of while taking this medication?

Steak Rationale: Lovastatin is a lipid-lowering agent. The client is instructed to consume foods that are low in fat, cholesterol, and complex sugars. The item highest in fat here is steak; therefore the client should limit the intake of steak. Fruits, vegetables, and chicken are low in fat.

A client is receiving an intravenous infusion of oxytocin to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately:

Stops the oxytocin infusion Rationale: Oxytocin is a synthetic compound identical to the natural hormone secreted from the posterior pituitary gland. It is used to induce or augment labor at or near term. The nurse monitors uterine activity for the establishment of an effective labor pattern and for complications associated with the use of the medication. If uterine hypertonicity or a nonreassuring fetal heart rate pattern is detected, the nurse must intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the oxytocin infusion and increase the rate of the nonadditive solution, position the client in a side-lying position, and administer oxygen with the use of a snug face mask at 8 to 10 L/min. The nurse would also notify the health care provider. Checking the vagina for crowning; encouraging the client to take short, deep breaths; and increasing the rate of the oxytocin infusion are not the immediate actions.

A nurse working the evening shift is helping clients get ready for sleep. A female client diagnosed with mania is hyperactive and pacing the hallway. The appropriate nursing action is to:

Take the client to the bathroom and provide her with a warm bath Rationale: For the client with mania, the nurse needs to promote relaxation, rest, and sleep and to minimize manic behavior. The nurse should encourage frequent rest periods during the day and keep the client in areas of low stimulation. At bedtime, the nurse should provide warm baths, soothing music, and medication when indicated. The client should not consume products containing caffeine. Staying with the client and observing her behavior, telling the client that it is time to go to sleep and to go to her room, and telling the client that other clients are trying to sleep and that she is being disruptive do not address the client's needs and are not measures that will help the client relax and sleep.

A client is taking prescribed ibuprofen, 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to:

Take the medication with food Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea (with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If gastrointestinal distress occurs, the client should be instructed to take the medication with milk or food. The nurse would not instruct the client to stop the medication or instruct the client to adjust the dosage of a prescribed medication; these actions are not within the legal scope of the role of the nurse. Contacting the health care provider is premature, because the client's complaints are side effects that occasionally occur and can be relieved by taking the medication with milk or food.

A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior:

Temporarily eases anxiety in the client Rationale: Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. Compulsions are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. The other options identify interpretations of the client's compulsive behavior.

The mother of an adolescent diagnosed with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother:

That the child should eat a carbohydrate snack about a half-hour before each soccer game Rationale: The child with diabetes mellitus who is active in sports requires additional food intake in the form of a carbohydrate snack about a half-hour before the anticipated activity. Additional food will need to be consumed, often as frequently as every 45 minutes to 1 hour, during prolonged periods of activity. If the blood glucose level is increased (240 mg/dL [13.3 mmol/L] or more) and ketones are present before planned exercise, the activity should be postponed until the blood glucose has been controlled. Moderate to high ketone values should be reported to the health care provider. There is no reason for the child to avoid participating in sports.

Disulfiram is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client:

That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol Rationale: Disulfiram is an alcohol abuse deterrent prescribed to motivated clients who have shown the ability to stay sober. Driving is not prohibited; however, the client is instructed to use caution when driving and performing other tasks that require alertness. The medication is taken daily (not just when the client has a desire to drink alcohol), and the effects of the medication last 5 days to 2 weeks after the last dose is taken. The medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol. Otherwise, an alcohol-disulfiram reaction will occur, with effects consisting of facial flushing, sweating, a throbbing headache, neck pain, tachycardia, respiratory distress, a potentially serious decrease in blood pressure, and nausea and vomiting. This reaction may last 30 to 120 minutes.

A client undergoing therapy with Carbidopa/Levodopa calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client:

That this is an occasional side effect of the medication Rationale: Carbidopa/levodopa, an antiparkinson agent, may cause darkening of the urine or sweat. The client should be reassured that this is a harmless side effect of the medication and that the medication's use should be continued. Although fluid intake is important, telling the client that he needs to drink more fluid is incorrect and unnecessary. Telling the client that the darkening of his urine may signal developing medication toxicity is incorrect and might alarm the client unnecessarily. There is no need for the client to call the health care provider.

A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which finding would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy?

The client reports a history of sexual abuse by her father. Rationale: Clients at risk for self-esteem problems and poor sexual adjustment after mastectomy include those who report a lack of support from a spouse or partner; the existence of an unhappy, unstable intimate relationship; or a history of sexual problems or of sexual abuse, such as rape or incest. Clients with problems involving intimate relationships and sexuality should be referred for counseling. The remaining options are unrelated to the problem of poor sexual adjustment.

Risperidone is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing health care provider before administering the medication?

The client takes a prescribed antihypertensive. Rationale: Risperidone is an antipsychotic medication. Contraindications to the use of risperidone include cardiac disorders, cerebrovascular disease, dehydration, hypovolemia, and therapy with antihypertensive agents. Risperidone is used with caution in clients with a history of seizures. History of cataracts, hypothyroidism, or allergy to aspirin does not affect the administration of this medication.

A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine:

The degree of fetal lung maturity Rationale: Amniocentesis is the aspiration of fluid from the amniotic sac for examination. Common indications for amniocentesis during the third trimester include assessment of fetal lung maturity and evaluation of fetal condition when the woman has Rh isoimmunization. A common purpose of amniocentesis in the second trimester is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Other methods of genetic analysis, such as those for metabolic defects in the fetus, may be performed on the cells as well. The sex and age of the fetus are not determined with the use of amniocentesis.

A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to:

Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10 Rationale: Kegel exercises strengthen the muscles of the pelvic floor. To perform the exercises, the client is taught to tighten the pelvic muscles to a slow count of 10, then relax to a slow count of 10. The client is also instructed to do this exercise 15 times while lying down, sitting up, and standing (a total of 45 repetitions). The client is told that an improvement in the control of urine will be noticed after several weeks of the exercises; some individuals report that improvement takes as long as 3 months.

A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which finding does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client?

Tongue protrusion Rationale: Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medications. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue ("flycatcher tongue"), and face. In its most severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued. Fever, diarrhea, and hypertension are not characteristics of tardive dyskinesia.

A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which finding does the nurse expect to note?

Top layer of skin off Rationale: A stage I ulcer is characterized by intact skin that is red and does not blanch under external pressure. A stage II ulcer is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A stage III ulcer is characterized by full-thickness skin loss, and the subcutaneous tissue may be damaged or necrotic. The damage extends down to but not through the underlying tissues. A deep crater-like appearance or eschar is present. A stage IV ulcer is characterized by full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Sinus tracts may develop.

A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that:

Urine output must be measured and that the health care provider should be notified if output is less than 500 mL in a 24-hour period Rationale: Preeclampsia is considered mild when the diastolic blood pressure does not exceed 100 mm Hg, proteinuria is no more than 500 mg/day (trace to 1+), and symptoms such as headache, visual disturbances, and abdominal pain are absent. The diet should provide ample protein and calories, and fluid and sodium should not be limited. The disease is considered severe when the blood pressure is higher than 160/110 mm Hg, proteinuria is greater than 5 g/24 hr (3+ or more), and oliguria is present (500 mL or less in 24 hours). Therefore, urine output of less than 500 mL/24 hr should prompt the client to notify the health care provider.

A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interprterm-33et this finding?

Uteroplacental insufficiency during a contraction Rationale: The observation that the has nurse noted in this tracing is late decelerations. Late decelerations constitute an ominous pattern in labor because they suggest uteroplacental insufficiency, possibly associated with a contraction. Early decelerations result from pressure on the fetal head during a contraction. Variable decelerations suggest umbilical cord compression. The term short-term variability refers to the difference between successive heartbeats, indicating that the natural pacemaker function of the fetal heart is working properly.