NCLEX Practice Exam Prep U

The nurse is teaching a client how to take care of an incision at home. The nurse should tell the client:

"Do not be concerned about uneven lumps under the suture lines." Explanation: The nurse should inform the client that as the incision heals uneven lumps might appear under the incision line because the collagen is growing new tissue at different rates. Eventually, the lumps will even out and the tissue will be smooth. The client can touch the incision with clean hands as needed to perform incisional care. The client should not clean the incision with hydrogen peroxide because it may dry out the natural skin oils. The surgeon will remove the staples for the client.

After giving birth to her second neonate, a client tells the nurse that she wants to breast-feed this neonate. She indicates that she was unsuccessful at breast-feeding her first child and that she bottle-fed after 3 days of trying to nurse. Which response best supports this client's breast-feeding efforts?

"It's important to room-in with your neonate so that you can respond to her nursing cues." Explanation: One way to help support this client's wishes to breast-feed is to instruct her to room-in with her neonate so she can respond to the neonate's cues. Sending the neonate to the nursery lessens the mother's ability to learn her neonate's breast-feeding cues. Arranging for the lactation consultant to visit, telling the client not to worry, and telling the client she must be committed to breast-feeding don't support the client's need for guidance.

A client is scheduled for a creatinine clearance test. The nurse should explain that this test is done to assess the kidneys' ability to remove a substance from the plasma in:

1 minute. Explanation: The creatinine clearance test determines the kidneys' ability to remove a substance from the plasma in 1 minute. It doesn't measure the kidneys' ability to remove a substance over a longer period.

A client is participating in a cardiac rehab program after a myocardial infarction and, at this point, sexual activity is allowed to be resumed. Which of the following statements by the nurse is accurate regarding the resumption of sexual activity? Select all that apply.

- "It is best to be well rested and in familiar surroundings." - "A comfortable position should be maintained during intercourse." Explanation: Once a client has recovered from a myocardial infarction, sexual activity may be resumed. The client would be taught to be well rested and in familiar surroundings to decrease any additional anxiety surrounding the resumption. The client would also be taught to assume a comfortable position to prevent any additional strain on the heart. Anal activity would be a caution as the vagus nerve could be stimulated and result in dysrhythmias. Chest pain would not commonly occur if the client had recovered.

The nurse is assessing an hour-old newborn. Which of the following observations would the nurse note as being abnormal? Select all that apply.

- Expiratory grunting -Temperature of 97.4° F (36.3° C) -Nasal flaring Explanation: Respiratory rate for a newborn is 30-60 and the heart rate is 120-160. Expiratory grunting and nasal flaring are signs of respiratory distress in the newborn. Temperature for a newborn should be between 97.5° F (36.4° C) and 99° F (37.2° C).

During the admission assessment, the nurse focuses on the client's reflexes, muscle strength, coordination, eye movements, and mental status. What symptoms would the nurse identify as suggestive of vascular dementia? Select all that apply.

- Losing bladder control - Laughing inappropriately -Shuffling gait Explanation: The typical symptoms of vascular dementia are confusion, memory deficits, wandering, shuffling gait, loss of bladder and bowel control, and inappropriate laughter. Leg swinging, head hyperextension, and joint deformities are not symptoms associated with vascular dementia.

A nurse is caring for a client with delirium. Which nursing interventions are important to implement after establishing a safe client environment? Select all that apply.

- Offering recreational activities - Providing a structured environment - Instituting measures to promote sleep Explanation: After providing a safe environment for the client with delirium, it would be appropriate for the nurse to offer recreational activities, provide a structured environment, and institute measures to promote sleep.

A client is post-operative following resection of a lower lobe of the lung and presents with a large amount of respiratory secretions. The nurse should include which of the following actions during care? Select all that apply.

- Turning and positioning every 2 hours -Administration of bronchodilators - Oxygen via humidified mask Explanation: Maintaining adequate airway clearance is a priority for a client who is post-operative a lung resection. Turning and positioning, administering bronchodilators, and providing oxygen via humidification will assist with breathing and moving secretions so they do not compromise recovery and lead to complications. Intermittent positive-pressure breathing would not be necessary as the client would be encouraged to cough and chest PT would be performed. Postural drainage would not be done immediately post-operatively as the client would still be under the effects of anesthesia.

There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply.

- an 8-year-old with third-degree burns over 10% of the body surface area (BSA) -a 20-year-old who inhaled the smoke of the fire - a 50-year-old diabetic with first- and second-degree burns on the left forearm (about 5% of the body surface area (BSA) Explanation: Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their BSA, clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients of any age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.

The parents of a 15-year-old female with a history of disordered eating are concerned about her loss of 24 lb (10.9 kg) during the previous month. The nurse tells the parents that she'll give their daughter a comprehensive examination and make appropriate referrals. Which initial referrals should the nurse make? Select all that apply.

-Nutritional consult -Psychiatric evaluation Explanation: A nurse must assess a client with disordered eating and create a care plan to stabilize body weight and prevent further weight loss. The nutritional consult helps determine nutritional needs to maintain body weight. A psychiatric evaluation establishes the baseline for a care plan to address the client's emotional needs, process the client's feelings and experiences, develop effective coping skills, and develop a realistic body image and positive self-image. After the adolescent's body weight stabilizes, she should have a dental assessment to identify dental problems resulting from malnutrition or purging. Although females with disordered eating may have amenorrhea, this adolescent shouldn't have a gynecologic examination unless a medical condition warrants one at a later time. She doesn't need a toxicology evaluation unless a severe substance-abuse problem is identified.

A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night. The nurse should instruct the client to do which activities? Select all that apply.

-Obtain adequate rest to reduce stimulation. -Eat small, frequent meals throughout the day. -Take all medications on time as ordered. - Sit up for 1 hour when awakened at night. Explanation: The nurse should encourage the client to reduce stimulation that may enhance gastric secretion. The nurse can also advise the client to utilize health practices that will prevent recurrences of ulcer pain, such as avoiding fatigue and elimination of smoking. Eating small, frequent meals helps to prevent gastric distention if not actively bleeding and decreases distension and release of gastrin. Medications should be administered promptly to maintain optimum levels. After awakening during the night, the client should eat a small snack and return to bed, keeping the head of the bed elevated for an hour after eating. It is not necessary to stay away from crowded areas.

A nurse is caring for a client who has just returned from surgery to treat a fractured mandible. The jaws are wired. Which items should always be available at this client's bedside? Select all that apply.

-wire cutters -suction equipment Explanation: Following surgery for a fractured mandible, the client's jaws will be wired. The nurse should be prepared to intervene quickly in case the client develops respiratory distress or begins to choke or vomit. Wire cutters or scissors should always be available in case the wires need to be cut in a medical emergency. Suction equipment should be available to help clear the client's airway if necessary. It is not necessary to keep a nasogastric tube or oxygen cannula at the client's bedside. Cardiopulmonary arrest is unlikely, so a code cart is not needed at the bedside.

A client with a deep vein thrombosis has heparin sodium infusing at 1,500 units/hour. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12 hour shift, how many milliliters of fluid will infuse? Record your answer using a whole number.

360 Explanation: 25,000 u/500 ml = 50 units/ml. 1 ml/50 units x 1500 units/hour = 30 ml/hour x 12 hours = 360 ml

Which condition may contribute to hyperparathyroidism?

Chronic renal failure Explanation: Because failing kidneys can't convert vitamin D, the serum calcium level declines. Parathyroid hormone release increases, causing hyperparathyroidism. Thyroidectomy may lead to hypoparathyroidism if the parathyroid is also removed during surgery. Serum calcium level may rise as a result of hyperparathyroidism, so it isn't a contributing factor. Steroid use causes calcium to leave bone, suppressing parathyroid hormone.

The nurse is providing care to a client with Alzheimer's-type dementia. Which nursing intervention is the priority?

Control the environment by providing structure and consistent boundaries Explanation: By controlling the environment and providing structure and consistent boundaries, the nurse is helping to keep the client safe and secure. Establishing a routine that reinforces memories, supports former habits, maintains pleasant surroundings, and structures a daily routine fosters a supportive environment; however, keeping the client safe and secure is the priority.

A nurse identifies a client's responses to actual or potential health problems during which step of the nursing process?

Diagnosis Explanation: The nurse identifies human responses to actual or potential health problems during the diagnosis step of the nursing process, which encompasses the nurse's ability to formulate a nursing diagnosis. During the assessment step, the nurse systematically collects data about the client or his family. During the planning step, she develops strategies to resolve or decrease the client's problem. During the evaluation step, the nurse determines the effectiveness of the care plan.

Cimetidine may also be used to treat hiatal hernia. The nurse should understand that this drug is used to prevent which of the following?

Esophagitis. Explanation: Cimetidine is a histamine receptor antagonist that decreases the quantity of gastric secretions. It may be used in hiatal hernia therapy to prevent or treat the esophagitis and heartburn associated with reflux. Cimetidine is not used to prevent reflux, dysphagia, or ulcer development.

The nurse is assessing a client's respiratory pattern. Which graphic illustrates Kussmaul's respirations?

Explanation: Kussmaul's breathing is characterized by rapid, deep breathing without pauses. Option A shows tachypnea (shallow breathing with an increased respiratory rate). Option C shows Cheyne-Stokes respirations (breaths gradually become faster and deeper than normal and then slower with intermittent periods of apnea). Option D shows hyperpnea (deep breathing at a normal rate).

The nurse is assessing the pulse in a client with aortoiliac disease. On the illustration below, indicate the pulse site that will give the nurse the most useful data.

Explanation: The nurse should assess the femoral artery. Weak or absent femoral pulses are symptomatic of aortoiliac disease.

A client has just been diagnosed with panic disorder. Which medication does the nurse anticipate administering for this diagnosis?

Fluoxetine Explanation: Selective serotonin reuptake inhibitors such as fluoxetine are the medications of choice for panic disorder. Propranolol and diazepam are occasionally used for the short-term management of this disorder; however, these are not the preferred medications. Clozapine may trigger the development of an anxiety disorder.

A client is hearing voices that are telling her to kill herself. She is demanding a knife to use on her wrists. Which is most appropriate intervention at this time?

Give oral PRN doses of haloperidol and lorazepam as prescribed. Explanation: Haloperidol and lorazepam together decrease hallucinations and agitation, thus decreasing the risk of self-harm. Putting the client in restraints is premature because danger is not imminent. Asking the client to talk about her anger is inappropriate because the client is beyond rational conversation. A room search is appropriate only after the crisis with the client is handled.

A nurse is preparing discharge teaching for a client with a new prescription for digoxin. Which of the following foods will the nurse teach the client to avoid when taking digoxin?

Large amounts of bran products Explanation: Bran can interfere and decrease the absorption of digoxin resulting in unexpectedly low serum concentration levels. Dairy products, foods high in purines, and foods high in vitamin K do not contain bran and do not decrease the absorption of digoxin.

Which measure should the nurse institute to help minimize joint pain in a child with rheumatic fever?

Limit movement of the affected joints. Explanation: In rheumatic fever, the joints—especially the knees, ankles, elbows, and wrists—are painful, swollen, red, and hot to the touch. Limiting movement of the affected joints typically minimizes pain. Massaging the joints likely will not aid in pain relief because the pain is due to the disease process and subsequent inflammation in the joint. Applying ice to the affected joints likely will not aid in pain relief because of the inflammation, edema, and effusion is too deep in the joint tissue. Exercise should be avoided because of the increased workload placed on the heart muscle. This is in contrast to usual recommendations for clients with other forms of arthritis. Despite joint involvement in rheumatic fever, permanent deformities do not occur.

The nurse is assessing a child's skeletal traction and notices that the weights are on the floor. What should the nurse do next?

Move the child up in bed. Explanation: The traction weights should be hanging freely to maintain pull. The child needs to be moved up in bed with the weights left untouched to continue countertraction. Then the nurse can determine whether blocks are necessary to maintain the child in the correct position. Raising the weights is inappropriate because doing so interferes with countertraction. The HCP does not need to be notified. The nurse can easily correct the problem by moving the child up in bed.

To prepare the irrigation solution used for removal of cerumen, the nurse should use:

Normal saline. Explanation: Normal saline is the solution that is generally used to irrigate the ear. Sterile water will cause tissue damage. An antiseptic solution is not typically used unless an infection is present. Warm tap water may cause tissue damage.

What is the priority action that a nurse should take after omitting an ordered medication?

Notify the prescriber. Explanation: A nurse who has omitted an ordered medication should prioritize the notification of the prescriber. She should then document the omission and the reason it occurred in the client's chart and, depending on facility policy, write an incident report. Depending on the facility's policy, the nursing supervisor may need to be notified, but this would be done after the prescriber has been notified.

A child had a colostomy performed 4 weeks ago. The parents report to the nurse that for the past 3 weeks the child's stoma drained adequate amounts of stool, but several days ago, the stoma ceased to drain stool. Which of the following interventions should the nurse take?

Obtain an order for a stool softener. Explanation: The child is exhibiting symptoms of stomal stenosis, which is defined as impairment of effluent drainage due to narrowing or contraction of the stomal tissue at the level of the skin or fascia. Conservative therapy involves use of stool softeners and a low-residue diet. Stomal belts are often used for stoma retraction. Stoma prolapse requires a larger pouch. Stoma necrosis should be reported immediately to the physician.

A client was talking with her husband by telephone, and then she began swearing at him. The nurse interrupts the call and offers to talk with the client. She says, "I cannot talk about that bastard right now. I just need to destroy something." What should the nurse do next?

Offer her a phone book to "destroy" while staying with her. Explanation: At this level of aggression, the client needs an appropriate physical outlet for the anger. She is beyond writing in a journal. Urging the client to talk to the nurse now or making threats, such as telling her that she will be restrained, is inappropriate and could lead to an escalation of her anger.

An 18-month-old child is experiencing supraventricular tachycardia (SVT). What should be the nurse's first intervention?

Placement of a bag of ice over the child's face Explanation: Vagal maneuvers, such as placing a bag of ice over the face for 15 to 30 seconds, or immersing the hands in cold water are commonly the first mechanism used to decrease the heart rate. Other vagal maneuvers include breath-holding, carotid massage, gagging, and placing the head lower than the rest of the body. Synchronized cardioversion may be required if vagal maneuvers and drugs are ineffective. If a child has low cardiac output, cardioversion may be used instead of drugs. Adenosine is the drug of choice for medical conversion of SVT. Verapamil isn't recommended in children under two years of age. Digoxin has a narrow therapeutic margin, has a risk of toxicity, and can delay the attainment of therapeutic levels.

A nurse is using Dorothea Orem's general theory of nursing while caring for a client, which intervention is appropriate?

Providing discharge teaching about new medication Explanation: Dorothea Orem's general theory of nursing addresses self-care deficits as the basis for nursing care. This theory posits that the nurse intervenes to reestablish the client's self-care capacity. Discharge teaching addresses the client's knowledge deficit increasing the ability for self-care. Dorothy Johnson's behavioral systems theory views nursing as a means to reestablish balance in the client's social and behavioral subsystems, which have been disrupted by stress. According to Virginia Henderson's theory of nursing, the nurse focuses on the client's basic needs. In Martha Rogers' unitary human beings theory, the nurse helps restore the client's energy and balance and the changes that occur as they constantly evolve.

A nurse is caring for a chronically malnourished homeless client who was admitted with severe diarrhea for 2 days. What does the nurse determine is a priority potential problem?

Renal calculi Explanation: Although hypervolemia is a possibility if the client is rehydrated too quickly, the question is asking what could result from the client's admitting condition. Clients who are malnourished and/or have diarrhea tend to have lower pH (acidic) urine levels, putting them at higher risk of renal calculi. The albumin level is normal. Hypoparathyroidism is not caused by diarrhea.

A nursing student understands that emphysema is directly related to which of the following?

Respiratory acidosis from airway obstruction In the later stages of emphysema, carbon dioxide elimination is impaired, resulting in increased carbon dioxide tension in arterial blood (hypercapnia) leading to respiratory acidosis.

Platelets should not be administered when?

The platelet bag is cold. Explanation: Platelets cannot survive cold temperatures. The platelets should be stored at room temperature and last for no more than 5 days.

Question 173 See full question 15s A student nurse working with a registered nurse is assessing a child with epiglottitis. The student nurse tells the child that she must look into his/her throat. Which intervention by the registered nurse is most appropriate?

Tell the student nurse that the anesthesiologist will visually examine the child's throat. Explanation: Direct visualization of the epiglottis can trigger reflex laryngospasm and cause complete airway obstruction. Only an anesthetist or a physician skilled in pediatric intubation may perform this procedure. Placing the child in a supine position may cause an airway obstruction.

Breast engorgement occurs on the second or third postpartum day in both breast-feeding and non-breast-feeding mothers. Which process causes engorgement?

Vasodilation, which causes the breast to feel full Explanation: Engorgement isn't caused by milk in the breasts but by increased blood levels from vasodilation. The body's natural response after giving birth, nuzzling by the neonate, and reduced estrogen levels contribute to milk production.

A healthy client comes to the clinic for a routine examination. When auscultating his lower lung lobes, the nurse should expect to hear which type of breath sound?

Vesicular Explanation: Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower lobes of the lung. They're prolonged on inhalation and shortened on exhalation. Bronchial breath sounds are loud, high-pitched sounds normally heard next to the trachea; discontinuous, they're loudest during expiration. Tracheal breath sounds are harsh, discontinuous sounds heard over the trachea during inhalation or exhalation. Bronchovesicular breath sounds are medium-pitched, continuous sounds that occur during inhalation or exhalation. They're best heard over the upper third of the sternum and between the scapulae.

Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 mm Hg and the heart rate is 65 bpm. Prior to medication administration at 0900, the nurse reviews the lab tests (see chart). What should the nurse do first?

Withhold the captopril. Explanation: The nurse should withhold the dose of captopril; captopril is an ACE-inhibitor and a side effect of the medication is hyperkalemia. The BUN and creatinine, which are normal, should be viewed prior to administration since renal insufficiency is another potential side effect of an ACE-I. The heart rate is within normal limits. The nurse should question the dose of metoprolol if the client's heart rate is bradycardic. The hemoglobin and hematocrit are normal for a female. The nurse should report the high potassium level and that the captopril was withheld.

Alprazolam has been prescribed for a client who has been experiencing panic attacks. The nurse reviews the client's records and determines further intervention is needed when the health history includes:

acute-angle glaucoma. Explanation: Acute-angle glaucoma is a medical problem that contraindicates the use of alprazolam. Alprazolam causes drowsiness and sedation, so the client should not experience insomnia. Seizure disorder isn't a contraindication for the use of alprazolam. Tartrazine hypersensitivity is associated with yellow dye used in some foods, and is not a contraindication for the use of alprazolam.

A client is to have a central venous line inserted for long-term central venous access. The client's plan of care includes implementing a central line bundle. When implementing skin antisepsis, which action would be the priority for the nurse?

allowing the solution to dry completely before the site is accessed Explanation: When performing skin antisepsis, the nurse should use chlorhexidine-based antiseptic agents which provide better skin antisepsis than other agents (such as povidone-iodine). It should be applied using a back-and-forth friction scrub for at least 30 seconds. Before puncturing the site, the physician (or other health care worker trained in CVC insertion) should allow the solution to dry completely; the site should not be wiped or blotted.

When preparing the teaching plan for a client who is to start clozapine, which information is crucial to include?

an emphasis on the need for weekly blood tests Explanation: Clozapine is associated with agranulocytosis. Therefore, the nurse must instruct the client about the need for weekly blood tests to monitor for this adverse effect. Akathisia and drug-induced parkinsonism are associated with high-potency antipsychotics. These effects are not common with this atypical antipsychotic agent. Constipation and sedation may occur with this drug.

A physician decides to artificially rupture a client's membranes. After this procedure, the nurse checks the fetal heart tones to:

assess for fetal bradycardia. Explanation: After a client has an amniotomy, the nurse should ensure that the cord isn't prolapsed and that the fetus tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery.

After teaching the parent of a child with severe burns about the importance of specific nutritional support in burn management, which selection of foods, if chosen by the parent from the child's diet menu, indicate the need for further instruction?

bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks Explanation: Hypoproteinemia is common after severe burns. The child's diet should be high in protein to compensate for protein loss and to promote tissue healing. The child will also require a diet that is high in calories and rich in iron. The menu of bacon, lettuce, and tomato sandwich; milk; and celery sticks is lacking in sufficient protein and calories.

The nurse has received a telephone call from the emergency department indicating that a multigravid client in early labor and diagnosed with probable placenta previa will be arriving soon. What is the priority invention when the client arrives at the unit?

continuous blood pressure monitoring Explanation: For a client diagnosed with probable placenta previa, hypovolemic shock is a complication. Continuous blood pressure monitoring with an electronic cuff is the priority assessment after the client's admission. Once the client is admitted, an ultrasound examination will be performed to determine the placement of the placenta. Whole blood replacement is not warranted at this time. However, it may be necessary if the client demonstrates signs and symptoms of hemorrhage or shock. Internal fetal heart rate monitoring is contraindicated because the monitoring device may puncture the placenta and place both the mother and fetus in jeopardy. An immediate cesarean birth is not necessary until there has been an assessment of the amount of bleeding and the location of the placenta previa.

A client with chronic myelogenous leukemia is taking imatinib. The nurse should instruct the client to report which adverse effect of this drug?

edema Explanation: Imatinib works by inhibiting the proliferation of abnormal cells. Adverse effects include edema and GI irritation. Typical effects of this drug do not include edema, numbness and tingling, bloody stools, or persistent cough. If the client has these symptoms, they may relate to disease occurrence or recurrence.

A 17-year-old with polycystic ovarian syndrom (PCOS) has been placed on metformin. The nurse determines the client needs more teaching about metformin if she states the medication helps achieve has which outcome?

increased insulin levels Explanation: Metformin works by decreasing the production of glucose in the liver and improving insulin sensitivity. These two mechanisms reduce insulin and blood glucose level. Reducing insulin levels reduces androgens and helps to restore menstruation.

A nurse is teaching a client about insulin therapy. The nurse knows the client needs additional teaching when she states that insulin may interact with:

metoprolol. Although metoprolol may mask the signs of hypoglycemia, it doesn't interact with insulin. Therefore, the client requires additional teaching. Thiazide diuretics such as hydrochlorothiazide, aspirin, and hormonal contraceptives all interact with insulin.

A female client with infertility related to anovulatory cycles is prescribed menotropins. The nurse should assess the client for which possible adverse effect of this medication?

ovarian enlargement Explanation: Ovarian enlargement, hyperstimulation syndrome, febrile reaction, and multiple pregnancies are considered adverse effects of menotropins. If ovarian enlargement occurs, the drug should be discontinued to prevent damage to the ovary. Pulmonary edema is not associated with menotropin use. Visual disturbances and breast tenderness are associated with the use of clomiphene citrate, another drug prescribed for infertility.

A client who has been taking hydrocodone with acetaminophen at home for 6 weeks following a fractured tibia is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths per minute and shallow. The nurse interprets these findings as indicating:

possible habituating effect of the long-term drug use. Explanation: Hypotension and depressed respirations are signs of high levels of ingestion of hydrocodone, and the client may be developing a habit of taking this drug for a prolonged period. Expected common adverse effects of hydrocodone and acetaminophen would include drowsiness, confusion, blurred vision, and constipation. Hemorrhage from gastrointestinal irritation is not associated with this drug. Hypersensitivity reactions would be manifested by pruritus and rashes.

During the evening shift on the day of a client's bowel resection surgery, the nasogastric (NG) tube drains 500 mL of green-brown fluid. The nurse should:

record the amount of drainage on the client's chart. Explanation: Because peristalsis has not been reestablished, this amount of gastric drainage would be expected. The green-brown color would also be expected. The appropriate nursing action is to chart the amount and color of output and continue monitoring the client. There is no need to notify the health care provider or to provide additional IV fluids. A patent NG tube does not require irrigation.

A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by:

showing the location of the obstruction and the collateral circulation. Explanation: An arteriogram involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels. It usually involves computed tomographic scanning. The velocity of the blood flow can be estimated by duplex ultrasound. The client's ankle-brachial index is determined, and then the client is requested to walk. The normal response is little or no drop in ankle systolic pressure after exercise.

As a client's level of anxiety increases to a debilitating degree, the nurse should expect which psychomotor behavior as indicating a panic level of anxiety?

suicide attempts or violence Explanation: Suicide attempts and violence are psychomotor responses to a panic level of anxiety. Desperation and rage are emotional responses. Disorganized reasoning and loss of contact with reality are cognitive responses.

A nurse is assessing tactile fremitus in a client with pneumonia. For this examination, the nurse should use the:

ulnar surface of her hand. Explanation: The nurse uses the ulnar surface, or ball, of her hand to assess tactile fremitus, thrills, and vocal vibrations through the chest wall. The fingertips and finger pads best distinguish texture and shape. The dorsal surface is most sensitive to warmth.

The nurse in the intensive care unit is giving a report to the nurse in the post surgical unit about a client who had a gastrectomy. The most effective way to assure essential information about the client is reported is to:

use a printed checklist with information individualized for the client. Explanation: Using a checklist assures that all key information is reported; the checklist can then serve as a record to which nurses can refer later. Giving a verbal report leaves room for error in memory; using an audiotape or an electronic health record requires nurses to spend unnecessary time retrieving information.

A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?

"I need to use laxatives regularly to prevent constipation." Explanation: The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health.

A client with newly diagnosed chronic obstructive pulmonary disease (COPD) comes to the clinic for a routine examination. The nurse teaches the client strategies for preventing airway irritation and infection. Which statement by the client best indicates that teaching was successful?

"I should avoid using powders." Explanation: There are many considerations when a client is diagnosed with COPD. A client with COPD should avoid exposure to powders, dust, and smoke from cigarettes, pipes, and cigars. The client should stay away from crowds should avoid aerosol sprays as a precaution. The client should also obtain immunizations against pneumococcal pneumonia as well as influenza. A combination of measures is needed to maintain the client's highest level of respiratory function.

A minister approaches a nurse caring for a client who is a member of the minister's congregation. The minister inquires as to whether the member has been made aware of his/her diagnosis. Which of the following would be the best response by the nurse?

"I understand your concern, but have you asked the client?" Explanation: The nurse must maintain confidentiality. The minister may mean well but is trying to gather information that is confidential. The nurse should acknowledge the minister's concern and then suggest asking the client about the reason for hospitalization. This allows the client to share with the minister whatever information the client wants to disclose. The other options are not correct because they do not protect the client's privacy. Telling the minister that it is not his/her business is not a decision the nurse should be making without discussing the situation with the client.

A nurse is teaching a client about type 2 diabetes mellitus. What information would reduce a client's risk of developing this disease?

"Maintain weight within normal limits for your body size and muscle mass." Explanation: The most important factor predisposing to the development of type 2 diabetes mellitus is obesity. Insulin resistance increases with obesity. Cigarette smoking is not a predisposing factor, but it is a risk factor that increases complications of diabetes mellitus. A high-protein diet does not prevent diabetes mellitus, but it may contribute to hyperlipidemia. Hypertension is not a predisposing factor, but it is a risk factor for developing complications of diabetes mellitus.

The nurse is caring for an infant admitted with a severe respiratory infection. The nurse is explaining the risk of airway obstruction and the need for frequent respiratory assessments to the parents. Which of the following statements by the nurse is most appropriate regarding the risk of airway obstruction?

"The infant's larger tongue and smaller oral cavity increase the risk of airway obstruction." Explanation: The relatively larger tongue and smaller oral cavity of a child means that the tongue is more likely to obstruct the airway and increase resistance to airflow than in an adult. A flattened rib wall, thin chest wall, and rapid respiratory rate are all accurate descriptions of a pediatric population but they do not potentially put the child at the greatest risk for airway obstruction.

An Asian-American client with hyperglycemia is admitted to the health care facility. After the client is stable, the nurse discovers that the client has not had his prescribed medicines. The client believes that eating saffron will keep his blood glucose level under control. The nurse determines that saffron is not known to influence blood glucose levels. What is the most appropriate response by the nurse?

"Why don't you take the medicines, too, and benefit from both?" Explanation: Although the nurse may disagree with the client's beliefs concerning the cause of health or illness, respect for these beliefs helps the client to achieve health care goals. Asking the client to consider the benefits of medicine is appropriate, because the nurse, without disrespecting the client's beliefs, persuades him to have medicines also. The nurse saying that saffron does not have any effect on blood glucose level is inappropriate, because it disregards the client's beliefs. The nurse's agreeing with the client may encourage him and indicate low faith in the present treatment. It is inappropriate to call the doctor and complain about the client.

The nurse is providing discharge instructions for the parents of an infant who has recently undergone cardiac surgery. The nurse determines that teaching was effective when the parents make which statements? Select all that apply.

- "I should keep giving my baby all prescribed medicines until the health care provider tells me to stop." - "I should wait about six weeks to schedule an appointment for my baby to get her immunizations." Explanation: Drugs, such as digoxin and furosemide, shouldn't be stopped abruptly. There are no dietary restrictions. Parents are encouraged to keep their child away from crowds for the first few weeks after surgery in order to prevent exposure to infections such as colds or respiratory syncytial virus bronchiolitis. Immunizations should be delayed for at least six weeks following surgery.

A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the client use to prevent skin breakdown? Select all that apply.

- Add baking soda to the water in a tub bath. -Keep nails short and clean. - Rub the skin when it itches with knuckles instead of nails. Explanation: Baking soda baths can decrease pruritus. Keeping nails short and rubbing the area with knuckles can decrease breakdown when scratching. Calamine lotions help relieve itching. Alcohol will increase skin dryness. Sodium in the diet will increase edema and weaken skin integrity.

A client arrives to the emergency department with suspected appendicitis. The admitting nurse performs an assessment. Order the following steps according to the sequence in which they are performed. All options must be used.

- Obtain a health history. - Inspect the abdomen, noting the shape, contours, and any visible peristalsis or pulsations. -Auscultate bowel sounds in all four quadrants. -Percuss all four abdominal quadrants. -Gently palpate all four quadrants, saving the painful area for last. Explanation: The first step in the data collection process is to obtain a health history. Then, the nurse would visually inspect the abdomen. Of the three remaining steps, it is important to auscultate before percussing or palpating the client's abdomen. Touching or palpating the abdomen before listening may actually change the bowel sounds, leading to faulty data.

A nurse is preparing for elective cardioversion on a client experiencing uncontrolled atrial fibrillation. In which order will the nurse perform the following steps?

- Obtain the consent. - Sedate the client. -Turn the defibrillator setting to synchronize. -Select the appropriate energy level. - Place the paddles on the client's chest. -Check the location of other staff and call out "all clear" and deliver the electrical charge. Explanation: The correct order is to obtain the consent before sedating the client, turn the defibrillator to synchronize, select the energy level, place the paddles on the chest, call all "clear," and then deliver the charge without endangering hospital staff.

A physician orders lithium for a client diagnosed with bipolar disorder. The nurse needs to provide appropriate education for the client receiving this drug. Which topics should the nurse cover? Select all that apply.

- Signs and symptoms of drug toxicity -The need to report for laboratory testing to monitor blood levels -Changes in his mood may take 7 to 21 days Explanation: Client education should cover the signs and symptoms of drug toxicity as well as the need to report them to the physician. The client should be instructed to report for follow-up laboratory studies to monitor his lithium level to avoid toxicity. The nurse should explain that it may take 7 to 21 days before the client notes a change in his mood. Lithium doesn't have addictive properties. Tardive dyskinesia isn't an adverse effect of lithium. Tyramine is a potential concern for clients taking monoamine oxidase inhibitors.

A client with a history of varicose veins has just delivered her first baby. A nurse suspects that the mother has developed pulmonary embolus. Which symptoms would confirm this suspicion? Select all that apply.

-Sudden dyspnea -Diaphoresis -Confusion Explanation: Sudden dyspnea along with diaphoresis and confusion are classic symptoms that develop when a thrombus from a varicose vein becomes an embolus that lodges in the pulmonary circulation. Chills and fever would indicate infection. A client with an embolus usually develops tachycardia.

A client is being discharged with a prescription for enoxaparin. What will the nurse document to address that medication teaching occurred? Select all that apply.

-The client's response to teaching - The client knows the time for the next dose - The client can select a site for injection - The client knows adverse effects such as bleeding, bloody or black stools. Explanation: The nurse has a legal duty to do teaching with the client including reporting adverse effects such as bleeding, bloody or black stools. The nurse will document client's ability to select site for injection and the client's response to teaching as well as confirming the next scheduled dose with client. The client's ability to pay for the medication is not part of the teaching obligation.

The health care provider has prescribed 5 mg warfarin orally for a hospitalized client. In planning care for this client, the nurse should verify that which services have been contacted? Check all that apply.

-pharmacy -dietary - laboratory Explanation: To assure client safety when using anticoagulants, the nurse should coordinate care at this time with the pharmacist, dietitian, and laboratory. The pharmacist will collaborate in teaching the client about using the drug; dietary services will plan a diet that limits foods that have high amounts of vitamin K (spinach, cabbage, blueberries) that will interfere with anticoagulation; and the laboratory will draw daily INR levels to assure accurate dosing. Although the nurse coordinates discharge planning at the time of admission to the hospital, at this point it is too soon for discharge planning services to be involved because it is not known if the client will continue to take the warfarin when discharged. There is no indication a chaplain is needed at this time.

A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution?

I.V. tubing with a volume-control chamber Explanation: Because infants have a small circulating blood volume, inadvertent administration of extra I.V. fluid can cause fluid volume excess. To prevent this from occurring, I.V. tubing with a volume-control chamber should always be used for infants and children to closely regulate the amount of fluid infused. The volume-control chamber should be filled only with enough I.V. fluid for the next two 2 hours. A microdrip chamber that allows for 60 drops/ml (as opposed to a macrodrip chamber, which allows for 10 to 20 drops/ml, depending on the manufacturer) should be used to infuse the smaller amounts of I.V. fluids an infant needs. A filter is typically used only for the administration of total parenteral nutrition and certain blood products. Standard I.V. tubing for adults should be avoided for infants because of the inability to closely regulate the amount of fluid infused.

An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note:

Ortolani's sign Explanation: In a child with a congenital hip dislocation, assessment typically reveals Ortolani's sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg's sign.

A nurse is caring for a client of African descent. Among the following, who should the nurse use as a key informant?

Church mothers. The nurse should use church mothers as key informants for the client. Voodoo priests are key informants for Haitians. For Mexicans and Roman Catholics, the curandera can serve as key informant. Spiritist healers are key informants for Puerto Ricans.

A nurse is caring for a client with end-stage heart failure who is awaiting a heart transplant. The client tells the nurse that he thinks he's going to die before a donor heart is found. He also tells the nurse that he hasn't been attending a church but wants to talk with a priest. What action should the nurse take?

Contact the clergy member who is assigned to the transplant team. Explanation: Each multidisciplinary transplant team has a clergy person assigned. The nurse should contact that person and request that he visit the client. It isn't appropriate for the nurse to ask her priest to see the client. Telling the client that he has nothing to worry about because donors are typically found offers false reassurance. Telling the client that it doesn't matter if he attends a church invalidates the client's concern.

After an amniotomy, which client goal should take the highest priority?

The client will maintain adequate fetal tissue perfusion. Explanation: Amniotomy increases the risk of umbilical cord prolapse, which would impair the fetal blood supply and tissue perfusion. Because the fetus's life depends on the oxygen carried by that blood, maintaining fetal tissue perfusion takes priority over goals related to increased knowledge, infection prevention, and pain relief.

Which of the following clients should the nurse assess first?

The client with stridor who just received the first dose of an antibiotic Explanation: The highest priority client is the client with stridor who started an antibiotic. Stridor is an assessment finding indicating an extremely narrowed airway. Airway is the top priority. Next, the nurse should assess the client with wheezing. Finally, the client with chest pain and elevated blood pressure should be assessed.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse. The client's morning ammonia level is 110 mcg/dl. The nurse should suspect which situation?

The client's hepatic function is decreasing. Explanation: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings are not indicative of reduced renal filtration.

A client with Cushing's disease tells the nurse that the health care provider (HCP) said the morning serum cortisol level was within normal limits. The client asks, "How can that be? I am not imagining all these symptoms!" The nurse's response will be based on the fact that?

The excessive cortisol levels seen in Cushing's disease commonly result from loss of the normal diurnal secretion pattern. Explanation: Cushing's disease is commonly caused by loss of the diurnal cortisol secretion pattern. The client's random morning cortisol level may be within normal limits, but secretion continues at that level throughout the entire day. Cortisol levels should normally decrease after the morning peak. Analysis of a 24-hour urine specimen is often useful in identifying the cumulative excess. Clients will not have symptoms with normal cortisol levels. Hormones are present in the blood.

A client's chest tube accidentally disconnects from the drainage tube. The nurse should first:

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

When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent:

contractures. Explanation: Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications. Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.

During the initial assessment of a child admitted to the pediatric unit with osteomyelitis of the left tibia, when assessing the area over the tibia, which is an expected finding?

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

A client at 28 weeks gestation is admitted to the maternity unit in preterm labor. The client asks the nurse if there is anything that can be done to stop the preterm labor. Which one of the following is the most appropriate response from the nurse?

"A cerclage may be performed depending on the competency of your cervix." Explanation: A cerclage is a surgical procedure where a stitch is placed by the physician in the cervix to prevent a spontaneous abortion or premature birth. The physician would have to determine the competency of the cervix, cervical dilation, and placement of the amniotic sac to determine whether the procedure is an option to stop progression of the birth. This is a potential option for the family. A 28-week fetus is considered viable and responding about confirming the viability of the fetus is not therapeutic at this time. Coordinating other family members to come into the hospital for support is an important response, but not the first response from the nurse.

A nurse is caring for a client that received a colostomy 2 days ago. Which is the priority intervention?

Assess the drainage from the stoma. Explanation: Assessing the stoma is important because of the potential for surgical site infection. Teaching on irrigation and dietary planning should be performed before discharge. The client should be encouraged to look at the stoma, but this is not the priority.

A client tells the nurse about having numbness from the back of the left buttock to the dorsum of the foot and big toe. The client is scheduled to undergo a laminectomy, and the operative consent form states "a left lumbar laminectomy of L3-L4." What should the nurse do next?

Call the surgeon. Explanation: Based on the client's comments, the nurse should call the surgeon to verify the location of the surgery. The client's comments indicate radiculopathy of L4-L5, but the informed consent form states L3-L4. Radiculopathy of L3-L4 involves pain radiating from the back to the buttocks to the posterior thigh to the inner calf. The nurse must act as a client advocate and not ask the client to sign the consent until the correct procedure is identified and confirmed on the consent. The nurse has no legal authority or responsibility to change the consent. The history is a source of information, but when the client is coherent and the history is contradictory, the health care provider (HCP) should be contacted to clarify the situation. Ultimately, it is the surgeon's responsibility to identify the site of surgery specified on the surgical consent form.

A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a systolic murmur. Diagnostic tests reveal that the client has hypertrophic cardiomyopathy (HCM). Which nursing diagnosis may be appropriate?

Decreased cardiac output Explanation: Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of Risk for deficient fluid volume isn't applicable. Ineffective thermoregulation and Risk for peripheral neurovascular dysfunction are inappropriate because HCM doesn't cause these problems.

A female client with bulimia nervosa reports that her major problem is eating too much food in a short period of time and then vomiting. Which short-term goal is the most important?

Determine the amount of food the client will eat without purging Explanation: This client must meet her nutritional needs to prevent further complications. She must identify the amount of food she can eat without purging as her first short-term goal. Binge eaters cannot recognize their satiety level or their feelings of fullness. Obtaining knowledge, or verbalizing her fears and feelings about food are not priority goals for this client. After meeting immediate physiologic needs, therapy is an important of treatment for this disorder.

A nurse is caring for a client in the manic phase of bipolar disorder who's ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is appropriate?

Expressing feelings of anxiety Explanation: Anxiety is a normal reaction to the termination of the nurse-client relationship. The nurse should help the client explore his feelings about the end of the therapeutic relationship. Although anger about the termination may be a healthy response, banging the table, shouting, and other forms of acting out aren't appropriate behavior. Withdrawal isn't a healthy response to the termination of a relationship. By rationalizing the termination, the client avoids expressing his feelings and emotions.

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants airborne isolation?

Measles Explanation: Measles warrants airborne isolation, which aims to prevent transmission of disease by airborne nuclei droplets. Other infections necessitating respiratory isolation include varicella and tuberculosis. The mumps call for droplet isolation; impetigo, contact isolation; and cholera, enteric isolation.

A client with type I diabetes mellitus is scheduled to have surgery. The client has been nothing-by-mouth (NPO) since midnight. In the morning, the nurse notices the client's daily insulin has not been prescribed. Which action should the nurse do first?

Obtain the client's blood glucose at the bedside. Explanation: The nurse should contact the health care provider and clarify whether the client's usual insulin dose should be given before surgery; having the blood glucose level is objective information that the health care provider may need to know before making a final decision as to the insulin dosage. The nurse should not assume that the usual insulin dose is to be given. It is not appropriate for the nurse to defer decision making on this issue until after surgery.

The nurse observes a family member of a client who is on contact precautions enter and exit the client's room without performing hand hygiene. What is the nurse's most appropriate action?

Offer to show family members how to perform hand hygiene using soap and water or alcohol rub. Explanation: The nurse should address the family member's oversight and promote infection control, but in a way that is nonconfrontational. Offering to show the family members how to perform hand hygiene achieves these goals. Moving signage may not result in a behavior change. Speaking about hospital-acquired infections may not result in improved hand hygiene.

A scrub nurse is assigned to the operating room for an appendectomy case. Which action by the scrub nurse violates the standards of sterility during the operation?

Tying the back of another nurse's gown. Explanation: Scrub nurses, also called perioperative nurses, are registered nurses who assist in surgical procedures by setting up the room before the operation, working with the doctor during surgery, and preparing the patient for the move to the recovery room. The scrub nurse must remain sterile during the operation as a primary responsibility is assisting the surgeon with surgical equipment. Touching the back of a nonsterile gown breaks sterility. All of the other measures maintain sterility.

The nurse is instructing a client about skin care while receiving radiation therapy to the chest. What should the nurse instruct the client to do?

Wash the area with tepid water and mild soap. Explanation: Clients receiving radiation experience dryness or redness in the area of the radiation. The nurse instructs the client to wash the area with soap and water and keep the area dry. The client does not apply lotion, shave, or cover the area.

Which finding would lead the nurse to suspect that a neonate born at 34 weeks' gestation receiving intravenous fluids has developed overhydration?

hypoproteinemia Explanation: Decreased protein or hypoproteinemia is a sign of overhydration, which can lead to patent ductus arteriosus or congestive heart failure. Bulging fontanels, decreased serum sodium, decreased urine specific gravity, and decreased hematocrit are other signs of overhydration. Hypernatremia (increased serum sodium concentration) or increased urine specific gravity would suggest dehydration, not overhydration. Polycythemia evidenced by an elevated hematocrit would suggest hypoxia or congenital heart disorder.

A 1-month-old infant in the neonatal intensive care unit is dying. His parents request that a nurse give the infant an opioid analgesic. The infant's heart rate is 68 beats/minute and his respiratory rate is 18 breaths/minute. He is on room air; oxygen saturation is 92%. The nurse's response to the parents' request should be based on the fact that:

providing an analgesic during the last days and hours is an ethically appropriate nursing action. Explanation: The nurse's action should be based on the fact that all clients, regardless of age, have the right to die with dignity and to be free of pain. Assisted suicide requires some action on the part of the client, which isn't possible in the case a 1-month-old infant. The parent's decision doesn't eliminate the nurse's ethical obligation to the infant and to the nursing profession. Withholding the opioid analgesic isn't appropriate because it isn't known that administering the drug would hasten death in this case.

The nurse is instructing the parents of a child with acquired immunodeficiency syndrome (AIDS) how to look for signs and symptoms of infection when the child has a cut or open wound. The nurse should tell the parents to report:

rectal temperature higher than 100.5° F (38° C). Explanation: Fever is a cardinal manifestation of infection in people with AIDS. Because the major physiologic alteration in AIDS is generalized immune system dysfunction, typical indicators of the body's response to infection (e.g., erythema, warmth, tenderness) may be absent.

The nurse is preparing a teaching plan about increased exercise for a female client who is receiving long-term corticosteroid therapy. What type of exercise is most appropriate for this client?

walking Explanation: The best exercise for females who are on long-term corticosteroid therapy is a low-impact, weightbearing exercise such as walking or weight lifting. Floor exercises do not provide for the weightbearing. Stretching is appropriate but does not offer sufficient weightbearing. Running provides for weightbearing but is hard on the joints and may cause bleeding.

A nurse is providing instruction to a 38-year-old male client undergoing treatment for anxiety and insomnia. The practitioner has prescribed lorazepam 1 mg/po/tid. The nurse determines that teaching has been effective when the client states:

"I'll avoid coffee." Explanation: Lorazepam is a benzodiazepine used to treat various forms of anxiety and insomnia. Caffeine is contraindicated because it is a stimulant and increases anxiety. A client taking lorazepam should avoid alcoholic beverages. Clients taking certain antipsychotic medications should avoid sunlight. Salt intake has no effect on lorazepam.

A nurse is caring for a client declared brain dead following a motor vehicle accident. When the nurse enters the client's room, his spouse and family are talking with friends about the possibility of organ donation. Which statement by the nurse reflects an ethical practice dilemma?

"If you're thinking about organ donation, my sister is waiting for a kidney transplant. She'd be an excellent recipient. I can give you her phone number." Explanation: The nurse demonstrates unethical behavior when she discusses personal information with the client's family and suggests her sister as an organ recipient. Offering to find resources, answer questions, and provide support to the client's family are within the scope of nursing practice.

During a prenatal visit, the client has told the nurse that she intends to give birth at a spiritual retreat center that is distant from population centers or health care facilities. What is the nurse's best response?

"It sounds like you have given this a lot of consideration. What is it about giving birth there that will be special for you?" Asking about what the woman hopes to gain or experience is an empathic and therapeutic way of initiating dialogue about this client's decision. Offering a warning will likely sever any follow-up discussion. Ultimately, clients do not need permission to enact a care plan. Acknowledging that nonhospital births are increasingly common is appropriate, but it is helpful to follow a statement with a question.

A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drip is initiated with 50 units of insulin in 100 ml of normal saline solution administered via an infusion pump set at 10 ml/hour. The nurse determines that the client is receiving how many units of insulin each hour? Record your answer using a whole number.

5 Explanation: To determine the number of insulin units the client is receiving per hour, the nurse must first determine the number of units in each milliliter of fluid (50 units ÷ 100 ml = 0.5 units/ml). Next, multiply the units per milliliter by the rate of milliliters per hour (0.5 units × 10 ml/hr = 5 units).

Before administering a tube feeding to a toddler, which method should the nurse use to check the placement of a nasogastric (NG) tube?

A check of the pH of fluid aspirated from the tube Explanation: Intestinal, gastric, and respiratory fluids have different pH values. Therefore, checking the pH of fluid aspirated from the tube is the most reliable technique for checking proper NG tube placement without taking X-rays before each feeding. X-rays can't be performed multiple times a day on a daily basis. Because auscultation of air can be heard when the tube is in the esophagus as well as in the stomach, this isn't the best test for checking placement. Observing the insertion measurement mark isn't a good check either because the mark may remain the same even though the tube has migrated up or down into the esophagus, lungs, or intestines.

The nurse in an inpatient psychiatric adult unit is assigned care for a group of clients. Which client would the nurse see first during morning rounds?

A client admitted to the hospital for agitation and paranoia Explanation: The client admitted to the hospital for agitation and paranoia needs to have the most immediate assessment. The nurse must establish whether the client is a danger to himself/herself or to others on the unit. The client to be discharged is the most stable and can be assessed at a later time. The client with depression who refused his/her medication is a concern, but there is no indication of acute safety concerns. The client with dementia who has not communicated would not be outside the normal course when the environment of a client with advanced dementia is changed. The nurse must do a further cognitive and neurologic exam.

A nurse is caring for a 22-year-old female client with type 1 diabetes mellitus and toxic shock syndrome (TSS). Which action should the nurse perform first?

Administer 5% dextrose in half-normal saline solution at 150 mL/h IV. Explanation: Fluid losses can occur from vomiting, diarrhea, and fever and can lead to hypovolemic shock. The first nursing action is to treat the hypovolemic shock that accompanies toxic shock, so the IV fluids must be administered immediately. The fluid replacement is critical to avoid circulatory collapse. Pain medication and teaching can be implemented later. Antibiotics will be given because TSS is caused by a staphylococcal infection; however, fluid replacement is initiated first to treat life-threatening hypovolemic shock.

Which intervention should a nurse use when administering oxygen by face mask to a client?

Assist the client to the semi-Fowler's position if possible. Explanation: By assisting the client to the semi-Fowler's position, the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could cause irritation. The nurse should apply the face mask from the client's nose down to the chin — not vice versa. The nurse should ensure that the connectors between the oxygen equipment and humidifier are airtight; loosened connectors can cause loss of oxygen.

A hospital is changing the format for documentation in an attempt to decrease the time the nurses are spending on charting. The new type of charting will require that nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?

Charting by exception. Explanation: Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes. Charting by exception decreases charting time. Focus charting does not use a problem list of nursing or medical diagnoses but incorporates many aspects of the client and client care into a focus column. The focus may be a client strength, problem, or need. Problem, Intervention, Evaluation (PIE) charting incorporates the plan of care into the progress note, and problems are identified by an assigned number. Variance charting is used when clients fail to meet an expected outcome or a planned intervention is not implemented in the case management model.

A client has a complex medical history involving consequences of type 1 diabetes. As a result of diabetic nephropathy, the client now is involved in the local hospital's dialysis program and has been referred to an ophthalmologist by his primary care physician following vision problems. In addition, he receives home care nursing for treatment of a foot ulcer that is slow to heal. This client's situation characterizes which of the following phenomena?

Fragmentation of care. Explanation: Fragmentation of care occurs when multiple, specialized practitioners are involved in various aspects of a complex client's care. This creates the potential for miscommunication and conflicting advice and treatment, with a lack of a unified plan of care. This situation is not indicative of primary care, and it is not necessarily a consequence or manifestation of case management and managed care.

A client in the postanesthesia care unit with a left below-the-knee amputation has pain in the left big toe. What should the nurse do first?

Give the client the prescribed opioid analgesic. Explanation: The nurse's first action should be to administer the prescribed opioid analgesic to the client because this phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain. Although it does relieve the client's apprehensions to be told that phantom sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation. Usually phantom sensation will go away. However, showing the client that the toes are not there does nothing to provide the client with relief.

In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment?

Health habits, family relationships, affect, and thought patterns Explanation: A psychosocial assessment involves assessment of health habits, family relationships, emotional responses, and thought patterns. These areas are important to assess to determine how the client is coping with illness. It is also important to identify the support systems of the client. Each of the other choices includes physical assessment factors, not just psychosocial factors.

A client with hypertension visits the health clinic for a routine checkup. The nurse measures the client's blood pressure at 184/92 mm Hg and notes a 5-lb (2.3-kg) weight gain within the past month. Which nursing diagnosis reflects the most serious problem in managing a client with hypertension?

Noncompliance (nonadherence to therapeutic regimen) Explanation: Noncompliance is the most serious problem in managing a client with hypertension. One authority estimates that 40% to 60% of hypertensive clients fail to comply with ordered treatment. Reasons for noncompliance include lack of symptoms, which makes the problem seem less serious; the difficulty of making required lifestyle changes, such as eating a low-sodium diet, stopping smoking, and losing or managing weight; adverse reactions to antihypertensive drugs; and the inconvenience and high cost of obtaining health care. Deficient knowledge contributes to noncompliance; Excess fluid volume, caused by excess sodium intake, and Imbalanced nutrition: More than body requirements may result from noncompliance.

A client experienced a right frontal stroke that left him with short-term memory loss and lack of impulse control. The nurse caring for the client on the previous shift identified him at high risk for falls. While making rounds to begin the shift, a nurse notices the client lying on the floor. The nurse assesses the client and notes no injuries. How should the nurse follow up this incident?

Notify the physician, then document the location of the fall, physician notification, any injury, necessary follow-up, and any changes in the care plan needed as a result of the fall. Explanation: The nurse should notify the physician, then document the facts related to the fall, such as the location of the fall, physician notification, injury if any, necessary follow-up, and any changes in the care plan that occurred as a result of the fall. The nurse shouldn't include any information that places blame on other health care members. The fall must be reported even if the client doesn't suffer an injury.

A client with pancreatitis returns from an endoscopic retrograde cholangiopancreatography (ERCP). Which assessment would be of most concern to the nurse?

Poor gag reflex Explanation: A poor gag reflex may lead to inability of the client to handle oral secretions and lead to decreased oxygen saturation. Upper abdominal pain is expected from the injection of CO2 to visualize the duodenum. Retrograde amnesia is expected from conscious sedation and a sore throat is expected from the endoscope being inserted during the procedure.

A 15-year-old client is 4 cm dilated and 100% effaced and is in active labor with her first baby. The nurse contacts the physician to communicate the findings of fetal heart rate decelerations, thick meconium in the amniotic fluid, and low fetal scalp pH results. What is the most appropriate nursing action at this time?

Prepare the client for an assisted or cesarean birth. Explanation: Fetal heart decelerations, thick meconium, and low fetal scalp pH indicate severe fetal distress. Because the client is a primigravida and in early labor at 4 cm cervical dilatation, it is unlikely that the baby will tolerate further labor and a vaginal birth. It is prudent for the nurse to begin preparing the client for an assisted or operative birth. While changing maternal position and increasing oxygen availability may enhance placental perfusion and fetal oxygenation, these interventions do not meet the immediate fetal needs. There are no implications that a social worker needs to be involved in the care provided at this particular stage.

A client with type 1 diabetes mellitus is conscious but confused, weak, diaphoretic, and is having heart palpitations. What is the nurse's priority action?

Provide 15 to 20 grams of a fast-acting oral carbohydrate Explanation: The client is exhibiting signs of hypoglycemia. Since the client is conscious, the first intervention is to give a fast-acting oral carbohydrate, such as orange juice, hard candy, or honey. If the client becomes unconscious, the nurse would administer IM or subQ glucagon or dextrose 50% IV if access is available. Administering insulin wouldn't be appropriate because the client is experiencing hypoglycemia.

A nurse administers albuterol, as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Respiratory rate of 22 breaths/minute Explanation: In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

Question 39 See full question 30s A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Weighing the client daily at the same time each day Explanation: Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

The nurse is educating a woman with type 2 diabetes from France who speaks English as a second language. What behavior(s) alerts the nurse to a possible lack of communication of the educational material? Select all that apply.

- asking questions about shopping -laughing at some of the brochures - looking away from the speaker Explanation: Some of the behaviors which indicate that the client is not understanding the nurse's teaching are: asking inappropriate questions to change the subject, laughing to disguise embarrassment, and looking away from the speaker. Taking notes and writing down medical terms are positive behaviors indicating that the client is engaged in learning.

The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply.

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

A nurse reports to work and is assigned a client requiring many unfamiliar procedures and overwhelming care demands. What are the alternatives the nurse has with regard to accepting the assignment? Select all that apply.

-Refuse to take the assignment. -Contact the state agency and be a whistle blower. Explanation: The nurse can refuse to accept the assignment and possibly violate the employee contract. The nurse can contact the state agency and be a whistle blower. If the nurse alerts the clients and documents the unfair assignment in the client's medical record or continues to work through the assignment expressing negative feelings to colleagues, the nurse is acting in a passive aggressive manner, which is not professional.

A nurse should take action when a healthy 3-month-old infant is:

A nurse should take action when a healthy 3-month-old infant is: Explanation: Incorrectly mixed formula can cause an infant to develop severe electrolyte and nutrition imbalances. This safety hazard necessitates immediate attention. Placing a 3-month-old infant in a rear-facing car seat is appropriate. Although an infant sleeping in a cardboard box on the floor may be a concern, it isn't an immediate safety hazard. An infant being put to sleep with a pacifier isn't a safety concern.

A 4-year-old has just returned from surgery. He has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, "I'm going to throw up." What should the nurse do first?

Irrigate the NG tube to ensure patency. Explanation: The nurse should first irrigate the NG tube because if the tube isn't draining properly or is kinked, the child will experience nausea. There's no reason to notify the physician immediately because a nurse should be able to handle the situation. Giving the child an antiemetic doesn't really address the problem. Encouraging the mother to calm the child is always a good intervention but isn't the first thing to do in this case.

What is a crucial goal of therapeutic communication when helping the client deal with personal issues and painful feelings?

conveying client respect and acceptance even if not all of the client's behaviors are tolerated Explanation: The nurse is required to set limits on inappropriate behavior while conveying respect and acceptance of that person. Doing so conveys to the client that he is worthy without posing any harm or embarrassment to the client. Touch is a complex issue that must be used cautiously. Touch may be misinterpreted or misperceived by a client who has been abused or who has perceptual or thought disturbances. Mutual sharing reflects a social friendship, not a therapeutic one. Total confidentiality is not desirable. For example, treatment team members and insurance companies need selected information to ensure quality services.

The development of disaster plans should take into consideration that children are more susceptible to the effects of a chemical attack than adults because children:

have thinner skin than adults. Explanation: Children are more susceptible to the effects of chemical and biological attacks because they have thinner skin than adults, increasing their risk of absorbing a chemical. They also have a larger, not smaller, body surface area in relation to their weight than do adults, which increases the chance of chemical absorption. Children breathe at a faster, not slower, rate than adults, allowing them to inhale greater amounts of a toxic agent. Additionally, some chemical agents are heavier than air and accumulate close to the ground, which is closer to a child's breathing zone than an adult's. Because they have less fluid reserve than adults, children are at greater risk of developing rapid dehydration from agents that cause vomiting or diarrhea.

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel has positioned the oxygen mask as shown. The nurse is assessing the neonate and determines that the mask:

is appropriate for the neonate. Explanation: The correct size covers the nose but not the eyes. The mask is too large if it covers the neonate's eyes. Masks that are too small may pinch the nose. Masks should fit snugly against the cheeks and chin. It is not necessary to cover the mask with a soft cloth. If the mask fits snugly, it will not be as likely to rub the skin.

A client with a history of pheochromocytoma is admitted to the hospital in an acute hypertensive crisis. To reverse hypertensive crisis caused by pheochromocytoma, the nurse expects to administer:

phentolamine. Explanation: Pheochromocytoma causes excessive production of epinephrine and norepinephrine, natural catecholamines that raise the blood pressure. Phentolamine, an alpha-adrenergic given by I.V. bolus or drip, antagonizes the body's response to circulating epinephrine and norepinephrine, reducing blood pressure quickly and effectively. Although methyldopa is an antihypertensive agent available in parenteral form, it is not effective in treating hypertensive emergencies. Mannitol, a diuretic, is not used to treat hypertensive emergencies. Felodipine, an antihypertensive agent, is available only in extended-release tablets and therefore, does not reduce blood pressure quickly enough to correct hypertensive crisis.

Considering a client's atrial fibrillation, a nurse must administer digoxin with caution because it:

stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. Explanation: A nurse must administer digoxin with caution in a client with atrial fibrillation because digoxin stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. The vagal effect slows the heart rate, increases the refractory period, and slows conduction through the atrioventricular node and junctional tissue, increasing the potential for new arrhythmias to develop. Digoxin doesn't constrict arteries. Although digoxin can trigger proarrhythmias, it does so by increasing vagal tone (not stroke volume).

A client is expecting her second child in 6 months. During the psychosocial assessment, she says to the nurse, "I've been through this before. Why are you asking me these questions?" What is the nurse's best response?

"Each pregnancy has a unique psychosocial meaning." Explanation: With each pregnancy, a woman explores a new aspect of the mother role and must reformulate her self-image as a pregnant woman and a mother. The other options don't address the client's feelings. No evidence suggests that a second pregnancy requires more adjustment. Couvade symptoms occur in the father, not the mother.

A client who is newly diagnosed with schizophrenia tells the nurse, "The aliens are telling me that I am defective and need to be eliminated." Which response by the nurse is most appropriate initially?

"I want you to agree to tell staff when you hear these voices." Explanation: The client may act on command hallucinations and harm himself or others. Therefore, the staff needs to know when the client is hearing such commands, to ensure safety first. Telling the client that the voices are real but that the nurse does not hear them would be an appropriate response later in the client's hospitalization when the client's safety is no longer an issue because antipsychotics are beginning to take effect. Telling the client that the hallucinations are part of the illness or that medications will help control the voices would be appropriate once the client has developed some insight into the symptoms of the illness.

The client with a spinal cord injury asks the nurse why the dietitian has recommended to decrease the total daily intake of calcium. Which response by the nurse would provide the most accurate information?

"Lack of weight bearing causes demineralization of the long bones." Explanation: Long-bone demineralization is a serious consequence of the loss of weight bearing. An excessive calcium load is brought to the kidneys, and precipitation may occur, predisposing to stone formation. Excessive intake of dairy products may promote constipation. However, this is not the most accurate reason for decreasing calcium intake. Immobility does not increase calcium absorption from the intestine. Dairy products do not necessarily contribute to weight gain.

On admission to the psychiatric unit, a client with major depression reports that a family member is physically abusive and requests that the nurse not release any personal information to anyone. When the allegedly abusive family member calls the unit and demands information about the client's treatment, what is the nurse's best response?

"To protect clients' confidentiality, I can't give any information, including whether your relative is receiving treatment here." Explanation: The client has the right to confidential treatment, and the nurse has a duty to protect his confidentiality. Stating that to protect clients' confidentiality no information will be given is a diplomatic response. Although simply telling the caller that information can't be released protects the client's confidentiality, this response isn't as diplomatic as the first response. Stating that the client isn't accepting phone calls or that the client didn't sign an information form with the caller's name on it divulges the client's whereabouts and status, violating confidentiality.

A client who is 16 days postpartum calls the nurse on a postpartum unit crying. The client describes her nipples as being cracked and bleeding. The client also says her left breast is sore to touch, and an area under the breast is firm, painful, and red. She is scheduled to go to a nurse-led postpartum breastfeeding support group later that evening. How should the nurse respond to the client's descriptions of her symptoms? Select all that apply.

- Advise her to see her physician as soon as possible. -Advise her to continue to breastfeed. -Advise her to seek the advice of a lactation consultant to prevent future breastfeeding issues. Explanation: The client needs to see her physician as soon as she can to treat the infection. The client should not wait to be seen by the nurse educator. The client can continue breastfeeding and can feed from both breasts. The baby likely already has the infection, as it may have been transferred through the milk earlier. Stopping breastfeeding may decrease the client's milk supply and/or cause engorgement. There are many strategies that can prevent mastitis, and a lactation consultant would be a good resource for teaching prevention.

A nurse is caring for a client with history of a warm, reddened, painful area in the breast diagnosed as mastitis as well as cracked and fissured nipples. The client expresses the desire to continue breast-feeding throughout treatment. Which instructions would the nurse include to prevent a recurrence of this condition? Select all that apply.

- Change the breast pads frequently. -Expose the nipples to air for part of each day. -Wash hands before handling the breast and breast-feeding. -Release the neonate's grasp on the nipple before removing him from the breast. Explanation: Mastitis is an infection of the breast tissue usually caused by Staphylococcus aureus. This infection typically occurs in the second or third postpartum week and is more frequent in primigravidas. To help prevent mastitis, the nurse would suggest measures to prevent cracked and fissured nipples. Changing breast pads frequently and exposing the nipples to air for part of the day help keep the nipples dry and prevent irritation. Washing hands before handling the breast reduces the chance of accidentally introducing organisms into the breast. Releasing the baby's grasp on the nipple before removing the baby from the breast also reduces the chance of irritation. Nipples would be washed with water only; soap tends to remove the natural oils and increases the chance of cracking. The baby would grasp both the nipple and areola.

A nurse is administering indomethacin to a neonate. What should the nurse do to ensure that the nurse has identified the neonate correctly? Select all that apply.

- Check the neonate's identification band against the medical record number. - Verify the date of birth from the medical record with the date of birth on the client's identification band. Explanation: The nurse should use at least two sources of identification prior to administering medication to any client, such as the medical record number and the client's date of birth. It is not safe practice to ask the parent or a nurse to verify the correct neonate. It is also not safe to use the room number or crib number as a source of identification because neonates' locations in the hospital change frequently.

A client with ulcerative colitis is to take sulfasalazine. Which instruction should the nurse provide for the client about taking this medication at home? Select all that apply.

- Drink enough fluids to maintain a urine output of at least 1,200 to 1,500 mL/day. - Discontinue therapy if symptoms of acute intolerance develop, and notify the health care provider (HCP). -Avoid activities that require alertness. Explanation: Sulfasalazine may cause dizziness, and the nurse should caution the client to avoid driving or other activities that require alertness until response to medication is known. If symptoms of acute intolerance (cramping, acute abdominal pain, bloody diarrhea, fever, headache, rash) occur, the client should discontinue therapy and notify the HCP immediately. Fluid intake should be sufficient to maintain a urine output of at least 1,200 to 1,500 mL daily to prevent crystalluria and stone formation. The nurse can also inform the client that this medication may cause orange-yellow discoloration of urine and skin, which is not significant and does not require the client to stop taking the medication. The nurse should instruct the client to take missed doses as soon as remembered unless it is almost time for the next dose.

There has been a fire in an apartment building, and it has spread to seven apartment units. Victims have suffered burns, minor injuries, and broken bones from jumping from windows. Which persons can be safely treated at the scene and transported to a health care facility after victims with more emergent problems have been transported first? Select all that apply.

- female client who is 5 months pregnant with no apparent injuries - child who is 10 years of age with an apparent simple fracture of the humerus -female who is 20 years of age with first-degree burns on hands and forearms Explanation: The pregnant woman is not in imminent danger or likely to have a precipitous birth. The child who is 10 years of age is not at risk of infection and can be treated in an outpatient facility. First-degree burns are considered less urgent. The male with respiratory distress and coughing is transported first as he is likely experiencing smoke inhalation. The 75-year-old male with second-degree burns should also be also transported to a burn center or emergency department.

The client with bipolar disorder, manic phase, has a valproic acid level of 15 mg/mL (104mmol/L). Which client behaviors should the nurse judge to be due to this level of valproic acid? Select all that apply.

- irritability -grandiosity -flight of ideas Explanation: The therapeutic level of valproic acid is 50 to 100 mg/mL (347 to 693 mmol/L). A level of 15 mg/mL (104mmol/L) is not considered therapeutic. Therefore, the client would be manifesting symptoms of mania. Irritability, euphoria, grandiosity, pressured speech, flight of ideas, distractibility, and a decreased need for sleep are some characteristics of a manic episode. Anhedonia and hypersomnia are related to a depressive illness and not mania.

A older adult client with a history of type 2 diabetes is being prepared for discharge from the health care facility. Discharge instructions include daily insulin injections, self blood glucose monitoring, and daily wound care. The client lives alone but has a son who lives about 45 minutes away. To promote continuity of care, the nurse case manager would ensure that a referral to which discipline is in place before discharge? Select all that apply.

- skilled nursing care -nutritional therapy - social services -community services Explanation: The client is in need of skilled nursing care to assist with and provide continued education about daily insulin injections, wound care, and self-blood glucose monitoring. Since the client lives alone, referrals to community services and social services would be important. Additionally, since the client is new to insulin and has experienced a complication related to his diabetes, a referral to nutritional therapy would be appropriate. At this time, a referral to physical therapy or occupational therapy is not indicated but may be appropriate if the client demonstrates problems related to mobility and activities of daily living.

The nurse is a member of a team that is planning a client-centered, community-based approach to care of clients with chronic obstructive pulmonary disease (COPD). In which areas should the team focus on improving quality of care and delivery? Select all that apply.

- the community -clinical information systems -delivery system design Explanation: The process of changing a health care system from an acute care model to a community-based care model uses continuous quality improvement (CQI) methods. The goal is to improve the health of chronically ill clients. Areas for improvement include: health systems, delivery system design, decision support, clinical information systems, self-management support, and the community. This system requires health care services that are client-centered and coordinated among members of the health care team and the client and the family. These changes do not focus on the administrative leadership or the care in the acute care setting alone.

The nurse sees a client in the postpartum clinic for a checkup related to a recent mastitis infection. The nurse wishes to assess how the client is managing the infant's needs and to do a breastfeeding assessment. The client informs the nurse that she is finishing her prescribed cloxacillin in a few days. What is the nurse's most appropriate response to the client about mastitis? Select all that apply.

-"Encourage your infant to feed from the infected breast first." -"You need to continue to breastfeed, and the antibiotics will protect your baby from infection." - "Allowing your infant to nurse is more therapeutic than pumping." Explanation: The antibiotics will protect and/or treat the baby as well as the mother for the infection. As well, continuing to breastfeed helps the mastitis to resolve more quickly. The milk does not need to be discarded, nor does the mother need to discontinue breastfeeding for the 10 days. Offering formula may lead to the baby refusing the breast and preferring the bottle. This will make it difficult to resume breastfeeding after 10 days. The infant nursing from the infected breast will facilitate more complete emptying of milk from the breast.

A nurse is caring for a newborn with transient tachypnea of the newborn (TTN). Which of the following responses made by the newborn's mother demonstrates that she understands the newborn's condition? Select all that apply.

-"Having a cesarean section increased the risk of transient tachypnea of the newborn." - "The healthcare provider will need chest X-rays to monitor respiratory distress." Explanation: TTN is caused by retention of extra amniotic fluid in the lung fields. Newborns who are born by cesarean section are more likely to have TTN because the mechanical squeezing of the newborn's rib cage does not occur with birth. The most distinguishing feature of TTN is the lung fields on a chest X-ray where there is hyperaeration of the alveoli. TTN usually lasts 48-72 hours and will need oxygen during this time period. TTN usually requires a low percentage of oxygenation (40% or less) along with supportive care such as IV fluid, antibiotics, and placement in a warmer. If the respiratory rate is consistently above 60 breaths/minute, the newborn takes nothing by mouth due to the risk of aspiration. Although smoking during pregnancy can lead to a smaller baby, smoking is not linked with TTN.

A client has been on antipsychotic medication for 20 years with little control of the positive and negative symptoms of schizophrenia. The client was recently switched to the second-generation antipsychotic clozapine. Which of the following assessment finds would indicate to the nurse that clozapine should be held? Select all that apply.

-A decrease in white blood cells -A seizure Explanation: Common side effects of psychotropic medications are a drop in blood pressure and an increase in weight. Adverse effects include decrease in white blood cells and seizure, and the medication must be discontinued if this occurs. Increase in motivation is a positive indication that the medication is working and is not a side effect.

The nurse is using a needleless port to administer an intravenous medication (view the figure). Which is the correct technique with this system? Select all that apply.

-Aspirate the line and flush with saline. -Use a separate syringe to administer the medication. Explanation: Prior to administering the medication, the nurse should use a separate saline-filled syringe to verify that the infusion system is still positioned in the client's vein, and then flush the line with saline. The nurse should then, using the syringe with the medication, administer the medication. It is not necessary to remove the tape prior to injecting the medication. It is not necessary to change gloves when changing syringes. The syringe should be disposed of in a labeled, puncture-proof and leakproof container.

A client requests a narcotic analgesic shortly after the oncoming nurse receives change-of-shift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM) within the past hour. In what order from first to last should the oncoming registered nurse (RN) perform the actions? All options must be used.

-Assess the client for manifestations of pain. - Check the medication documentation as to when morphine 10 mg (IM) was dispensed and to whom. - Validate with the outgoing RN that morphine 10 mg (IM) had been administered. Check to ascertain if any discrepancy had been documented with accompanying reasons. Explanation: The oncoming nurse should first assess the client for pain. Next, the nurse should check the documentation and then validate with the nurse who reported giving the medication that the medication had been given. Finally, the nurse should determine if there is a discrepancy between administration and documentation.

The nurse manager on a pediatric floor is updating safety recommendations for the unit. Which strategy would help reduce pediatric medication errors? Select all that apply.

-Avoid using parenteral syringes when administering liquid oral medications. -Limit the size of IV fluid bags that can be hung on small children. -Reduce the available concentrations or dose strengths of high-alert medications to the minimum. Explanation: Using only oral syringes to administer oral medications reduces the chance that the medication will be given intravenously. The use of smart pumps alone is not enough to prevent IV fluid administration. An additional measure that pediatric floors can institute to prevent accidental fluid overload is to use smaller IV fluid bags, such as 250 mL. Whenever a medication comes in multiple concentrations and doses, there is risk of administering the wrong dose. The use of pediatric satellite pharmacies with pediatric pharmacists greatly increases the safety of medication administration. Any time steps are added to the medication administration process, there is one more place where an error might occur.

While instructing the client about breast-feeding, which instructions should the nurse include to help the mother prevent mastitis? Select all that apply.

-Change the breast pads frequently. - Expose your nipples to air part of the day. -Wash your hands before handling your breast and breast-feeding. -Release the baby's grasp on the nipple before removing him or her from the breast. Because mastitis is an infection commonly associated with a break in the skin surface of the nipple, measures to prevent cracked and fissured nipples help to prevent mastitis. Changing breast pads frequently and exposing the nipples to air part of the day help keep the nipples dry and prevent irritation. Washing one's hands before handling the breast reduces the chance of accidentally introducing organisms into the breast. Releasing the baby's grasp on the nipple before removing the baby from the breast also reduces the chance of irritation. Nipples should be washed with water only. Soap can remove the body's natural oils and increases the chance of cracking. The baby should grasp both the nipple and areola.

A nurse is teaching a client about insulin infusion pump use. What intervention(s) should the nurse include to prevent infection at the injection site? Select all that apply.

-Change the needle every 3 days. -Use sterile techniques when changing the needle. -Cleanse the skin at the insertion site for 15 seconds using alcohol. Explanation: The nurse should teach the client to change the needle every 3 days to prevent infection, use sterile techniques, and properly cleanse the skin. The client does not need to wear gloves when inserting the needle. Antibiotic therapy is not necessary before initiating treatment.

During the nurse's shift in the emergency department, a nurse assesses a client who is suspected of being under the influence of amphetamines. Which symptoms are indicative of amphetamine use? Select all that apply.

-Diaphoresis -Shallow respirations -Tremors - Dilated pupils Explanation: A client under the influence of amphetamines may present with euphoria, diaphoresis, shallow respirations, dilated pupils, dry mouth, anorexia, tachycardia, hypertension, hyperthermia, tremors, seizures, and altered mental status. Depressed affect and hypotension are not associated with amphetamine use.

A client with an intravenous line in place states having pain at the insertion site. Assessment of the site reveals a vein that is red, warm, and hard. Which actions would the nurse take? Select all that apply.

-Discontinue the infusion at the affected site. -Apply warm soaks to the intravenous site. -Document the assessment, nursing actions taken, and the client's response. Explanation: Redness, warmth, pain, and a hard, cordlike vein at the intravenous catheter insertion site suggest that the client has phlebitis. The nurse would discontinue the intravenous infusion and insert a new catheter proximal to or above the discontinued site or in the other arm. Applying warm soaks to the site reduces inflammation. The nurse would document the assessment of the intravenous. site, the actions taken, and client's response to the situation. Slowing the infusion rate would not reduce the phlebitis. Restarting the infusion at a site distal to the phlebitis may contribute to the inflammation. Skin sloughing is not a symptom of phlebitis; it is associated with extravasation of certain toxic medications.

During morning care, a nurse notes that a client who's had a spinal cord injury has experienced a change in level of consciousness and isn't answering questions appropriately. The nurse checks the client's vital signs and measures his blood pressure at 180/110 mm Hg and his heart rate at 125 beats/minute. She determines that the client may be experiencing dysreflexia. What other assessments should the nurse make? Select all that apply.

-Most recent bowel movement -Urine output -Pain level Explanation: The objective in treating a client with dysreflexia is to remove the triggering event and prevent complications. Common causes are distended bladder, constipation or impaction, skin stimulation, and pain. Percentage of meals taken isn't a priority assessment. Medications ordered for hypertension are of lesser priority than making assessments to identify the cause.

While undergoing treatment with a caustic chemotherapeutic agent, a client experiences extravasation. Indicate how the nurse would respond to extravasation by placing the following nursing interventions in chronological order. All options must be used.

-Discontinue the intravenous infusion. -Follow facility policy for dealing with extravasation. -Notify the physician. -Implement physician's orders. -Document all signs and symptoms thoroughly. -Monitor the client throughout the shift and give a detailed report to the oncoming shift. Explanation: Extravasation is the accidental administration of intravenous fluid into the extracellular space/tissue. Immediately, the intravenous infusion would be discontinued so that the client will not continue to receive more of the medication and damage the tissue. The facility will have a policy on how to deal with extravasation (usually the application of ice) that can be implemented while the physician is being notified. After the physician is notified, the specific orders will need to be implemented. All signs and symptoms that the client is experiencing would be documented thoroughly in preparation for the report to be given to the oncoming shift.

After having a lobectomy for lung cancer, a client receives a chest tube connected to a three-chamber chest drainage system. The nurse observes that the drainage system is functioning correctly when noting which of the following? Select all that apply.

-Fluctuations in the water-seal chamber occur when the client breathes. - Intermittent bubbling occurs in the water-seal chamber. - Gentle bubbling occurs in the suction control chamber. - Drainage is collecting in the drainage chamber. Explanation: Fluctuations in the water-seal compartment (or tidal movements) indicate normal function of the system as the pressure in the tubing changes with the client's respirations. There also should be intermittent bubbling in the water-seal chamber, indicating that air is being removed from the pleural cavity by the system. Gentle bubbling in the suction control chamber indicates that the proper suction level has been reached. Drainage is expected to collect in the drainage chamber after a lobectomy. Crepitus indicates that air is leaking into the subcutaneous tissues. The physician should be notified of this finding.

The nurse is preparing to care for a postoperative thyroidectomy client who has just returned to the unit after surgery. What are the most important nursing interventions for this client? Select all that apply.

-Have emergency tracheotomy set on hand -Check behind the neck for bleeding -Monitor voice quality regularly -Observe for sudden increase in temperature, respiratory distress, and tetany Explanation: Postoperative thyroidectomy clients may need humidified oxygen and should be placed in the semi-Fowler's position. Vital signs will need to be monitored for any changes, and the client should be observed for bleeding behind the neck under the dressing. It is important to observe for signs of respiratory distress and to have tracheotomy equipment on hand. Monitor voice quality for injury to vocal chords. If the client develops postoperative thyroid storm/crisis, the temperature could rise as high as 106° F (41.1° C), and tetany may develop if the parathyroid glands were injured or removed.

A client with chronic renal failure who receives hemodialysis three times a week is experiencing severe nausea. What should the nurse advise the client to do to manage the nausea? Select all that apply.

-Have limited amounts of fluids only when thirsty. -Keep all dialysis appointments. -Eat smaller, more frequent meals. Explanation: To manage nausea, the nurse can advise the client to drink limited amounts of fluid only when thirsty, eat food before drinking fluids to alleviate dry mouth, encourage strict follow-up for blood work, dialysis, and health care provider (HCP) visits. Smaller, more frequent meals may help to reduce nausea and facilitate medication taking. The client should be as active as possible to avoid immobilization because it increases bone demineralization. The client should also maintain the dialysis schedule because the dialysis will remove wastes that can contribute to nausea.

A nurse has witnessed an automobile accident. Which nursing interventions are best for a client with a suspected fracture at the scene of this accident? Select all that apply.

-Immobilize the extremity -Move the client to safety immediately Explanation: At the scene of an accident, a client with a suspected fracture should have the extremity immobilized and then be moved to safety. If the client is in a safe place, do not try to move him. Do not sit the client up, as this could make the fracture worse.

A nurse manager of the crisis access center of a psychiatric facility in a major city notices a sudden increase in the number of incoming calls one afternoon. After quickly surveying the call sheets, the nurse finds that most callers are very anxious after military aircraft flew very low over the city. Which strategies would be most appropriate in this situation? Select all that apply.

-Instruct the crisis workers to additionally screen callers about where they were during the 9/11/2001 attacks and their memories of that event. -Give the crisis workers a list of symptoms of posttraumatic stress disorder (PTSD) and techniques for dealing with these symptoms. Give the crisis workers a list of symptoms of posttraumatic stress disorder (PTSD) and techniques for dealing with these symptoms. -Ask for an emergency meeting with the managers of the inpatient and outpatient services to formulate a contingency plan for increased services if needed. -Ask the major media outlets in the city to make a scripted public service announcement about the possible recurrence of symptoms experienced after the events of 9/11/2001. -Prepare for a scripted interview with the local media about PTSD symptoms and techniques for dealing with these symptoms. Explanation: All of the options are correct and in an appropriate sequence of actions except for option 6. The flyover is likely to trigger vivid memories and emotions in those living near the city related to the tragedy of the Twin Towers on 9/11/2001. The severity of the flashbacks will vary in degree, just as they did after the original event. Asking the military for an apology will not address the caller's symptoms.

What nursing interventions should a nurse expect to implement when caring for a child in acute sickle cell crisis? Select all that apply.

-Maintaining adequate hydration - Providing adequate pain control -Frequently monitoring vital signs Explanation: Because the child is in acute crisis, providing adequate hydration, controlling pain, and carefully monitoring vital signs are priority points of care. When the child's condition has stabilized, the nurse may evaluate family learning needs, encourage healthful eating habits, and attend to play needs.

A nurse is screening participants at a health fair for cancer risk. Which of the following clients will the nurse refer for further evaluation? Select all that apply.

-Older adult male with a history of smoking -Older adult female who works as a toll collector -Middle-aged female with human papillomavirus (HPV) Explanation: Most head and neck cancers occur in people ages 50 and older with prolonged exposure to tobacco and alcohol. Inhalation of noxious fumes, infection with HPV, and a diet lacking fruits and vegetables are also contributing factors. Men are affected two to five times more often than women. Autoimmune disorders are not risk factors for laryngeal cancer.

A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who is caring for the client is teaching a graduate nurse about central venous catheter care. How often should the nurse instruct the graduate nurse to change the dressing? Select all that apply.

-Per hospital policy -When the dressing is becoming loose -When the dressing is soiled -When the site is reddened Explanation: Research demonstrates that central lines are a large infection risk for clients. The dressing must be clean, dry, and intact to be effective. Sterile dressing change is indicated when the dressing does not meet this criteria; otherwise it is changed per hospital policy.

The nurse is transferring an immobilized client. What is the best way for the nurse to maintain safety? Select all that apply.

-Place the feet apart to increase the stability of the body. -Ask for assistance from another staff member. Explanation: Placing the feet apart creates a wider base of support and brings the center of gravity closer to the ground. This improves stability. Asking for assistance will also reduce the risk of injury for the nurse. The other choices all place the nurse at risk for back injury.

A nurse is assessing a client for dementia. What history would the nurse expect to find in a client with dementia? Select all that apply.

-There's a slow progression of symptoms. -The family can't determine when the symptoms first appeared. -There are changes in the client's basic personality. - The client has great difficulty paying attention to others. Explanation: Common characteristics of dementia are a slow onset of symptoms, progressing to noticeable changes in the client's personality, and impaired ability to pay attention to other people. Feelings of sadness, apathy, and pessimism are symptoms of depression.

The nurse teaches appropriate care measures to the parents of a 5-year-old child who has been given trimethoprim/sulfamethoxazole for a urinary tract infection. What directives should be included in the teaching plan? Select all that apply.

-Use a sunscreen. - Keep medication out of the sunlight. -Keep the child well hydrated. Explanation: The child receiving trimethoprim/sulfamethoxazole should wear sunscreen daily while on the medication, and the medication must be kept out of direct sunlight. (It comes in a dark bottle.) Children with a urinary tract infection should drink lots of fluids to help flush the organisms from the bladder. The medication does need to be taken with milk or food. Trimethoprim/sulfamethoxazole has been associated with Steven-Johnson syndrome, so any rash requires prompt attention.

What instructions should the nurse give a client experiencing signs and symptoms related to decreased arterial insufficiency? Select all that apply.

-Use additional bed clothes at night. -Avoid smoking and exposure to the cold. -Take aspirin or clopidogrel as prescribed. Explanation: Smoking and exposure to the cold cause vasoconstriction and should be avoided. Aspirin and clopidogrel should be taken as prescribed for the antiplatelet properties. Using extra bed cloths at night provide warmth, which increases vasodilation. The presence of pain should be investigated as it could indicate increasing arterial insufficiency. Tight socks should be avoided as they could impair circulation.

A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed prior to administering anesthesia to the client to avoid wrong-site surgery? Select all that apply.

-Verify that the surgeon has marked with a permanent marker the correct knee for the surgical site. -Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision. -Verify the correct client with the correct operative site from medical records and diagnostic reports. - Verbally ask the client to state his or her name, surgical site, and procedure .Explanation: The root cause of wrong-site surgery involves a breakdown in communication between the client and family and the health care team. Information retrieved from the client in the preoperative assessment, such as the client's name, surgical site, and procedure, should be verbally assessed and verified with medical records and radiographic diagnostic reports. This information should be compiled in a checklist that the intraoperative team can recheck, thus avoiding unnecessary distraction and delay in the operating room. The nurse in the operating room is responsible for calling a "time out" so that every surgical team member can double-check the correct site of surgery, verify the site using the operative consent form, and verify that the surgeon has marked the operative site on the client. Showing the client an anatomic model will assist the client in understanding the location of the surgery, but it will not prevent anyone from identifying the wrong site on the client.

The nurse is caring for a client, newly diagnosed with cancer, who speaks limited English. The client's family speaks limited English also and a friend drives him to his doctor's appointments. The nurse selects Deficient knowledge as a priority. Which nursing interventions are appropriate? Select all that apply.

-Work with an interpreter to discuss the situation. -Assess any community resources for support groups and communication -Obtain a "type to speak" computerized translation dictionary to express information -Obtain common pictures to provide a common ground for understanding Explanation: It is very difficult to discuss specific cancer treatments and options when there is a language barrier. Clients have a difficult time with medical terminology associated with diagnosis and treatment. To improve the knowledge base, it is best to have an interpreter, with medical background if possible, become part of the health care team. Most agencies ask all health care workers if they speak another language and then will pull on this group as needed. It is not appropriate to have the client's driver interpret unless this is approved by the client. Also, the health care providers are unsure if the driver understands the information to translate. Community resources can be helpful as well as a pictorial guide or "type to speak" dictionary. Brochures are not helpful unless the client understands the information provided.

A nurse is completing an admission assessment with an adult client in a long-term care facility. What are important nursing actions to provide fall safety for the client with dementia in a long-term care facility? Select all that apply.

-complete the fall risk plan of care -identify the client as a high risk for falls - establish a toileting program

The client states to the nurse, "I take citalopram 40 mg every day as my health care provider prescribed. I have also been taking St. John's wort 750 mg daily for the past 2 weeks." Which findings would indicate that the client is developing serotonin syndrome? Select all that apply.

-confusion -restlessness -diaphoresis -ataxia Explanation: Serotonin syndrome can occur if a selective serotonin reuptake inhibitor is combined with a monoamine oxidase inhibitor, a tryptophan-serotonin precursor, or St. John's wort. Signs and symptoms of serotonin syndrome include mental status changes (such as confusion, restlessness, or agitation) headache, diaphoresis, ataxia, myoclonus, shivering, tremor, diarrhea, nausea, abdominal cramps, and hyperreflexia. Constipation is not associated with serotonin syndrome.

Which finding should the nurse expect to assess as normal skin changes in an elderly client? Select all that apply.

-diminished hair on scalp and pubic areas -solar lentigo - wrinkles - xerosis Explanation: Skin changes associated with aging include the following: diminished hair on scalp and pubic areas, solar lentigo (liver spots), wrinkles, and xerosis (dryness). Dusky rubor of the left lower extremity may indicate the individual has a venous stasis problem in the affected extremity and is generally associated with "unsuccessful aging." Yellow pigmentation of the skin that may be associated with liver inflammation is generally known as jaundice.

A client asks why she feels so much variability in fetal activity each day. The nurse explains that fetal movement is affected by which factors? Select all that apply.

-fetal sleep - blood glucose - time of day -cigarette smoking Explanation: The fetus does go through sleep cycles, rendering it less likely to move while it is asleep. Blood glucose does cross the placenta and can affect fetal movement. Cigarette smoking causes carbon monoxide to cross the placenta, which reduces fetal oxygen. Pregnant women are more likely to notice fetal movement while they are sitting or lying down, and time of day often determines this. Most pregnant women notice fetal movement in the evening. Barometric pressure does not affect fetal activity in utero.

There has been an increase in medication errors and errors in prescribing laboratory studies in the emergency department. The nurse manager is conducting a staff education session on when to use "read-back" procedures. "Read-back" procedures should be performed in which situations? Select all that apply.

-when a medication prescription or critical laboratory result is received verbally or over the telephone - when any verbal or phone prescription is received Explanation: A goal of client safety is to improve the effectiveness of communication among caregivers. For verbal or telephone prescriptions, or for telephone reporting of critical test results, one must verify the complete prescription or test result by having the individual receiving the information record "read-back" the complete prescription or test result. The unit secretary is not a licensed health care professional who has a Scope of Practice or the authority to receive prescriptions or results. The type of charting system used by the health care agency is not a factor in using "read-back" prescriptions.

The health care provider writes an order that a client may have 12 ounces of clear liquids at each meal and may supplement this with an additional 10 ounces at each shift (7-3, 3-11, and 11-7). How many milliliters would the nurse document for the day shift (7-3) if the client took in all of the ordered volumes? Record your answer using a whole number.

1020 Explanation: The nurse must add all the volumes together, knowing that 1 ounce equals 30 milliliters. There are two meals in the day shift (7-3). 12 oz x 30 ml = 360 ml; 360 ml x 2 meals = 720 ml; 10 oz. (supplement) x 30 ml = 300 ml; 720 ml + 300 ml = 1020 ml

The neonate has a prescribed IV rate of 8 mL/h. Fluid totals are recorded every 2 hours on the even hours. There is a new prescription written at 1030 to decrease the IV rate to 6 mL/h. What is the fluid total to be infused and recorded at 1200? Record your answer using a whole number.

13 Explanation: 1000 to 1030 = 4 mL (hourly rate 8), 1030 to 1100 = 3 mL (hourly rate 6 mL), 1100 to 1200 = 6 mL (hourly rate 6 mL). 4 + 3 + 6 = 13.

What important assessment data will help the nurse ensure accurate fluid replacement for a client with burns?

Age, weight, vital signs, and tissue turgor Explanation: Considering the client's physiologic status by age and weight is important in determining the fluid requirements. Assessing the amount of damage to skin and mucus membranes is also important because fluid will extravasate into the burned tissue. Monitoring vital signs and tissue turgor levels will also help indicate how the client's body is compensating. The remaining answers are secondary in importance to ensuring airway patency.

When providing health teaching to a primigravid client, the nurse tells the client that she's likely to experience Braxton Hicks contractions. When does a client typically start to feel these contractions?

Between 23 and 27 weeks' gestation Explanation: Pregnant clients typically start to feel Braxton Hicks contractions between 23 and 27 weeks' gestation. Fetal rebound is possible between 18 and 22 weeks. The fetal outline becomes palpable and the fetus is highly mobile between 28 and 31 weeks. Braxton Hicks contractions increase in frequency and intensity between 32 and 35 weeks.

The emergency nurse is performing an assessment on a client who experienced second and third degree burns of the arms and hands from a kitchen grease fire. Which assessment should be performed first?

Blood pressure and heart rate Explanation: When a client is burned, breathing should be the first concern if the client may have experienced an inhalation injury. Since this client did not, circulation and perfusion become the greatest concern which are assessed with blood pressure and heart rate. Skin assessment of the burns is important after circulation is stabilized. Information about the detail of the incident are not a priority.

When developing the plan of care for an infant diagnosed with myelomeningocele and the parents who have just been informed of the infant's diagnosis, which action should the nurse include as the priority when the parents visit the infant for the first time?

Emphasize the infant's normal and positive features. Explanation: The parents should see the neonate as soon as possible, because the longer they must wait to see the neonate, the more anxiety they will feel. Because the parents are acutely aware of the deficit, the nurse should emphasize the neonate's normal and positive features during the visit. All parents, but especially those with a child who has a disability or defect, need to hear positive comments and comments that reflect how the infant is normal. Although the parents need to discuss their fears and concerns, the priority on the first visit is to emphasize the neonate's normal and positive features. Reinforcing the HCP's explanation of the defect may be necessary later. Reinforcing the explanation at this initial visit emphasizes the defect, not the child. The parents should spend time with or care for the neonate after birth because parent-infant contact is necessary for attachment. The parents cannot feed the neonate before the defect is repaired because the repair typically occurs within 24 hours. The infant will be prone in an isolette or warmed and watched closely. However, the parents can fondle and stroke the neonate.

The nurse is caring for a 4-year-old child who is admitted for minor elective surgery. The child is frightened and anxious. Which of the following interventions would be most appropriate for the nurse to take to help the child?

Encourage parental reinforcement. Explanation: Positive parental reinforcement has the greatest impact on a child and provides reassurance and comfort to face potentially frightening experiences. The other options will not have this impact.

A client is undergoing a bone marrow aspiration and biopsy. What is the best way for the nurse to help the client and two upset family members handle anxiety during the procedure?

Encourage the client to take slow, deep breaths to relax. Explanation: Encouraging the client to take slow, deep breaths during uncomfortable parts of procedures is the best method of decreasing the stress response of tightening and tensing the muscles. Slow, deep breathing affects the level of carbon dioxide in the brain to increase the client's sense of well-being. Allowing the client's family to stay may be appropriate if the family has a calming effect on the client, but this family is upset and may contribute to the client's stress. Silence can be therapeutic, but when the client is faced with a potentially life-threatening diagnosis and a new, invasive procedure, taking deep breaths will be more effective in reducing the stress response. Expressing feelings is important, but deep breathing will promote relaxation; the nurse can encourage the client to express feelings when the procedure is completed.

A client presents in the emergency department with symptoms of cough, headache, and generalized aches and pains. Upon assessment, the nurse documents a temperature of 101.5° F (38.6° C) and a red, irritating rash on the arms, legs, and upper chest. She also notes that the client takes eight different medications each day. What nursing diagnosis is the priority for this client?

Impaired tissue integrity Explanation: The client is showing signs of Stevens-Johnson Syndrome (SJS), which is triggered by a reaction to medications. Signs and symptoms of SJS include conjunctival burning, fever, cough, sore throat, headache, aches and pains, and erythema and mucous membranes. As the disease progresses, large portions of the epidermis are shed, exposing the dermis and causing tender skin and a weeping surface. Keeping the tissue intact is the main priority for this client. Although Impaired physical mobility, Impaired thermoregulation, and Ineffective therapeutic regimen management apply to this client, these nursing diagnoses are lower priorities than Impaired tissue integrity.

At the health clinic, a sexually active 15-year-old girl tells a nurse she is worried that her parents may find out about her sexual activity. "They would never approve," she says. Which nursing diagnoses should the nurse formulate?

Ineffective sexuality patterns related to parent expectations Explanation: This girl is expressing concerns about the conflict between her parents' expectations and her own desires. Sexual activity is a normal experimental pattern for many adolescents, but she verbalizes that she is worried and anxious regarding parental expectations against this behavior. Sexual activity does not suggest a delay in growth and development, the expression of fear, or problems with social interactions.

Eight farm workers are admitted to the emergency department after they were splashed with "a couple of chemicals" at work 30 minutes ago. They have watery/itchy eyes, slight cough, diaphoresis, constricted pupils, and are conscious and oriented. Their clothes are wet. What action should the nurse do first?

Isolate the clients. Explanation: Safety of the staff and others is the first priority. Isolating reduces the chance of contaminating others (secondary contamination). Vital signs can be obtained when it is safe—after protecting staff, clients, and visitors from secondary contamination. Oxygen is not indicated for any of the listed symptoms. Removing clothing is important to prevent further exposure to the client, but must be done in a safe manner to prevent secondary contamination to others. The clients can remove their own clothes and place them in plastic bags. After the safety of the staff and others is addressed, and the facility is prepared and properly trained staff is ready, the clients can be given a decontamination shower. If the staff is not trained, 911 may be the most appropriate response. Finding out which chemicals were involved is important, but does not take priority over preventing secondary contamination.

A client with chronic obstructive pulmonary disease (COPD) takes theophylline, 200 mg P.O. twice per day. During a routine clinic visit, the client asks the nurse how the drug works. What is the mechanism of action of theophylline in treating a nonreversible obstructive airway disease such as COPD?

It makes the central respiratory center more sensitive to carbon dioxide and stimulates the respiratory drive. Explanation: Theophylline and other methylxanthine agents make the central respiratory center more sensitive to carbon dioxide and stimulate the respiratory drive. Inhibition of phosphodiesterase is the drug's mechanism of action in treating asthma and other reversible obstructive airway diseases — not COPD. Methylxanthine agents inhibit rather than stimulate adenosine receptors. Although these agents reduce diaphragmatic fatigue in clients with chronic bronchitis or emphysema, they don't alter diaphragm movement to increase chest expansion and enhance gas exchange.

A client seeks medical attention after developing acute abdominal pain. Which action by the nurse helps ensure accurate auscultation of the client's bowel sounds?

Making sure the client's bladder is empty before auscultating Explanation: The nurse should make sure the client's bladder is empty before auscultating, because a full bladder may interfere with bowel sounds. To auscultate bowel sounds, the nurse uses the diaphragm of the stethoscope. (The nurse uses the bell to auscultate vascular sounds.) To confirm absence of bowel sounds, the nurse must listen in each quadrant for 1 minute. The nurse should press the stethoscope lightly, not deeply, on the abdominal wall in all four quadrants.

A physician orders an intestinal tube to decompress a client's GI tract. When gathering equipment for this procedure, a nurse should obtain a:

Miller-Abbott tube. Explanation: A Miller-Abbott tube is an intestinal tube. A Sengstaken-Blakemore tube is an esophageal tube. Levin tubes and Salem sump tubes are nasogastric tubes.

The treatment team plans to place a client in full leather restraints. What is the best care for this client?

Remove the leather restraints every 10-15 minutes Explanation: The nurse must check the client's circulation every 10 to 15 minutes because blood vessel damage, as well as skin and nerve damage, can occur within 15 minutes. Checking every 30 or 60 minutes is not often enough and could result in permanent damage to the client's extremities. Range-of-motion exercises should be performed every 2 hours.

A client who's 12 weeks pregnant is complaining of severe left lower quadrant pain and vaginal spotting. She is admitted for treatment of an ectopic pregnancy. The nurse should give the highest priority to which nursing diagnosis?

Risk for deficient fluid volume Explanation: A ruptured ectopic pregnancy is a medical emergency because of the large quantity of blood that may be lost in the pelvic and abdominal cavities. Shock may develop from blood loss, and large quantities of I.V. fluids are needed to restore intravascular volume until the bleeding is surgically controlled. Although the other nursing diagnoses are relevant for a woman with an ectopic pregnancy, fluid volume loss through hemorrhage is the greatest threat to her physiological integrity and must be stopped. Anxiety may result from such factors as the risk of dying and the fear of future infertility. Pain may be caused by a ruptured or distended fallopian tube or blood in the peritoneal cavity. Impaired gas exchange may result from the loss of oxygen-carrying hemoglobin through blood loss.

What should the nurse teach a client receiving vitamin D therapy for hypoparathyroidism?

Vitamin D is taken to increase absorption of calcium. Explanation: A client with hypoparathyroidism has a decreased serum calcium level. Variable doses of vitamin D preparations enhance the absorption of calcium from the gastrointestinal tract. This does not cure the client's hypoparathyroidism. Vitamins A, C, and E are not involved with this process. Vitamin D therapy will not assist in stabilizing potassium.

An emergency department nurse is caring for a child diagnosed with moderately severe croup. The nebulizer treatment of choice for a child with moderate to severe croup is:

epinephrine. Explanation: Nebulized epinephrine is an adrenergic that reduces inflammation and edema of the tissue surrounding the trachea in a client with croup. Albuterol, metaproterenol, and other beta2-adrenergic drugs are used to treat asthma. Ipratropium is an anticholinergic used to treat severe asthma. Budesonide is a corticosteriod inhaler that is recommended for children with mild to moderate croup. However, in moderate to severe group, it is preferred that the corticosteriod is given orally.

After having surgery to reduce the invagination of intussusception, an infant has a nasogastric tube in place, is receiving IV fluids, and is allowed nothing by mouth. In addition to body weight, what parameter is most important to use to calculate the amount of IV fluid and electrolyte solution to infuse over the next 24 hours?

gastric output Explanation: The volume of parenteral fluids needed is based on fluid requirements determined according to body weight and, in this situation, gastric output. If these fluids are not replaced with an appropriate IV solution, serious fluid and electrolyte imbalances could develop. Although stool output, urine output, and temperature are monitored, they are not used to calculate maintenance and replacement needs.

The nurse is inspecting the client's abdomen (see the accompanying image). The nurse should document that the client's abdomen:

is flat and symmetrical. Explanation: The client's abdomen is flat and without abnormalities. There is no aortic pulsation (motion is client's breathing). There is no hernia; the umbilicus is normal. There are no markings or lines (striae) on this client's abdomen.

A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed?

laxative Explanation: After a barium enema, a laxative is ordinarily prescribed. This is done to promote elimination of the barium. Retained barium predisposes the client to constipation and fecal impaction. Anticholinergic drugs decrease gastrointestinal motility. Antacids decrease gastric acid secretion. Demulcents soothe mucous membranes of the gastrointestinal tract and are used to treat diarrhea.

Assessment of a 2-day-old neonate born at 34 weeks' gestation reveals absent apical pulse left of the midclavicular line, cyanosis, grunting, and diminished breath sounds. The priority intervention is to:

obtain a prescription for a stat chest x-ray. Explanation: With an absent apical pulse left of the midclavicular line accompanied by cyanosis, grunting, and diminished breath sounds, the neonate is most likely experiencing pneumothorax. Pneumothorax occurs when alveoli are overdistended and subsequently the lung collapses, compressing the heart and lung and compromising the venous return to the right side of the heart. This condition can be confirmed by x-ray. An echocardiogram would be indicated if the chest x-ray did not reveal a respiratory cause for the problem or suggested a cardiac problem. Repositioning the infant may open the airway, and obtaining blood studies for infection will rule that out, but until pneumothorax is resolved, the other symptoms will continue.

During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When developing the client's plan of care, which problem should the nurse expect to assess for frequently?

uterine atony Uterine atony is more common in clients who have received oxytocin during labor because the uterine muscle becomes fatigued and does not contract effectively to compress the vessels at the placental site. Respiratory depression, not typically associated with oxytocin induction, may occur with narcotic overdose or excessive magnesium sulfate administration. Increased pulse rate and hypertension are not typically associated with oxytocin induction during labor.

The nurse is performing a complete neurological assessment on an older adult client. Which question by the nurse would best assess cerebral function?

"Have you noticed a change in your memory?" Explanation: To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, memory, and other aspects of mental status. Questions about muscle strength help evaluate the client's motor system. Questions about coordination help her assess cerebellar function. Questions about eyesight help the nurse evaluate the cranial nerves associated with vision.

The client asks the nurse if surgery is needed to correct a hiatal hernia. Which reply by the nurse would be most accurate?

"Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes." Explanation: Most clients can be treated successfully with a combination of diet restrictions, medications, weight control, and lifestyle modifications. Surgery to correct a hiatal hernia, which commonly produces complications, is performed only when medical therapy fails to control the symptoms.

A day-shift nurse on the pediatric neurologic unit has just received a report from the previous shift. Which infant should the nurse assess first?

A restless infant with a high-pitched cry who was transferred from the intensive care unit (ICU) the previous evening Explanation: An infant's restlessness and high-pitched cry can indicate increased intracranial pressure (ICP). Because the infant was transferred from the ICU the previous night, assessing for increased ICP should be a nursing priority. The infant with a pulse of 140-160 bpm exhibits normal parameters. Although the nurse must assess a low-grade fever on the third postoperative day, this stable infant isn't the priority at this time. Decreased respirations are indicative of increased intracranial pressure, but this infant's respirations of 38 breaths per minute would not be a priority concern.

A health care provider is legally and ethically required to disclose certain information. Which confidential information should the nurse disclose?

A taxi driver's diagnosis of an uncontrolled seizure disorder to his licensing agency Explanation: The health care provider may lawfully disclose confidential information about a client when the welfare of others is at stake. The health care provider is required to inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder because it's in the best interest of the public's and client's safety. Confidentiality of HIV testing is required. Disclosing a client's cancer diagnosis to a significant other or pregnancy to a legally separated partner do not affect the welfare of person.

A nurse is teaching a client with left leg weakness to walk with a cane. The nurse should instruct the client to proceed in which manner?

Hold the cane in the right hand. Explanation: To ambulate safely, a client with a leg weakness should hold the cane in the hand opposite the weak leg 4 to 6 inches (10 to 15 cm) from the base of the little toe. Therefore, this client should hold the cane in his right hand. The client should hold the cane close to his body to prevent leaning and he should move the cane and the involved leg (left, in this case) simultaneously, and then move the uninvolved leg.

The nurse instructs the unlicensed assistive personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which technique should the nurse ask the UAP to incorporate into the client's daily care?

Use a soft toothbrush to brush the client's teeth after each meal. Explanation: A soft toothbrush should be used to brush the client's teeth after every meal and more often as needed. Mechanical cleaning is necessary to maintain oral health, stimulate gingiva, and remove plaque. Assessing the oral cavity and recording observations is the responsibility of the nurse, not the UAP. Swabbing with a safe foam applicator does not provide enough friction to clean the mouth. Mouthwash can be a drying irritant and is not recommended for frequent use.

When preparing discharge instructions for a client after an abdominal hysterectomy, the nurse should first:

assess the client's available social supports. Explanation: Assessment is the first step in planning client education. Assessing social support resources is a key aspect of discharge planning that begins when the client is admitted to the hospital. It is imperative to know what assistance and support the client has at home. Assessment includes obtaining data about any family or home responsibilities the client is concerned with during the recovery period. It is within the scope of nursing practice to provide discharge instructions. A social worker is not needed at this time. The nurse should assess the client's needs before determining whether using a video or reading instructions to the client is appropriate.

The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to:

eat a diet high in protein and vitamins C and D. Explanation: The goal of care for this client is healing and tissue growth while the client continues on long-term antibiotic therapy to clear the infection. A diet high in protein and vitamins C and D promotes healing. Herbal supplements may potentiate bleeding (e.g., ginkgo, ginger, tumeric, chamomile, kelp, horse chestnut, garlic, and dong quai) and have not been proven through research to promote healing. Frequent passive motion will increase circulation but may also aggravate localized bone pain. It is not appropriate to advise the client to change antibiotics as treatment may take time.

Which night clothes would the nurse recommend for an infant with atopic dermatitis?

one-piece cotton pajamas with long sleeves Explanation: Atopic dermatitis results in pruritus. The infant's skin should be covered as completely as possible to keep him from scratching himself. Cotton is the preferred material because it allows the skin to breathe and moisture to evaporate.A short-sleeved shirt would be inappropriate because the infant could scratch the uncovered arms, exacerbating the condition. Flannel may be too warm, causing the child to perspire, which will aggravate the condition. Because atopic dermatitis is commonly associated with allergies, wool garments should be avoided.

While assessing a preschooler brought by her parents to the emergency department after ingestion of kerosene, the nurse should be alert for which complication?

pneumonitis Explanation: Chemical pneumonitis is the most common complication of ingestion of hydrocarbons, such as in kerosene. The pneumonitis is caused by irritation from the hydrocarbons aspirated into the lungs. Uremia is the result of renal insufficiency, which causes nitrogenous waste products to build up in the blood rather than being excreted. Hepatitis is caused by a viral infection. Carditis in a preschooler may be the result of rheumatic fever.

A 38-year-old client at about 14 weeks' gestation is admitted to the hospital with a diagnosis of complete hydatidiform mole. Soon after admission, the nurse would assess the client for signs and symptoms of which signs and symptoms?

pregnancy-induced hypertension Explanation: Hydatidiform mole is suspected when the following are present: gestational hypertension before the 24th week of gestation, brownish or prune-colored vaginal bleeding, anemia, absence of fetal heart tones, passage of hydropic vessels, uterine enlargement greater than expected for gestational age, and increased human chorionic gonadotropin levels. Gestational diabetes is related to an increased risk of preeclampsia and urinary tract infections, but it is not associated with hydatidiform mole. Hyperthyroidism, not hypothyroidism, occurs occasionally with hydatidiform mole. If it does occur, it can be a serious complication, possibly life-threatening to the mother and fetus from cardiac problems. Polycythemia is not associated with hydatidiform mole. Rather, anemia from blood loss is associated with molar pregnancies.

A client who is very depressed exhibits psychomotor retardation, a flat affect, and apathy. The nurse observes the client to be in need of grooming and hygiene. Which nursing action is most appropriate?

stating to the client that it is time for him to take a shower Explanation: The client with depression is preoccupied, has decreased energy, and cannot make decisions, even simple ones. Therefore, the nurse presents the situation, "It is time for a shower," and assists the client with personal hygiene to preserve his dignity and self-esteem. Explaining the importance of good hygiene to the client is inappropriate because the client may know the benefits of hygiene but is too fatigued and preoccupied to pay attention to self-care. Asking the client if he is ready for a shower is not helpful because the client with depression commonly cannot make even simple decisions. This action also reinforces the client's feeling about not caring about showering. Waiting for the family to visit to help with the client's hygiene is inappropriate and irresponsible on the part of the nurse. The nurse is responsible for making basic decisions for the client until the client can make decisions for himself.