NCLEX Practice Questions

Esophageal Stricture

a significant narrowing of the esophagus that may significantly interfere with swallowing

Why would someone need a thyroidectomy?

- Hyperthyroidism - Thyroid nodules - Respiratory obstruction caused by goiter - Thyroid cancer - Thyroid lymphoma

Possible causes of metabolic alkalosis (HCO3 retention, acid loss)?

- pH > 7.45 - HCO3- > 26 - PaCO2 > 45 - Loss of hydrochloric acid from prolonged vomiting or gastric suctioning - Loss of potassium due to increased renal excretion (as in diuretic therapy) or steroid overdose. - Excessive alkali ingestion - Compensation for chronic respiratory acidosis

What is the highest priority action by the nurse before administering a bolus tube feeding?

Assessing stomach residual. The picture provided is of a nurse administering a bolus tube feeding. Prior to administration, the highest priority would be to assess tube patency and stomach residual. Both can be accomplished by checking stomach residual. The client is placed in a Fowler's position for feeding, not supine. It is common to flush the tube after patency and residual are assessed. Bowel sounds are assessed as part of a routine assessment.

Tracheoesophageal fistula (TEF)

Congenital defect resulting in a connection between the esophagus and trachea. Can also result from blunt trauma or injuries to the neck & thorax or from prolonged endotracheal intubation with a cuffed tube. TEF is a life-threatening condition that requires immediate intervention. Because the patient may aspirate saliva and gastric secretions into the lungs through the abnormal opening in the trachea, normal swallowing and digestion of food can't occur.

What is Dexamethasone used for?

Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This action reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring. Dexamethasone and other anti-inflammatory agents don't inhibit the action of carbonic anhydrase or produce any type of miotic reaction.

Normal results of an arterial blood gas (ABG)

- PaO2 levels of 80 to 100 mm Hg (SI, 10.6 to 13.3 kPa). - PaCO2 levels of 35 to 45 mm Hg (SI, 4.7 to 5.3 kPa). - pH levels of 7.35 to 7.45 (SI, 7.35 to 7.45). - O2CT levels of 15% to 23% (SI, 0.15 to 0.23). - SaO2 levels of 94% to 100% (SI, 0.94 to 1). - HCO3− levels of 22 to 25 mEq/L (SI, 22 to 25 mmol/L).

Possible causes of metabolic acidosis (HCO3 loss, acid retention)?

- pH < 7.45 - HCO3- < 22 - PaCO2 < 35 - HCO3 depletion due to renal disease, diarrhea, or small-bowel fistulas - Excessive production of organic acids due to hepatic disease; endocrine disorders, including diabetes mellitus, hypoxia, shock; and drug intoxication. - Inadequate excretion of acids due to renal disease

Possible causes of respiratory alkalosis (excess CO2 excretion)?

- pH > 7.45 - HCO3- < 22 - PaCO2 < 35 - Hyperventilation due to anxiety, pain, or improper ventilator settings - Respiratory stimulation caused by drugs, disease, hypoxia, fever, or high room temperature. - Gram-negative bacteremia - Compensation for metabolic acidosis (chronic renal failure)

What is the adequate urine output for a child over 1 years old?

1mL/kg/h

A client with deep vein thrombosis has an I.V. infusion of heparin infusing at 1,500 units/hour. The concentration in the bag is 25,000 units/500 ml. How many milliliters of solution should the nurse document as intake from this infusion for an 8-hour shift? Record your answer using a whole number.

240 mL First, calculate how many units are in each milliliter of the medication: 25,000 units/500 ml = 50 units/ml Next, calculate how many milliliters the client receives each hour: 1 ml/50 units × 1,500 units/hour = 30 ml/hour Lastly, multiply by 8 hours: 30 ml/hour × 8 hours = 240 ml

An infusion of lidocaine hydrochloride is running at 30 mL/hour. The dilution is 1,000 mg/250 mL. What dosage is the client receiving per minute? Record your answer using a whole number.

2mg/min First, calculate the concentration of mg/mL: 1,000 mg divided by 250 mL equals 4mg/mL. Next, multiply the number of milligrams per milliliter by the pump setting in milliliters per hour: 4 mg/mL x 30 mL/h = 120 mg/h. Next, divide the milligrams per hour by 60 to obtain milligrams per minute: 120 mg/h divided by 60 min/h equals 2 mg/min.

A nurse has an order to start magnesium sulfate on a preterm labor client. The order reads: Give a 4-g bolus over 15 minutes, then decrease the rate to 2g/hour. The nurse has 50 g of magnesium sulfate mixed in 1000 mL of lactated Ringer's on hand. What is the rate the nurse will set the pump to deliver the 2g maintenance dose? Record your answer using a whole number.

40 mL/hr (2 g)/(1 hour) × 1000 mL/50 g = 2000/50 = 40 mL/hour

A child weighing 44 lb (20 kg) is to receive 45 mg/kg/day of penicillin V potassium oral suspension in 4 divided doses for every 6 hours. The suspension that is available is penicillin V potassium 125 mg/5 ml. How many milliliters would the nurse administer for each dose? Record your answer using a whole number.

9mL. First, convert the child's weight to kilograms (if not already done): 44 lb ÷ 2.2 lb/kg = 20 kg. Next, determine the daily dose: 45 mg/1 kg = X/20 kg X = 45 mg/kg X 20 kg = 900 mg. Then, determine the dose to administer every 6 hours (four doses): 900 mg ÷ 4 = 225 mg. Finally, determine the volume to be given at each dose: 125 mg/5 ml = 225 mg/X. X = (225 mg X 5 ml) ÷ 125 mg = 9 ml.

Abdominal Aortic Aneurysm (AAA)

A rapidly fatal condition in which the walls of the aorta in the abdomen weaken and blood leaks into the layers of the vessel, causing it to bulge. Pain in the abdomen and back signifies that the aneurysm is pressing downward on the lumbar nerve root.

Meniere's Disease

Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears). Many clients are able to identify an incipient attack of Ménière's disease by a feeling of fullness in the ear that reflects the evolving congestion. Nausea may result after this classic symptom occurs.

Adrenal Crisis (Addisonian crisis or adrenal hypofunction)

Acute critical deficiency of mineralocorticoids and glucocorticoids generally following acute stress, sepsis, trauma, surgery, or the omission of steroid therapy in patients who have chronic adrenal insufficiency; a medical emergency that needs immediate, vigorous treatment. Diet: small, frequent meals. High-sodium, high-protein, low-potassium

Hemophilia

An X-linked recessive disorder in which blood fails to clot properly, leading to excessive bleeding if injured. Insufficient amounts of thrombin are generated by the factor IX (Hemophilia B) and VIII (Hemophilia A) complex in the intrinsic coagulation pathway. Advise patients to avoid aspirin and other OTC anti-inflammatory drugs.

A client is receiving a bowel preparation of magnesium citrate the evening before a scheduled colonoscopy. Which factor should the nurse consider when providing care for this client? A. Antidiarrheal medication should be given if the client has more than two loose stools. B. Eating large meals should be encouraged to prevent weight loss. C. The client may require fluid and electrolyte replacement. D. Side rails should be raised at all times.

C. Bowel preparation, which usually involves laxatives and sometimes enemas, may cause severe fluid and electrolyte loss. The nurse should monitor the client for dehydration and electrolyte loss. Diarrhea is expected after bowel preparation and shouldn't be treated. Most clients eat a light meal the evening before the procedure or are ordered a clear liquid diet. Raising the side rails may increase the risk of fall for a client with frequent diarrhea.

What is the RAAS System and what does it do?

Renin Angiotensin Aldosterone System. Renin is produced by the kidneys in response to impaired blood flow & tissue perfusion, and converts angiotensinogen in the blood to angiotensin I; ACE converts angiotensin I to angiotensin II in the lungs. Angiotensin II then vasoconstricts and stimulates the release of aldosterone. Aldosterone then promotes Na and water retention as well as K excretion.

Hyperthyroidism

Excess thyroid hormone increases the metabolic rate, leading to increased heat production & cardiac activity. Most commonly caused by Graves disease (an autoimmune disease).

Failure to Thrive (FTT)

Nonspecific clinical syndrome of weight loss (more than 5%), decreased appetite and poor nutrition, and inactivity commonly accompanied by dehydration, depression, immune dysfunction, and low cholesterol. Usually the result of physical frailty, cognitive impairment, and functional disability

Which topic is most important to include in the teaching plan for a client newly diagnosed with Addison's disease who will be taking corticosteroids? a. the importance of watching for signs of hyperglycemia b. the need to adjust the steroid dose based on dietary intake and exercise c. To notify the health care provider (HCP) when the blood pressure is suddenly high d. how to decrease the dose of the corticosteroids when the client experiences stress

Since Addison's disease can be life threatening, treatment often begins with administration of corticosteroids. Corticosteroids, such as prednisone, may be taken orally or intravenously, depending on the client. A serious adverse effect of corticosteroids is hyperglycemia. Clients do not adjust their steroid dose based on dietary intake and exercise; insulin is adjusted based on diet and exercise. Addisonian crisis can occur secondary to hypoadrenocorticism, resulting in a crisis situation of acute hypotension, not increased blood pressure. Addison's disease is a disease of inadequate adrenal hormone, and therefore the client will have inadequate response to stress. If the client takes more medication than prescribed, there can be a potential increase in potassium depletion, fluid retention, and hyperglycemia. Taking less medication than was prescribed can trigger Addisonian crisis state, which is a medical emergency manifested by signs of shock.

What age does the posterior fontanel close by? Anterior fontanel? Sagittal suture? Frontal suture?

The posterior fontanel should be closed by age 2 months. The anterior fontanel and sagittal and frontal sutures should be closed by age 18 months.

Early this morning, a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?

Thyroid Crisis

Thyroid crisis or "Thyroid Storm"

Usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyperthyroidism, such as high fever, tachycardia, extreme restlessness, cardiac arrhythmias, hypotension, agitation, anxiety, delirium, psychosis, stupor, coma, severe nausea, vomiting, diarrhea, & abdominal pain.

The nurse instructs a client with coronary artery disease in the proper use of nitroglycerin. The client has had 2 previous episodes of coronary artery disease. At the onset of chest pain, what should the client do? a. Call 911 when three nitroglycerin tablets taken every 5 minutes are not effective. b. Call 911 when five nitroglycerin tablets taken every 5 minutes are not effective. c. Take one tablet and then immediately call 911. d. Go to the emergency department if two nitroglycerin tablets taken 5 minutes apart are not effective.

a.

A nurse is caring for a 3-year-old child admitted to the pediatric unit with acetaminophen poisoning. The nurse administers acetylcysteine every 4 hours for 72 hours. Which laboratory findings confirm the effectiveness of the drug therapy? a. alanine aminotransferase and aspartate aminotransferase b. creatine kinase-MB c. blood urea nitrogen and serum creatinine d. complete blood count

a. Acetaminophen poisoning causes liver damage, raising the liver enzymes alanine aminotransferase and aspartate aminotransferase. Creatine kinase-MB levels are elevated with heart muscle damage and aren't associated with acetaminophen poisoning. Blood urea nitrogen and serum creatinine levels provide information on renal function and aren't indicators of effectiveness of drug therapy in acetaminophen poisoning. A complete blood count won't give the nurse information on the effectiveness of therapy.

A nurse must apply an elastic bandage to a client's ankle and calf. The nurse should apply the bandage beginning at the client's a. lower foot. b. ankle. c. lower thigh. d. knee.

a. An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee will not promote venous return.

Which statement indicates that the client with diabetes insipidus understands how to manage care? The client will: a. maintain normal fluid and electrolyte balance. b. select a diabetic diet correctly. c. state dietary restrictions. d. exhibit serum glucose level within normal range.

a. Because diabetes insipidus involves excretion of large amounts of fluid, maintaining normal fluid and electrolyte balance is a priority for this client. Special dietary programs or restrictions are not indicated in treatment of diabetes insipidus. Serum glucose levels are priorities in diabetes mellitus but not in diabetes insipidus. Diabetes mellitus is more commonly known simply as diabetes. It's when your pancreas doesn't produce enough insulin to control the amount of glucose, or sugar, in your blood. Diabetes insipidus is a rare condition that has nothing to do with the pancreas or blood sugar.

A nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect the birth. The nurse should know that: a. labor may need to be induced early. b. the birth must be cesarean. c. the mother will carry to term safely. d. it's too early to tell.

a. Early induction or early cesarean birth are possibilities if the mother has diabetes and euglycemia that haven't been maintained during pregnancy. Cesarean birth isn't always necessary.

A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved? a. The entry should include clearer descriptions of the client's mood and behavior. b. The entry should avoid mentioning cognitive or psychosocial issues. c. The entry should list the specific reasons that the client was upset. d. The entry should specify the subsequent interventions that were performed.

a. Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.

A 9-year-old client with a mild concussion is discharged following a magnetic resonance imaging (MRI) of the brain. Before discharge, the client reports a headache. The parent questions pain medication for home. Which response by the nurse is most appropriate? a. "Your child has a mild concussion; acetaminophen can be given." b. "Maybe the health care provider will prescribe ibuprofen for the head pain." c. "Pain medication is avoided after a head injury to avoid hiding a worsening condition." d. "Opioid medications may lead to vomiting, which increases the intracranial pressure (ICP)."

a. Following MRI of the brain, it is confirmed that there is no bleeding on the brain; thus, pain medication may be administered. The mother asks for medication for a headache. The most appropriate response is that acetaminophen may be given. Opioids may mask changes in the level of consciousness (LOC) that indicate increased intracranial pressure (ICP); therefore, it would not be given. Also, this level of analgesia is not typically given for mild concussions. Ibuprofen is a common over-the-counter pain reliever; however, ibuprofen is a nonsteroidal anti-inflammatory medication, which reduces the ability of the blood to clot.

A nurse's coworker tells the nurse, "I am not going to get this year's flu vaccination. Last year I felt sick right after I got it." What is the nurse's best response? a. "Reducing your own risk of getting influenza ultimately benefits your clients." b. "If you could guarantee that you will not get influenza for a year, why would you not do it?" c. "I hope you change your mind. I am sure it was just coincidence that you did not feel well after getting it last year." d. "It is our responsibility as healthcare providers to keep vaccinations up to date."

a. Framing the issue in terms of benefiting clients is likely more effective than making a declaration about professional responsibility. Influenza vaccinations do not confer 100% protection against the disease.

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

a. Have the teenager talk to other teenagers who are going through similar experiences. Talking to age-appropriate peers will make a bigger impact than trying to force the teenager to conform.

A nurse is caring for a client with gastroenteritis. The nurse administers an as-needed dose of kaolin and pectin mixture as ordered. The nurse should complete which assessment 30 minutes after administering the medication? a. Determine if the client has had any more loose stools. b. Perform a pain assessment. c. Monitor for respiratory depression. d. Determine if the client has relief from nausea.

a. Kaolin and pectin is given to decrease the amount of loose stools. The onset of kaolin and pectin occurs within 30 minutes. The nurse should follow up with the client to determine if the frequency of the loose stools is decreasing to assess for drug effectiveness. Performing a pain assessment, monitoring for respiratory depression, and determining if the client has relief from nausea aren't necessary assessments for this client.

When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for which health problem? a. aspiration b. bladder dysfunction c. hypertension d. sensory loss

a. Loss of motor function to the face and throat can cause dysphagia and places the client at risk for aspiration. Bladder dysfunction and hypertension are not associated with myasthenia gravis. Myasthenia affects nerve impulses at the neuromuscular junction, causing loss of motor function; there is no sensory deficit.

The nurse is admitting a client diagnosed with multiple sclerosis (MS). Which medication would the nurse expect to find on the client's record? a. baclofen b. methotrexate c. carbidopa-levodopa d. tetracycline

a. Multiple sclerosis (MS) is a progressive disease characterized by demyelination of the brain and spinal cord. This disease causes a number of manifestations including muscle spasticity. Therefore, baclofen will be given on a routine basis. Antibiotics are not routinely needed. Sinemet is given for Parkinson's disease, not for MS. Methotrexate is given for rheumatoid arthritis.

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as what? a. nonmaleficence b. informed consent c. self-determination d. pro-choice

a. Nonmaleficence is the principle of creating no harm. It refers to preventing or minimizing harm to an individual. The other options do not represent the situation presented in the question.

A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. Which assessment findings are consistent with this syndrome? a. fever, decreased level of consciousness (LOC), and impaired liver function b. joint inflammation, red macular rash with a clear center, and low-grade fever c. peripheral edema, fever for 5 or more days, and "strawberry tongue" d. red, raised "bull's eye" rash, malaise, and joint pain

a. Reye's syndrome occurs in children with a history of a viral infection, varicella, or influenza. It's commonly associated with the administration of aspirin. The child presents with fever and decreased LOC, which can lead to coma and death. As the disease progresses, the child also develops impaired liver function. A child with joint pain, a red macular rash with a clear center, and a low-grade fever probably has rheumatic fever. A child presenting with peripheral edema, fever for more than 5 days, and a "strawberry tongue" probably has Kawasaki disease. A child with a red, raised "bull's eye" rash, malaise, and joint pain should be tested for Lyme disease.

The nurse is assessing a client who has had a stent inserted in a coronary artery via the right femoral artery. The client is receiving intravenous heparin sodium at 1,000 units per hour. During the second postprocedure check, the nurse notes that the puncture site at the groin has begun to steadily ooze blood. What should the nurse do first? a. Don gloves and apply direct pressure over the site. b. Observe and document the bleeding. c. Notify the health care provider (HCP). d. Prepare protamine sulfate for intravenous administration.

a. The nurse should first don gloves and apply direct pressure over the site to stop blood loss from the femoral artery. While the nurse will later observe the site for further bleeding and record the extent of bleeding, this is not the first action that is needed. If the bleeding cannot be controlled, the HCP who performed the procedure should be contacted, but first an attempt to manually stop the bleeding with direct pressure is warranted. Protamine sulfate is the antidote for heparin sodium, but this is not an initial action to control the bleeding.

A laboring client at -2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. What should the nurse do first? a. Place gentle pressure upward on the fetal head. b. Place the cord back into the vagina to keep it moist. c. Begin oxygen by face mask at 8 to 10 L/min. d. Turn the client on her left side.

a. The nurse should place a hand on the fetal head and provide gentle upward pressure to relieve the compression on the cord. Doing so allows oxygen to continue flowing to the fetus. The cord should never be placed back into the vagina because doing so may further compress it. Administering oxygen is an appropriate measure but will not serve a useful purpose until the pressure is relieved on the cord, enabling perfusion to the infant. Turning the client to her left side facilitates better perfusion to the mother, but until the compression on the cord is relieved, the increased oxygen will not serve its purpose. Placing the client in a Trendelenburg or knee-chest position would be position changes to increase perfusion to the infant by relieving cord compression.

A nurse is assessing the family of an infant and observes that the parents are argumentative and appear fatigued. They indicate that the baby is not breastfeeding well and cries through the night. What would be the nurse's priority nursing diagnosis for this infant? a. altered nutrition (less than body requirements) related to difficulty sucking b. parental sleep pattern disturbance related to the baby's feeding schedule c. knowledge deficit related to normal infant growth and development d. altered role performance related to new responsibilities within the family

a. The nurse's initial priority should be to address the caloric intake of the baby through health teaching and support of the parents to ensure that the baby will meet age-appropriate growth and development milestones.

A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the priority? a. Instruct the client to remain in bed. b. Use pillows to support the client's head. c. Remind the client to ask for assistance when turning. d. Assist the client to the restroom every hour.

a. The priority intervention is to have the client remain in bed to prevent falls. The other options are correct; however, client safety is the priority.

A nurse must irrigate a gaping abdominal incision with sterile normal saline using a piston syringe. How would the nurse proceed? a. Irrigate continuously until the solution becomes clear. b. After the irrigation, moisten the area around the wound with normal saline. c. After the irrigation, apply a wet-to-damp dressing to the wound. d. Rapidly instill a stream of irrigating solution into the wound.

a. To wash away tissue debris and drainage effectively, the nurse would irrigate the wound until the solution becomes clear. After irrigation, the nurse would dry the area around the wound; moistening this area promotes microorganism growth and skin irritation. When the area is dry, the nurse would apply a dry, sterile dressing or dress the wound as prescribed. The nurse should always instill the irrigating solution gently. Rapid or forceful instillation can damage the tissues.

A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged? a. The client voids 500 mL of urine. b. The client tolerates eating a hamburger. c. The client is pain free. d. The client walks in the hallway unassisted.

a. Urinary elimination in the first 8 hours postoperatively is a requirement before the client who has had an inguinal hernia repair can be discharged from same-day surgery. Ingestion of fluids without nausea and vomiting is important, but eating solid foods is not a requirement for discharge from same-day surgery. Being completely pain free is an unrealistic expectation for the time frame and is not a requirement for leaving same-day surgery. However, the client should be comfortable, and his pain should be controlled. It is not a requirement for the client to ambulate in the hallway, but the client should be able to sit up and go to the bathroom without assistance.

The nurse is planning discharge teaching for a client who will continue taking the prescribed warfarin at home. What early symptoms of occult blood loss should the nurse teach the client? a. Increasing fatigue and shortness of breath. b. Decrease in blood pressure. c. Decreased hemoglobin level. d. Decreased urine output and lightheadedness.

a. Warfarin is an anticoagulant, so the priority teaching would include watching for signs of hemorrhage that can be occult (not visible). Early symptoms the nurse should focus on are ones the client will feel rather than signs that need to be measured by a laboratory such as hemoglobin levels. The earlier signs related to the reduction in oxygen carrying capacity include a feeling of fatigue and dyspnea. Later signs (not symptoms) include a drop in blood pressure (manifested by the symptom of lightheadedness) and decreased urine output which will only be obvious to the client once renal perfusion is signficantly affected.

The nurse is developing a discharge plan for a client who has had a myocardial infarction and been in the cardiac care unit for 2 days. The client will be transferred to a telemetry unit tomorrow. When can the client begin cardiac rehabilitation? a. today, with a gradual increase of daily activities b. when transferred to the telemetry unit c. after an EKG shows 2 days of normal sinus rhythm d. when discharged from the hospital

a. A basic principle of rehabilitation, including cardiac rehabilitation, is that rehabilitation begins on hospital admission and the client should increase activities as tolerated each day. It is not necessary to wait until the client is moved to a telemetry unit as the client will have EKG monitoring in both units. It is not necessary for the client to have normal sinus rhythm to increase activity; monitoring will detect potentially dangerous dysrhythmias. Delaying rehabilitation activities is associated with poorer client outcomes.

The nurse is caring for a client with pancreatitis. What assessment finding would the nurse expect? a. fever b. lower abdominal pain c. bradycardia d. polyuria

a. Clients with acute pancreatitis often experience fever as one of the many clinical manifestations of the disease. Clients with pancreatitis would have upper abdominal pain, not lower abdominal pain, as well as a rapid pulse. Pancreatitis is not associated with polyuria.

The nurse is caring for a client with peripheral artery disease (PAD) who has just returned from having a percutaneous transluminal balloon angioplasty. Which finding requires immediate attention from the nurse? a. a change in the intensity of the pulse from the baseline b. pain "2 out of 10" at the catheterization site c. shiny skin and a hairless appearance on the affected leg d. the presence of an ulcer on the limb of the catheterization site

a. A change in the intensity of a pulse maybe indicative of arterial closure and warrants immediate attention; the nurse should notify the health care provider (HCP) immediately. A pain level of 2 out of 10 it is not uncommon from the catheter insertion site especially after the placement of a stent. Shiny and hairless skin is expected in clients with PAD. A client undergoing a catheterization may experience pain at the catheterization site as large bore sheaths are place in the femoral artery. Because people with PAD have poor circulation in their lower extremities, it is possible for them to develop leg ulcers. However it is unlikely that the percutaneous transluminal balloon angioplasty caused this.

After the physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond? a. Provide the information requested. b. Encourage the client to withdraw from the trial. c. Not provide the information because it's beyond the scope of nursing practice. d. Tell the client that the information should come from the physician who first presented it to them.

a. As part of the multidisciplinary team, the nurse is empowered to assist the client to better understand the process, as long as the nurse has an understanding of the treatment plan. The nurse shouldn't discourage the client from participating in the research study. Providing information to the client about the clinical trial isn't beyond the scope of nursing practice. The information doesn't need to come from the physician who originally presented the material to the client.

A new nurse working on a mental health unit observes a senior nurse administer a parenteral dose of haloperidol to a client against the client's wishes. What should the new nurse do in response to this observation? a. Advise the nurse that a charge of battery could be made. b. Inform the nurse that an accusation of negligence could be made. c. Ask the nurse if this is acceptable practice for this unit. d. Notify the licensing body of the nurse's behavior.

a. Battery is defined as an intentional and wrongful physical contact with a person that entails an injury or offensive touching. The other options are not correct because they do not describe the nurse's behavior.

When teaching a client about lithium, the nurse should instruct the client to: a. drink at least six to eight glasses of water per day and avoid caffeine. b. limit the use of salt in the diet. c. discontinue the medicine when the client is feeling better. d. increase the amount of sodium in the diet.

a. Caffeine should be avoided because it increases urine output. Clients need to maintain adequate fluid intake to avoid lithium toxicity. Don't limit or increase salt intake; the kidneys will retain or excrete lithium if salt intake varies. Clients should remain on medication even though they're feeling better.

A nurse is assigned to four clients. Which client should the nurse see first? a. A client who is being prepared for a major surgery receiving clopidogrel b. A client who had open reduction internal fixation (ORIF) receiving fondaparinux c. A client with a low white blood cell count receiving pegfilgrastim d. A client with acquired immunodeficiency syndrome receiving emtricitabine

a. Clopidogrel is an anti-platelet drug that should be stopped seven days prior to surgery because it can increase the risk of bleeding. All the other options are correct. Fondaparinux can be given to a client who had ORIF to prevent blood clot formation. Pegfilgrastim is given to a client with low white blood cell (WBC). Emtricitabine is a nucleoside-nucleotide reverse transcriptase inhibitor (NNRTI) drug used for clients with HIV/AIDS.

The nurse is obtaining a health history from a client of Puerto Rican descent. Which is most likely to be a health problem with a cultural connection for this client? a. lactose enzyme deficiency b. tuberculosis c. sickle-cell anemia d. suicide

a. Common health problems that may affect the Puerto Rican population include lactose enzyme deficiency and parasitic diseases. Tuberculosis is a common health problem for the Native American population. Sickle-cell anemia predominantly affects the African-American population and suicide is a common health problem for the Native American and white middle-class populations.

A 9-month-old infant is admitted with diarrhea and dehydration. The nurse plans to assess the child's vital signs frequently. Which other action provides important assessment information? a. measuring the infant's weight b. obtaining a stool specimen for analysis c. obtaining a urine specimen for analysis d. inspecting the infant's posterior fontanel

a. Frequent weight measurement provides the most important information about fluid balance and the infant's response to fluid replacement. Although stool or urine analysis may provide some information, the results typically aren't available immediately, making the tests less useful than measuring weight. The posterior fontanel usually closes from ages 6 to 8 weeks and therefore doesn't reflect fluid balance in a 9-month-old infant.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise? a. cerebral edema b. hypovolemic shock c. severe hyperkalemia d. tetany

a. Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.

What is the most important assessment for the nurse to make when administering tamsulosin to a client with benign prostatic hyperplasia (BPH)? a. voiding pattern b. size of the prostate c. creatinine clearance d. serum testosterone level

a. The alpha-adrenergic blocker tamsulosin relaxes the smooth muscle of the bladder neck and prostate, so the urinary voiding symptoms of BPH are reduced in many clients. These drugs do not affect the size of the prostate, renal function, or the production or metabolism of testosterone.

A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for: a. Vertigo. b. Facial paralysis. c. Impaired vision. d. Difficulty swallowing.

a. The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for hearing and equilibrium. Streptomycin can damage this nerve (ototoxicity). Symptoms of ototoxicity include vertigo, tinnitus, hearing loss, and ataxia. Facial paralysis would result from damage to the facial nerve (VII). Impaired vision would result from damage to the optic (II), oculomotor (III), or the trochlear (IV) nerves. Difficulty swallowing would result from damage to the glossopharyngeal (IX) or the vagus (X) nerve.

A client's partner uses the call bell to tell the nurse that the client's membranes have ruptured and "something is hanging out on the bed!" The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action? a. Place the mother in a knee-to-chest position. b. Palpate the cord for pulsations before notifying the physician. c. Attempt an external cephalic rotation. d. Restore circulation by stimulating the cord with a sterile glove.

a. The knee-to-chest position helps lift the presenting part off the umbilical cord. If, upon vaginal examination, a loop of cord is discovered, the nurse should keep gloved fingers in the vagina and push on the fetal presenting part to keep the part off the cord, thus relieving cord compression until the physician or midwife arrives. It is inappropriate to attempt an external cephalic rotation. Cord pulsations may not be felt; therefore, oxygen should be administered and electronic fetal monitoring should be put in place immediately to monitor the fetal heart rate and well being.

The primary care provider prescribes cefepime 250 mg every 6 hours for a child weighing 25 kg who had infected burns. The normal dosage for this antibiotic and condition is 20 to 50 mg/kg per 24 hours. Which actions would be most appropriate? a. Carry out the prescription because the prescribed dose is acceptable. b. Give the dose recommended by the pharmacy reference material. c. Question the prescription because the dose is too low. d. Question the prescription because the dose is a toxic amount.

a. The prescribed dose is 250 mg every 6 hours, which is 1,000 mg in 24 hours. The recommended dose is 20 to 50 mg times the weight of 25 kg in 24 hours, which is 500 to 1,250 mg in 24 hours. Therefore, because the prescribed dose is within the recommended range, the nurse should carry out the prescription. The nurse cannot independently rewrite a medication prescription using a pharmacy reference to determine the dose.

A client receiving total parenteral nutrition (TPN) is ordered to undergo a 24-hour urine test for creatinine clearance. Which actions should the client take to initiate this collection? a. Start with the first voiding of the day and then continue for exactly 24 hours. b. Discard the first morning void, then continue the collection for exactly 24 hours. c. Begin at 0800 and then continue until 0759 on the following day. d. Start immediately after initiation of TPN and then continue for exactly 24 hours.

b. Evidence-based practice (EBP) dictates that the nurse should start the test after the first morning void, but this first void should be discarded. The other choices are not correct.

During the fourth stage of labor, the client should be assessed carefully for a. uterine atony. b. complete cervical dilation. c. placental expulsion. d. umbilical cord prolapse.

a. Uterine atony should be carefully assessed during the fourth stage. The second stage of labor begins with complete cervical dilation and ends with birth. The third stage begins immediately after birth and ends with the separation and expulsion of the placenta. Immediately after delivery, the placenta is evaluated carefully for completeness, and the client is assessed for excessive bleeding or a relaxed uterus. After delivery of the placenta is the fourth stage and assessing for relaxed uterus helps determine uterine atony. Umbilical cord prolapse, displacement of the umbilical cord to a position at or below the fetus's presenting part, occurs most commonly when amniotic membranes rupture before fetal descent. The client should be assessed for a visible or palpable umbilical cord in the birth canal, violent fetal activity, or fetal bradycardia with variable deceleration during contractions. The presence of umbilical cord prolapse requires an emergency delivery.

The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately? a. The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. b. The LPN/VN places an infant having a cyanotic episode in a knee-chest position. c. The LPN/VN checks a child's apical heart rate prior to administering digoxin. d. The LPN/VN brings breakfast to a child who is scheduled for an electrocardiogram.

a. Because the femoral artery is usually used as the access site during a cardiac catheterization, children are required to remain on bed rest (with the head only slightly elevated) for several hours after the procedure to avoid arterial bleeding at the site. A knee chest position is the correct position for an infant during a cyanotic episode as it will create peripheral resistance to the extremities, shunting blood to the heart. The apical heart rate is assessed prior to administering this medication; administration can be performed by an experienced LPN/VN, although medication is checked with the RN prior to administration. Because echocardiography is noninvasive, there is no need to withhold meals before this procedure.

The nurse reads the chart entry for a client who attends group therapy and uses cannabis daily: 2/10 1700 The client is congested, with a dry hacking cough. The client could not verbalize treatment goals when asked in the group session. The client laughed when the therapist gave each participant a worksheet to fill out and bring back to the next group, and stated, "I'm not doing that." What health problem is this client experiencing because of extended cannabis use? a. amotivational syndrome b. delirium tremens c. vascular dementia d. cognitive distortions

a. Long-term use of cannabis is associated with amotivational syndrome. Amotivational syndrome is a psychological health condition that is characterized by losing interest in cognitive and social activities. The client will display a sense of apathy. Delirium tremens is associated with alcohol withdrawal. Vascular dementia is associated with an alteration in a person's thought processes caused by disrupted blood flow to the brain. Cognitive distortions are inaccurate thoughts used to reinforce negative thoughts or feelings, and are common in clients with depression.

The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis? a. pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L b. pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L c. pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L d. pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L

a. Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.

A client needs to be transferred to the oncology unit for further care. Which information is necessary to include in the transfer report? a. current client assessment b. client's admission number c. nursing treatment initiated d. results of laboratory tests

a. The nurse should include the current assessment of the client in the transfer report because it enables the receiving nurse to prepare for the client before arrival and to clarify any information from written transfer summaries they may have obtained. It is not important to mention the client's admission number during the transfer report. Information regarding the nursing treatment initiated and information about laboratory tests is important when reporting to the primary care provider and not in the transfer report.

A client is prescribed furosemide to manage heart failure. What laboratory values should the nurse monitor while the client receives this medication? Select all that apply. a. complete blood count b. serum potassium c. prothrombin time (PT) d. thrombin time e. international normalized ratio

a. and b. Complete blood count should be monitored, because furosemide can cause agranulocytosis, anemia, leukopenia, and thrombocytopenia. Because loop diuretics such as furosemide promote excretion of potassium, the nurse should also monitor serum potassium levels. Potassium replacement therapy may be necessary to prevent hypokalemia. Thrombin time, PT, and INR do not have to be monitored in a client receiving furosemide.

The nurse just started an infusion of blood on a client. A few minutes pass and the client develops a sudden fever. What are the priority interventions by the nurse? Select all that apply. a. Start the normal saline infusion. b. Continue to monitor vital signs. c. Stop the blood infusion. d. Notify the healthcare provider. e. Force oral fluids.

a., b., c., and d. Development of fever during blood transfusion can indicate a transfusion reaction. The appropriate nursing action is to discontinue the blood transfusion, infuse normal saline to prevent a more severe reaction, continue to monitor vital signs, and call the healthcare provider. Other interventions include serum analysis of BUN and creatinine, and returning the blood and tubing to the laboratory to be analyzed. Forcing oral fluids is not part of transfusion reaction care.

Strabismus

abnormal deviation of the eyes (cross-eyed) in a newborn. This is a normal finding during the newborn stage and should be documented. This is not harmful and there's no need to contact the physician.

The nurse is counseling a client regarding treatment of the client's newly diagnosed depression. The nurse emphasizes that full benefit from antidepressant therapy usually takes how long? a. 1 week b. 2 to 4 weeks c. 5 to 7 weeks d. 8 weeks

b.

After undergoing a liver biopsy, a client should be placed in which position? a. Semi-Fowler's position b. right lateral decubitus position c. supine position d. prone position

b. After a liver biopsy, the client is placed on the right side (right lateral decubitus position) to exert pressure on the liver and prevent bleeding. Semi-Fowler's position and the supine and prone positions wouldn't achieve this goal.

A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching? a. "I'm going to visit my pastor weekly for a while." b. "I will have to take vitamin B12 shots up to 1 year after surgery." c. "I will call my physician if I begin to have abdominal pain." d. "I will weight myself each day and record the weight."

b. After a total gastrectomy, a client will need to take vitamin B12 shots for LIFE. Dietary B12 is absorbed in the stomach, and the inability to absorb it could lead to pernicious anemia. Visiting clergy for emotional support is normal after receiving a cancer diagnosis. This action should be encouraged by the nurse. It's appropriate for the client to call the physician if the client experiences signs and symptoms of intestinal blockage or obstruction, such as abdominal pain. Because a client with a total gastrectomy will receive enteral feedings or parenteral feedings, they should weigh himself each day and keep a record of the weights.

A client who is 16 weeks pregnant has an elevated alpha-fetoprotein (AFP) level. The nurse understands that the physician is likely to refer this client to a. a nutritionist. b. a perinatologist. c. a nurse-midwife. d. an endocrinologist.

b. An elevated AFP level may indicate a fetal congenital abnormality. The physician will likely refer the client to a perinatologist, who cares for clients with high-risk pregnancies. A nutritionist provides guidance about a healthy diet. A nurse-midwife follows low-risk pregnancy cases. An endocrinologist deals with metabolic disorders. Referrals to these providers aren't necessary at this time.

A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is best associated with restraint use in the client who requires BiPAP? a. The client will remain safe. b. The client will maintain adequate oxygenation. c. The client will understand the rationale for restraints. d. The client, in collaboration with the health care team, will begin discharge planning.

b. BiPAP is a type of continuous positive airway pressure in which both inspiratory and expiratory pressures are set above atmospheric pressure. This type of ventilatory support assists clients with COPD who retain PaCO2. Restraints are necessary in this client to maintain BiPAP therapy if the client attempts to dislodge the mask despite instruction not to do so. Maintaining oxygenation is the expected outcome in this client. Remaining safe, understanding the rationale for restraints, and collaborating with the health care team to begin discharge planning are important, but not the best outcome with relation to BiPAP.

A nurse is caring for a group of pediatric clients. The nurse understands that which age group would most likely identify their pain as punishment for past behavior? a. infant (age 9-12 months) b. preschool or toddler (age 2-5 years) c. school age children (age 6 -11 years) d. adolescents (age 12-17 years)

b. Children in this age group are in Piaget's preoperational stage of cognitive development and relate pain as punishment for past behavior. A priority nursing action is to provide reassurance.

At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? a. early in the morning, when the client's energy level is high b. to coincide with the peak action of drug therapy c. immediately after a rest period d. when family members will be available

b. Demanding physical activity should be performed during the peak action of drug therapy. Clients should be encouraged to maintain independence in self-care activities to the greatest extent possible. Although some clients may have more energy in the morning or after rest, tremors are managed with drug therapy.

A nurse is caring for a client with suspected diabetes insipidus. Which test does the nurse anticipate the physician will order to confirm the diagnosis? a. capillary blood glucose test b. fluid deprivation test c. serum ketone test d. urine glucose test

b. Diabetes insipidus (DI) involves deficient production or lack of effective action of antidiuretic hormone (ADH or arginine vasopressin). ADH stimulates the kidney to conserve fluid. Deficient production of ADH or lack of effective action of ADH causes a high urine output, thirst, dehydration, and low blood pressure in advanced cases. The fluid deprivation test involves withholding water for 4 to 18 hours and periodically checking urine and plasma osmolarity. It is used to assess the ability of the patient to concentrate urine when fluids are withheld. A client with diabetes insipidus will have an increased serum osmolarity of less than 300 mOsm/kg. Urine osmolarity won't increase. The capillary blood glucose test rapidly measures glucose level in whole blood. The serum ketone test is used to diagnose diabetic ketoacidosis. The urine glucose test monitors glucose levels in urine; however, diabetes insipidus doesn't affect urine glucose levels, so this test isn't appropriate.

The rate at which IV fluids are infused is based on the burn client's: a. lean muscle mass and body surface area (BSA) burned. b. total body weight and BSA burned. c. total BSA and BSA burned. d. height and weight and BSA burned.

b. During the first 24 hours, fluid replacement for an adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight. Total surface area is estimated by taking into account the individual's height and weight. Height is not a common variable used in formulas for fluid replacement.

When administering an I.V. medication through a central line, the nurse notes that a client's central line gauze dressing was last changed 24 hours previously. What is the appropriate action by the nurse? a. Change the central line dressing. b. Proceed to administer the I.V. medication. c. Complete an incident report. d. Contact the healthcare provider.

b. Gauze dressings should be changed every 2 days so the nurse should proceed to administer the medication. There is no need for an incident report or to contact the healthcare provider.

A client asks to be discharged from the healthcare facility against medical advice (AMA). What should the nurse do first? a. Prevent the client from leaving. b. Notify the physician. c. Have the client sign an AMA form. d. Call a security guard to help detain the client.

b. If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for any medical problems the client may experience after discharge. If the physician isn't available, the nurse should discuss the AMA form with the client and obtain the client's signature. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left.

What is the nurse's priority action in caring for a client who has just had a liver biopsy? a. Assess the level of pain. b. Monitor vital signs. c. Assess for feelings about body image. d. Instruct the client to avoid alcohol in the future.

b. Internal bleeding is a potential complication following a liver biopsy. Elevated pulse and decreased blood pressure are indications that the client may be developing shock, which results in altered circulation. Physiologic needs take priority over psychological needs, Assessing feelings and teaching should be addressed after immediate needs. Pain is considered a psychological reaction unless the client is experiencing an acute episode that is causing physiologic response.

The nurse is caring for a client on a second course of antibiotics to eliminate osteomyelitis. It is most essential for the nurse to instruct on which aspect of daily care? a. use of opioid therapy for pain management b. a diet high in protein and nutrients c. use of assistive devices when ambulating d. exercise limited only to bathroom privileges

b. It is essential for the nurse to instruct on a diet that is high in protein and nutrients to increase healing and strengthen the immune system. This, in addition to the second course of antibiotics, may be sufficient to eliminate the osteomyelitis. Opioids may be needed for pain management but this is not most essential. Bed rest is not common in care and assistive devices are used only in the acute period.

A nurse is planning care for a 14-year-old client following an appendectomy. What is the most important intervention? a. Reduce conflict between the client and the parents. b. Promote the development of an identity and independence. c. Encourage the development of trust. d. Confirm plans for the future.

b. Since adolescents are in Erikson's identity versus role confusion stage, planning care should include interventions that promote a sense of identity and independence. During adolescence, conflict is usually intensified, not reduced. Trust is a developmental task of infancy. Plans for the future aren't confirmed at age 14.

When developing the teaching plan for an adolescent with insulin-dependent diabetes, the nurse should include what information about the relationship between exercise, diet, and insulin? a. "Before running, inject your insulin into the leg muscle for quicker absorption." b. "If your blood glucose is 240 mg/dL (13.3 mmol/L) or above, do not run." c. "You'll need to take extra insulin before you go running." d. "Don't eat your snack before running because you'll get a stomachache."

b. Strenuous exercise, such as running, should be avoided if the adolescent's blood glucose level is 240 mg/dL (13.3 mmol/L) or above because it places the client at risk for hypoglycemia. When insulin levels are not adequate, the cells cannot receive glucose, even though the blood glucose level is high. With low insulin levels, glucagons act to increase hepatic glucose production, thus raising the blood glucose level, which cannot be used at the muscle site. Taking extra insulin prior to strenuous exercise also increases the risk of hypoglycemia. Vigorous muscle contraction increases local blood flow and absorption of insulin injected into that area. Because exercise decreases blood glucose levels, snacks should be given before strenuous exercise to prevent hypoglycemia. If the adolescent cannot tolerate the extra needed food, insulin dosage may have to be reduced.

A mother asks the nurse, "How did my children get pinworms?" The nurse explains that pinworms are most commonly spread by which route? a. food b. hands c. animals d. toilet seats

b. The adult pinworm emerges from the rectum and colon at night onto the perianal area to lay its eggs. Itching and scratching introduces the eggs to the hands, from where they can easily reinfect the child or infect others. Nightclothes and bed linens can be sources of infection. The eggs can also be transmitted by dust in the home. Although transmission through contaminated food and water supplies is possible, it is rare. Contaminated animals can spread histoplasmosis and salmonella. The spread of infections by toilet seats has not been supported by research.

Which client is the best candidate for a vaginal birth after a caesarean (VBAC)? a. client who had an emergency caesarean birth because of fetal distress during her last birth and has a classic incision b. client who had a breech presentation in her last pregnancy, and this pregnancy is a vertex pregnancy c. client who dilated 6 cm in her last delivery and failed to progress beyond this point despite 5 more hours of labor d. diabetic client whose last infant was over 10 lbs (4.5 kg). This infant is larger, as seen on ultrasound.

b. The best candidate for a VBAC is a woman who had a cesarean section in her last birth because of a problem related to the infant that is not repeated in this pregnancy. The woman with the breech presentation in her last birth and a vertex pregnancy in this pregnancy would be the best candidate, especially if she had other vaginal births. The woman who was unable to dilate beyond 6 cm (failure to progress) may try a VBAC but is likely to experience the same problem with this birth. The woman with the very large infant is likely to experience cephalopelvic disproportion with this birth if she experienced cephalopelvic disproportion with her last infant who was large. A classic cesarean birth scar is a contraindication for a VBAC because that type of scar may not be strong enough to withstand the stress of hours of uterine contractions and may result in a uterine disruption.

A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104° F (40° C), and the apical pulse is 140 bpm. The white blood cell count is 16,000/mm3 (16,000 X 109/L). What is priority for nursing intervention? a. infection b. airway obstruction c. difficulty breathing d. potential for aspiration

b. The child's signs and symptoms in conjunction with the acute onset suggest possible croup or epiglottitis. The priority diagnosis at this time is airway obstruction. The airway may become completely occluded by the epiglottis at any time. Although the child has an infection, and the client has respiratory distress, the immediate priority is to establish and maintain a patent airway. No evidence is provided to support the potential for aspiration.

Which intervention would be least appropriate for a client who is in a double hip spica cast? a. encouraging the intake of cranberry juice b. advising the client to eat large amounts of cheese c. establishing regular times for elimination d. having the client dangle at the bedside

b. The client in a double hip spica cast should avoid eating foods that can be constipating, such as cheese. Rather, fresh fruits and vegetables should be encouraged, and the client should be encouraged to drink at least 2,500 mL/day. Drinking cranberry juice, which helps keep urine acidic, thereby avoiding the development of renal calculi, is encouraged. The client should be encouraged to establish regular times for elimination to promote regularity in bowel and bladder habits. The client will develop orthostatic hypotension unless the circulatory system is reconditioned slowly through dangling and standing exercises.

A client has had a cast applied to the arm. When discharging the client, the nurse should tell the client to: a. use powder on the skin around the cast. b. smell the cast for foul odors. c. use a padded ruler to reach inside and rub under the cast. d. apply a heating pad to the arm for 24 hours after the injury.

b. The client should be instructed to smell the cast to note foul odors, a sign of potential infection. Powder should not be used around the cast, because it can get under the cast and become a potential medium for infection. Nothing should be inserted into the cast because a break in skin integrity can lead to an infection. A heating pad is not applied to a fracture; rather, the application of cold may be used to decrease edema and help decrease pain.

Which lab values should the nurse report to the health care provider (HCP) when the client has anemia? a. Schilling test result, elevated b. intrinsic factor, absent c. sedimentation rate, 16 mm per hour d. red blood cells (RBCs) within normal range

b. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B cannot be absorbed in the small intestine and folic acid needs vitamin B for deoxyribonucleic acid synthesis of RBCs. The gastric analysis is done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B in the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation; it is not specific to anemias. An RBC value within the normal range does not indicate an anemia.

The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. What should the nurse advise the client to do? a. Use herbal supplements. b. Eat a diet high in protein and vitamins C and D. c. Ask the health care provider for a change of antibiotics. d. Encourage frequent passive range-of-motion to the affected extremity.

b. 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.

The client is suspicious of staff members and other clients. To help establish a therapeutic relationship with the client, which plan would be best? a. Initiate conversations with the client whenever he becomes agitated. b. Spend brief intervals with the client each day. c. Allow the client to initiate conversations when he feels ready for them. d. Do not approach the client for interactions until he has been stabilized on medications.

b. To promote a therapeutic relationship with a suspicious client, it is best to spend brief intervals with the client each day to develop trust, respect, and rapport. It is difficult to have meaningful conversations that promote a therapeutic relationship when meetings occur only when the client is agitated, although the nurse may need to intervene at those times as well. It is inappropriate to wait until the client initiates meetings because nonthreatening interactions help to establish trust and rapport. It is inappropriate, not therapeutic, and impractical to wait until the client is stabilized on medication before interacting with him.

A client admitted with pneumonia and dementia has attempted several times to pull out the IV and Foley catheter. After trying other options, the nurse obtains a prescription for bilateral soft wrist restraints. Which nursing action is most appropriate? a. Perform circulation checks to bilateral upper extremities each shift. b. Attach the ties of the restraints to the bedframe. c. Reevaluate the need for restraints and document weekly. d. Ensure the restraint prescription has been signed by the health care provider (HCP) within 72 hours.

b. Restraints should be secured to the bedframe, not the siderails, to ensure that the siderails can be raised and lowered safely. Circulation checks, reevaluating need for restraints, and documentation should be done every 1 to 2 hours. Medical restraint prescriptions must be renewed and signed by a HCP every 24 hours.

Which nursing intervention would be most effective in helping a 2-year-old child stay quiet after a bronchoscopy? a. Allow the child to go to the playroom. b. Have the parents stay at the bedside. c. Have the child play with another child in the room. d. Turn on the television so the child can watch cartoons.

b. A toddler has a short attention span and is energetic. Thus, keeping a 2-year-old child quiet is a challenge. Because the parents know their child well, the parents have a better chance of helping the child stay quiet. Therefore, they should be encouraged to stay with the child at the bedside. Allowing the child to go to the playroom would most likely encourage the child to be active rather than quiet. A 2-year-old child engages in parallel play but does not know how to play with others. A 2-year-old child's attention span is short, so watching television would keep the child quiet for only a short time.

Which of the following is a normal response from an adolescent who has just returned to her room after an open appendectomy? a. "I will need plastic surgery for this scar." b. "I am worried about the size of my scar." c. "I do not want to have any pain." d. "What will my boyfriend say about the scar?"

b. Adolescents are concerned about the immediate state and functioning of their bodies. The adolescent needs to know whether any changes (e.g., illness, trauma, surgery) will alter her lifestyle or interfere with her quest for physical perfection. Having a scar may be devastating to the adolescent. The need for plastic surgery cannot be determined at this point. The adolescent has just returned from surgery and has yet to see the scar. Healing has yet to occur. Typically scars become smaller and fade over time. The desire for no pain is unrealistic. Although adolescents are worried about pain and how they will respond, they typically are discharged within 24 hours after an appendectomy with pain well controlled by oral analgesics. The immediate concern of adolescents is the state and functioning of their bodies. After concerns about themselves, then adolescents are concerned about their peer group and their responses. Although the boyfriend's response will matter, this concern would be more common later in the course of the adolescent's recovery.

A nurse is assessing a client with possible osteoarthritis. The most significant risk factor for primary osteoarthritis is a. congenital deformity. b. age. c. trauma. d. obesity.

b. Age is the most significant risk factor for developing primary osteoarthritis. Development of primary osteoarthritis is influenced by genetic, metabolic, mechanical, and chemical factors. Secondary osteoarthritis usually has identifiable precipitating events such as trauma.

A client reports abdominal pain. Which action allows the nurse to investigate this complaint? a. using deep palpation b. assessing the painful area last c. assessing the painful area first d. checking for warmth in the painful area

b. Assessing the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. The nurse should always let the client know when the nurse will be assessing the painful area. Pressure resulting from deep palpation may cause an underlying mass to rupture. Checking for warmth in the painful area offers no real information about the client's pain.

A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention? a. All personnel should wear protective clothing, including a gown, gloves, and respiratory protection. b. Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper. c. Clients should be instructed to wash thoroughly with soap and water. d. Access to the area should be restricted.

b. Clients exposed to anthrax should place contaminated clothes in a plastic bag and mark the bag "contaminated." Wearing protective clothing, instructing exposed clients to wash thoroughly, and restricting access to the exposed area are appropriate actions to take in response to a bioterrorism threat.

A nurse is reviewing the medication list of a client who presents with slow, involuntary muscle spasms of the arms and legs and twisting of the neck. The nurse reviews the client's prescriptions for which medication that could correlate with these symptoms? a. diazepam b. haloperidol c. amitriptyline hydrochloride d. clonazepam

b. Haloperidol is a phenothiazine and is capable of causing dystonic reactions. Dystonia involves slow, involuntary contractions of an isolated muscle or groups of muscles in the limbs, trunk, and neck. It may involve spasmodic torticollis (involuntary turning of the neck). Diazepam and clonazepam are benzodiazepines. Benzodiazepines don't cause dystonic reactions; however, they can cause drowsiness, lethargy, and hypotension. Tricyclic antidepressants, like amitriptyline, rarely cause severe dystonic reactions; however, they can cause a decreased level of consciousness, tachycardia, dry mouth, and dilated pupils.

A client with severe shortness of breath comes to the emergency department. The client tells the emergency department staff that they recently traveled to China for business. Based on the client's travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute? a. droplet precautions b. airborne and contact precautions c. contact and droplet precautions d. contact precautions

b. SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection.

A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that a. the client requires an antiviral agent. b. enteric precautions must be continued. c. enteric precautions can be discontinued. d. the client's infection may be caused by droplet transmission.

b. The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.

When assessing for signs of a blood transfusion reaction in a client with dark skin, what sign should the nurse assess? a. hypertension b. diaphoresis c. polyuria d. warm skin

b. The nurse should assess for signs of impending shock such as diaphoresis. The client would have hypotension, dysuria, and cool skin.

A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should a. leave the client and get help. b. assess the client for pain. c. read the facility's policy on restraints. d. order soft restraints from the storeroom.

b. The nurse should assess the client for possible causes of the behavior, such as pain. A client should never be left alone while the nurse summons assistance. All staff members must receive annual instruction on the use of restraints and the nurse should be familiar with the facility's policy. In most settings, the nurse must have a physician's order before restraining a client.

A young child is being treated for a broken arm while visiting family in another state. In the hospital, the child begins to experience a seizure and the child's parents take out a jar of oil and begin to apply it to the child. What is the nurse's best response? a. "You cannot use medicine not prescribed by our doctor." b. "Could we please step outside to speak for a moment?" c. "Excuse me, I need to give your child some medicine." d. "If that is CBD, it is illegal to use it in this state."

b. The nurse should recognize there is some evidence that a component of Cannabis (marijuana) cannabidiol (CBD), is being used in some areas for treatment of childhood seizures. The best action is to request a moment away from the child for a private discussion to demonstrate respect for the parent's caring action. There is no information to indicate that the nurse will be administering any medication. It is disrespectful and argumentative to automatically assume that the oil is a medication or an illegal substance.

An adolescent girl is being treated for anogenital warts caused by the human papillomavirus (HPV). What is the nurse's priority intervention for this client? a. Educate the client about the need to adhere to antibiotic therapy. b. Educate the client about the accompanying risk of cervical cancer. c. Assess the client's knowledge of hormonal contraceptives. d. Assess the client for signs and symptoms of systemic infection.

b. This client's external lesions should be treated, and she should receive education regarding the relationship between HPV and cervical cancer. Antibiotics would be ineffective because of the viral etiology of HPV. Hormonal contraceptives are of no benefit, and HPV is not normally the cause of systemic infection.

After a dilatation and curettage (D&C) to evacuate a molar pregnancy, assessing the client for signs and symptoms of which signs and symptoms would be most important? a. urinary tract infection b. hemorrhage c. abdominal distention d. chorioamnionitis

b. After a D&C to evacuate a molar pregnancy, the nurse should assess the client's vital signs and monitor for signs of hemorrhage, because the surgical procedure may have traumatized the uterine lining, leading to hemorrhage. Urinary tract infections, not common after evacuation of a molar pregnancy, are most commonly related to urinary catheterization. Typically, urinary catheters are not used during evacuation of a molar pregnancy. The client should not experience abdominal distention because the contents of the uterus have been removed. Chorioamnionitis is an inflammation of the amniotic fluid membranes. With complete mole, no embryonic or fetal tissue or membranes are present.

The nurse teaches the parents of a neonate who has undergone corrective surgery for tracheoesophageal fistula about the need for long-term health care. The nurse bases the teaching on the child's high risk for which condition? a. speech problems b. esophageal stricture c. gastric ulcers d. recurrent mild diarrhea with dehydration

b. After corrective surgery for repair of tracheoesophageal fistula (TEF), the risk for esophageal stricture is high because scar tissue forms at the site of the esophageal anastomosis, commonly requiring dilation at the anastomosis site during the first years of childhood in about half of such children. Speech problems are likely if other abnormalities are present to produce them. However, the larynx and structures of speech are not affected by TEF. Although dysphagia and strictures may decrease food intake and poor weight gain may result, gastric ulcers are not associated with TEF repair. Recurrent mild diarrhea with dehydration typically does not develop from surgery to correct TEF.

The nurse understands that the client with severe dementia and motor apraxia may be able to perform which action? a. Balance a checkbook accurately. b. Brush the teeth when handed a toothbrush. c. Use confabulation when telling a story. d. Find misplaced car keys.

b. Highly conditioned motor skills, such as brushing teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia. Confabulation is fabrication of details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function.

A client presents with a congenital heart defect and increased pulmonary blood flow. Which signs or symptoms will alert the nurse that congestive heart failure is occurring? Select all that apply. a. weight loss b. coughing c. tachypnea with feeding d. polyuria e. course breath sounds

b., c., and e. Congestive heart failure is caused by increased pulmonary blood flow or obstruction to the systemic blood outflow tract. Signs of this occurring would be an increase in weight, coughing, difficulty or fast breathing (tachypnea) with feeding, oliguria, and course breath sounds.

A client admitted for alcohol detoxification is taking disulfiram. The nurse should instruct the client to avoid ingestion of which foods and/or liquids? Select all that apply. a. aged cheese b. beer c. communal wine at church d. chocolates e. cough syrup

b., c., and e. The client who is taking disulfiram is advised to avoid all forms of alcohol including beer, communal wine at church, and cough syrup; these can trigger a serious physical reaction. Aged cheeses and chocolate are to be avoided by the client taking monoamine oxidase inhibitors.

A nurse is reviewing a teaching plan with parents of an infant undergoing repair for a cleft lip. Which instructions are the most appropriate for the nurse to give? Select all that apply. a. Offer a pacifier as needed. b. Sit the infant up for each feeding. c. Loosen the arm restraints every 4 hours. d. Give the infant extra care and support. e. Clean the suture line after each feeding by dabbing it with saline solution.

b., d., and e. The nurse should instruct the parents to feed the infant in the upright position with a syringe and attached tubing to prevent stress to the suture line from sucking. In addition, to prevent crusts and scarring, the suture line should be cleaned after each feeding by dabbing it with half-strength hydrogen peroxide or saline solution. The parents should give the infant extra care and support because the infant cannot meet emotional needs by sucking. Extra attention may also prevent crying, which stresses the suture line. Offering a pacifier is not appropriate. Pacifiers should not be used during the healing process because they stress the suture line. Arm restraints keep the infant's hands away from the infant's mouth; the restraints should be loosened every 2 hours, not every 4 hours.

A group of nursing students are reviewing current nursing Codes of Ethics. Such a code is important in the nursing profession because a. nurses are highly vulnerable to criminal and civil prosecution in the course of their work. b. nurses interact with clients and families from diverse cultural and religious backgrounds. c. nursing practice involves numerous interactions between laws and individual values. d. nurses are responsible for carrying out actions that have been ordered by other individuals.

c.

A nurse is preparing to discharge a child who has rheumatic fever. The nurse plans to teach the parents about which medication that will be used to prevent a recurrence of the disease? a. corticosteroids b. digoxin c. antibiotics d. anti-inflammatory medications

c. A child with rheumatic fever is at risk for a recurrence, especially if carditis complicates the condition. The child will need long-term antibiotic therapy into adulthood, maybe even for life. A physician may order digoxin to treat heart failure but digoxin doesn't prevent recurrence of rheumatic fever. Corticosteroids and anti-inflammatory medications reduce inflammation in rheumatic fever but won't prevent a recurrence.

After the nurse has taught the client who is being discharged on lithium about the drug, which client statement would indicate that the teaching has been successful? a. "I need to restrict eating any foods that contain salt." b. "If I forget a dose, I can double the dose the next time I take it." c. "I'll call my health care provider right away for any vomiting or muscle weakness." d. "I should increase my fluid intake to five to six 8-oz glasses (1,200 to 1,420 mL) of water each day."

c. A client receiving lithium is at risk for toxicity, evidenced by diarrhea, vomiting, ataxia, tremor, drowsiness, lack of coordination, or muscle weakness. Thus, the client's statement about notifying the health care provider about possible signs of lithium toxicity reflects accurate knowledge about the drug and successful teaching. The other client statements demonstrate unsuccessful teaching. Eliminating salt from the diet, doubling the dose to make up for a missed dose, and drinking fewer than ten to twelve 8-oz glasses (2,400 to 2,840 mL) of water per day can all lead to lithium toxicity.

While preparing to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes, which would be most important for the nurse to do? a. Check the diaper for recent urination. b. Give the infant a pacifier. c. Ensure that the room is kept warm. d. Tap lightly on the left inguinal ring.

c. A cold environment can cause the testes to retract. Cold and touch stimulate the cremasteric reflex, which causes a normal retraction of the testes toward the body. Therefore, the nurse should warm the hands and make sure that the environment also is warm. Checking the diaper for urination provides information about the infant's voiding and urinary function, not information about the testes. Giving the infant a pacifier may help to calm the infant and possibly make the examination easier, but the concern here is with the temperature of the environment. Tapping on the inguinal ring would not be helpful in assessing the infant.

Which nursing diagnosis takes highest priority for a client with a compound fracture? a. Imbalanced nutrition: Less than body requirements related to immobility b. Impaired physical mobility related to trauma c. Risk for infection related to effects of trauma d. Activity intolerance related to weight-bearing limitations

c. A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.

A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. The nurse anticipates that, because the client's fallopian tube has not yet ruptured, which medication may be prescribed? a. progestin contraceptives b. medroxyprogesterone c. methotrexate d. dyphylline

c. Because the fallopian tube has not yet ruptured, methotrexate may be given, followed by leucovorin. This chemotherapeutic agent attacks the fast-growing zygote and trophoblast cells. RU-486 is also effective. A hysterosalpingogram is usually performed after chemotherapy to determine whether the tube is still patent. Progestin-only contraceptives and medroxyprogesterone are ineffective in clearing the fallopian tube. Dyphylline is a bronchodilator and is not used.

A client who's 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping the client cope with these cramps? a. suggesting that she walk for 1 hour twice per day b. advising her to take over-the-counter calcium supplements twice per day. c. teaching her to dorsiflex her foot during the cramp d. instructing her to increase milk and cheese intake to 8 to 10 servings per day.

c. Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours daily during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client's need for calcium supplements. If the client eats a well-balanced diet, calcium supplements and additional servings of high-calcium foods may be unnecessary.

The school nurse learns that at least one of the children in the school has a new diagnosis of erythema infectiosum (human parvovirus) after developing a bright red facial rash. What interventions should be implemented to prevent a possible spread of the infection to other students in the school? a. Require the client to remain at home until the rash fades. b. Remove the pets from the classroom. c. Teach everyone to implement hand hygiene. d. Administer acetaminophen to the client.

c. Erythema infectiosum (human parvovirus) is transmitted through direct contact with respiratory secretions. The client is contagious for a week prior to the appearance of the rash, but not after the rash appears, so quarantine of the diagnosed client will not reduce transmission. However, other children may already have been infected and hand hygiene can reduce the spread of the infection. Human parvovirus is not transmitted by animals. Administering a pain reliever to the client will not reduce the risk of infection to others.

When discussing the use of a fluticasone and salmeterol inhaler with the parent of a child diagnosed with asthma, the nurse should teach the parent that the medication will be most effective if it is administered at which time? a. intermittently for short-term use b. during an asthma attack c. twice daily d. prior to riding a bicycle for a block

c. Fluticasone and salmeterol is a combination drug used as a prophylactic agent to help prevent bronchial asthma attacks. The fluticasone is an inhaled corticosteroid that reduces inflammation. The salmeterol is a LONG-ACTING beta agonist (LABA) that reduces bronchospasms. The drug must be taken on a consistent basis, twice a day, over a long period of time to be effective. Short-term dosing are use right before exercise provides no benefits. LABAs are of no use during an acute asthma attack.

When a nurse asks themselves questions such as "Why am I here?" the nurse is attempting to a. develop the concepts of holism and integration. b. become a more spiritual being for other people. c. develop a philosophical base for clearer thinking. d. strive toward unity with a higher power.

c. In terms of spiritual care, your own background, family, culture, and religion are integral parts of interactions with clients. For this reason, taking a step back and examining your own spirituality, values, and beliefs is essential.

Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon regaining consciousness. The client is not able to make a sound. The nurse determines that the client is experiencing which complication of the surgery? a. internal hemorrhage b. decreasing level of consciousness c. laryngeal nerve damage d. upper airway obstruction

c. Laryngeal nerve damage is a potential complication of thyroid surgery because of the proximity of the thyroid gland to the recurrent laryngeal nerve. Asking the client to speak helps assess for signs of laryngeal nerve damage. Persistent or worsening hoarseness and weak voice are signs of laryngeal nerve damage and should be reported to the health care provider (HCP) immediately. Internal hemorrhage is detected by changes in vital signs. The client's level of consciousness can be partially assessed by asking her to speak, but that is not the primary reason for doing so in this situation. Upper airway obstruction is detected by color and respiratory rate and pattern.

The health care provider (HCP) has prescribed intravenous mannitol for a child with a head injury. The best indicator that the drug has been effective is which assessment finding? a. increased urine output. b. improved level of consciousness. c. decreased intracranial pressure. d. decreased edema.

c. Mannitol is an osmotic diuretic used to reduce intracranial pressure. The use of the drug is controversial and should be reserved to cases that do not respond to other treatments or when brain herniation is likely. Children this sick should be on intracranial pressure (ICP) monitoring. The best indicator that the drug has produced the desired results is a reduction in the ICP. Improved levels of consciousness should follow reduced ICP. While the drug will cause increased urine output, that measurement in and of itself does not indicate successful treatment. Because the drug is being used for head injuries, not to improve urine output in acute renal failure, the child may not have visible edema.

Which client should receive a shingles vaccine? a. a client who has never had chickenpox b. a client who is at risk for genital herpes c. a client who is over 50 years of age d. a client who has a compromised immune system

c. People older than 50 years should receive shingles vaccine to prevent the disease. The vaccine is not effective for genital herpes. The vaccine can be given to persons who have or have not had chickenpox. The vaccine is not advised for persons with a compromised immune system, for example, those receiving chemotherapy or radiation therapy.

The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? a. hypercalcemia b. metabolic acidosis c. metabolic alkalosis d. respiratory acidosis

c. Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.

A client is admitted with fever and flank pain and is diagnosed with pyelonephritis. What is a priority nursing intervention in a client with this disorder? a. straining all urine b. obtaining a clean catch urine specimen for specific gravity c. monitoring laboratory values, especially WBCs d. initiating a 24-hour urine collection after the first morning void

c. Pyelonephritis generally causes fever, chills, flank pain, nausea, vomiting, increased white blood cells, pyuria, bacteriuria, and hematuria. As such, the nurse should be monitoring laboratory values, especially white blood cell count for trends, and to observe if antibiotic therapy is effective. Urine is strained if renal calculi are suspected. Specific gravity values and a 24-hour urine collection are not consistent with the treatment of pyelonephritis.

A physician orders electroconvulsive therapy (ECT) for a severely depressed client who fails to respond to drug therapy. When teaching the client and family about the treatment, the nurse should include which point about ECT? a. An anesthetist will administer ECT. b. ECT can cure depression. c. ECT will induce a seizure. d. The client will remember the shock of ECT but not the pain.

c. Reserved for clients with acute depression who don't respond to pharmacologic or psychiatric measures, ECT is the passage of an electrical current through the brain to induce a brief seizure. According to ECT proponents, the desirable changes the seizure causes in neurotransmitters and receptor sites are similar to those caused by antidepressant drugs. ECT is administered under a general anesthetic by a physician and an anesthetist. Although ECT may reduce the severity of depression, it doesn't necessarily cure the illness. Before undergoing ECT, the client is given a medication that provides short-term amnesia of the entire event.

A client is taking aluminum hydroxide tablets along with sucralfate daily 1 hour before meals. The nurse should teach the client which of the following? a. Sucralfate should be taken every 4 hours to be effective. b. Aluminum hydroxide and sucralfate should not be taken together. c. Sucralfate should be taken on an empty stomach 1 hour before meals. d. Sucralfate and aluminum hydroxide should be taken early in the morning.

c. Sucralfate is taken on an empty stomach at least 1 hour before meals and at bedtime to allow a protective coating to form over the ulcer before high levels of gastric acidity occur. It is not to be taken every 4 hours. Aluminum hydroxide and sucralfate are effective when prescribed together. Aluminum hydroxide should be taken for 2 hours before or after taking sucralfate, not at the same time.

The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the health care provider (HCP) to further assess the baby and request which prescription? a. a lactation consultation b. an arterial blood gas c. an x-ray for gastric tube placement d. a serum blood glucose level

c. The drooling and excessive mucus production is highly suggestive of a tracheoesophageal fistula (TEF). The initial diagnosis is made when a gastric tube cannot be passed to the stomach. A lactation consult would be warranted only after determining feedings were safe to continue. While cyanosis can be a sign of sepsis and hypoglycemia, the cyanosis is most likely related to the excessive secretions and airway patency. A blood gas may be needed, but only after ruling out a TEF.

A client's membranes have just ruptured, and the amniotic fluid is clear. Her medical history includes testing positive for human immunodeficiency virus (HIV). The client inquires about having the fetal scalp electrode placed because she's worried about her baby. Which response by a nurse is best? a. The fetal scalp electrode is a small device that looks like a corkscrew. It's applied quickly after the baby's scalp is carefully palpated. b. Inform the client that she'll have to remain on bedrest after the fetal scalp electrode is applied. c. Explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. d. Inform the client that the fetal scalp electrode helps monitor fetal heart rate and assists with shortening the first stage of labor.

c. The nurse should explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Therefore, its use is contraindicated in clients that test HIV positive. Explaining what the fetal scalp electrode is, how it's applied, and that bedrest is required after application provides correct information about fetal scalp electrode application; however, these statements don't address the client's clinical situation, which prevents fetal scalp electrode application. The fetal scalp electrode helps monitor fetal heart rate, but it doesn't shorten labor.

After a local factory explodes, a nurse begins to triage the victims. Victim 1 is unconscious and not breathing. After opening the victim's airway, the victim resumes spontaneous respirations at a rate of 18 and has a capillary refill time of less than 2 seconds but remains unconscious. What color tag should the nurse use for this victim? a. green b. yellow c. red d. black

c. The nurse should us a red tag for this client. The red tag is for those who require medical attention within 60 minutes for survival including compromise to airway and breathing. Yellow tags are for serious and potentially life-threatening injuries, but the client's status is not expected to deteriorate significantly over the next several hours. Green is a victim with relatively minor injuries whose status is unlikely to deteriorate over time and may be able to assist in one's own care. Black tags include deceased victims, victims unlikely to survive due to the severity of injuries, level of available care, or both. Palliative care and pain relief should be provided.

A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which characteristic of abusive families? a. tight, impermeable boundaries b. unbalanced power ratio c. role stereotyping d. dysfunctional feeling tone

c. The traditional and rigid gender roles described by the client are examples of role stereotyping. Impermeable boundaries, unbalanced power ratio, and dysfunctional feeling tone are also common in abusive families.

A client is taking methotrexate for severe rheumatoid arthritis. The nurse instructs the client that it will be necessary to monitor: a. serum glucose. b. serum electrolytes. c. complete blood count (CBC) with differential and platelet count. d. sedimentation rate.

c. This client should be monitored for blood dyscrasias, evidenced by decreased platelet count and white blood cell count with changes in the CBC differential.

A client who underwent abdominal surgery and has a nasogastric (NG) tube in place begins to complain of abdominal pain described as "feeling full and uncomfortable." Which assessment should the nurse perform first? a. Measure abdominal girth. b. Auscultate bowel sounds. c. Assess patency of the NG tube. d. Assess vital signs.

c. When an NG tube is no longer patent, stomach contents collect in the stomach, giving the client a sensation of fullness. The nurse should begin by assessing patency of the NG tube. The nurse can measure abdominal girth, auscultate bowels, and assess vital signs, but the nurse should check NG tube patency first to help relieve the client's discomfort.

The nurse is instructing a college student with Addison's disease how to adjust the dose of glucocorticoids. The nurse should explain that the client may need an increased dosage of glucocorticoids in which situation? a. completing course work. b. gaining 4 lb (1.8 kg) c. becoming engaged d. having wisdom teeth extracted

d. Adrenal crisis can occur with physical stress, such as surgery, dental work, infection, flu, trauma, and pregnancy. In these situations, glucocorticoid and mineralocorticoid dosages are increased. Weight loss, not gain, occurs with adrenal insufficiency. Psychological stress has less effect on corticosteroid need than physical stress.

The nurse can assign an unlicensed assistive personnel (UAP) to which client? A client who: a. is 1 day postoperative following cranial surgery. b. has prostate cancer undergoing radiation implant seeding. c. had a newly created urinary diversion 3 days ago. d. was admitted to the hospital showing signs of progressive confusion.

c. When delegating care, the nurse should consider the skill level of the UAP and the needs of the client. The UAP is able to assist with activities of daily living and basic care activities. The client who had surgery to establish a urinary diversion 3 days ago is the most stable of the clients and can be assigned to the UAP for basic care. The client with cranial surgery is 1 day postoperative and will require frequent neurological assessment; this client should be assigned to a registered nurse. The client with a radiation seeding is on radiation precautions and should be assigned to a registered nurse. The client showing signs of progressive confusion is the least stable and requires direct care by a nurse.

Which discharge instruction should a nurse give a client who's had surgery to repair a hip fracture? a. "Don't flex your hip more than 30 degrees, don't cross your legs, and have someone help you put your shoes on." b. "Don't flex your hip more than 60 degrees, don't cross your legs, and have someone help you put your shoes on." c. "Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." d. "Don't flex your hip more than 120 degrees, don't cross your legs, and have someone help you put your shoes on."

c. 90 degrees.

A client is experiencing autonomic dysreflexia. The nurse should first: a. administer nitroprusside sodium IV. b. call the health care provider. c. place the client in Fowler's position. d. send a urine sample for culture.

c. Autonomic dysreflexia is a medical emergency. The rising blood pressure can cause cerebrovascular accident, blindness, or even death. Placing the client in Fowler's position lowers blood pressure. Administering nitroprusside IV is appropriate if the conservative measures are ineffective. Although notifying the health care provider is important, it is more essential that the nurse intervene immediately in the situation. A urine sample for culture should be obtained if the client has an elevated temperature and no other cause for the dysreflexia is found. A urinary tract infection may be causing symptoms.

A client with acute renal failure is undergoing dialysis for the first time. The nurse monitors the client closely for dialysis disequilibrium syndrome. Which assessment is the priority? a. vital signs b. laboratory values c. neurological status d. pain in the flank region

c. Clients experiencing dialysis for the first time often have confusion and even seizures and should be monitored closely. Vital signs and laboratory values are important assessments but do not specifically address dialysis disequilibrium syndrome. Pain in the flank region is not associated with dialysis. Dialysis disequilibrium syndrome (DDS) is the occurrence of neurologic signs and symptoms, attributed to cerebral edema, during or following shortly after intermittent hemodialysis.

The nurse is preparing a client for a cardiac catheterization. Which client statements would the nurse need to report to the health care provider immediately? a. "I am allergic to penicillin and midazolam." b. "I have not been able to eat since yesterday." c. "I took my metformin this morning." d. "I am very claustrophobic in small spaces."

c. The priority would be to notify the health care provider of the metformin because it cannot be taken 48 hours before or after contrast, as there is an increased risk of lactic acidosis and acute renal failure with iodinated contrast material. It would be appropriate for the client to take nothing by mouth. It is important to determine the client's allergies; however, it is not the priority. Claustrophobia would not be an issue during a cardiac catheterization.

A client with diabetes mellitus has a foot ulcer. The physician orders bed rest, a wet-to-damp dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are wet-to-damp dressings used for this client? a. They contain exudate and provide a moist wound environment. b. They protect the wound from mechanical trauma and promote healing. c. They debride the wound and promote healing by secondary intention. d. They prevent the entrance of microorganisms and minimize wound discomfort.

c. For this client, wet-to-damp dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Dry, sterile dressings protect the wound from mechanical trauma and promote healing. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort.

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated? a. IgA b. IgB c. IgE d. IgG

c. Immunoglobulin E (IgE) is involved with an allergic reaction. IgA combines with antigens and activates the complement system. IgB coats the surface of B lymphocytes. IgG is the principal immunoglobulin formed in response to most infectious agents.

For a client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume? a. cool, clammy skin b. jugular vein distention c. increased urine osmolarity d. decreased serum sodium level

c. In hyperglycemia, urine osmolarity (the measurement of dissolved particles in the urine) increases as glucose particles move into the urine. The client experiences glycosuria and polyuria, losing body fluids and experiencing deficient fluid volume. Cool, clammy skin; jugular vein distention; and a decreased serum sodium level are signs of fluid volume excess, the opposite imbalance.

A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask? a. "Do you have a history of GERD (gastroesophageal reflux disease)?" b. "Have you ever had pain like this before?" c. "What were you doing when the pain started?" d. "Do you take any medications on a regular basis?"

c. Subjective data (data from the client) about the chest pain helps the nurse determine the specific health problem. For example, asking about the setting in which the pain developed can provide helpful information about its cause. Asking about the history and medications will yield helpful information, but would not be the most helpful.

A client comes to a community mental health clinic for a psychiatric evaluation at the family's request. During the initial interview, the client tells the nurse about painting the streets to beautify the city, lecturing subway riders about germ control, and banning smoking in order to clean up the environment. The client is irritable and easily distracted by the slightest sound. Which stage of mania is the client exhibiting? a. hypomania b. delirious mania c. acute mania d. dementia mania

c. The client is demonstrating an expansive mood, high energy level, racing thoughts, and disjointed thinking. Any type of stimulation will distract the client from the current conversation. This behavior is indicative of the acute manic phase of mania. Hypomania is a mania phase characterized by an abnormally elevated mood, signs of inflated self-esteem, decreased sleep, flight of ideas, and pleasure-seeking behaviors. This phase lasts for 4 days or less. The delirious mania phase is when the client exhibits signs and symptoms of mania and delirium. Dementia mania isn't a phase of mania.

When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved the client. The client tells the nurse, "The nursing assistant on the last shift was rough. I asked the nursing assistant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first? a. Prepare an incident report. b. Prepare a disciplinary warning for the nursing assistant. c. Document the findings. d. Contact the shift supervisor.

c. The nurse must first document the assessment findings; timely documentation helps ensure accuracy. The nurse should notify the shift supervisor after completing the documentation. The nurse must follow the chain of command. The nurse isn't a manager or supervisor and may not have the authority to administer discipline. Although it might be appropriate for the nurse to make an incident report, the nurse doesn't yet have adequate information to prepare a complete report.

When developing the plan of care for a client with acute stress disorder who lost her sister in a boating accident, which intervention should the nurse initiate? a. helping the client to evaluate her sister's behavior b. telling the client to avoid details of the accident c. facilitating progressive review of the accident and its consequences d. postponing discussion of the accident until the client brings it up

c. The nurse should facilitate progressive review of the accident and its consequences to help the client integrate feelings and memories and to begin the grieving process. Helping the client to evaluate her sister's behavior, telling the client to avoid details of the accident, or postponing the discussion of the accident until the client brings it up is not therapeutic and does not facilitate the development of trust in the nurse. Such actions do not facilitate review of the accident, which is necessary to help the client integrate feelings and memories and begin the grieving process.

To prevent shoulder ankylosis following chest surgery, what should the nurse teach the client to do? a. Turn from side to side. b. Raise and lower the head. c. Raise the arm on the affected side over the head. d. Flex and extend the elbow on the affected side.

c. The nurse should teach a client who has undergone chest surgery to raise the arm on the affected side over the head to help prevent shoulder ankylosis. Shoulder ankylosis is a stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint. This exercise helps restore normal shoulder movement, prevents stiffening of the shoulder joint, and improves muscle tone and power.

A client with human immunodeficiency virus (HIV) infection gives birth to a neonate. When assessing the neonate, the nurse is most likely to detect a. skin vesicles. b. limb dysmorphism. c. conjunctivitis. d. hepatosplenomegaly.

d. A neonate with HIV infection typically has hepatosplenomegaly, a distinctive facial dysmorphism, interstitial pneumonia, recurrent infections, behavioral deviations, and neurologic abnormalities. Skin vesicles, limb dysmorphism, and conjunctivitis aren't typical findings in neonates with HIV infection.

A nurse is preparing to palpate a client's thyroid gland. Which action by the nurse is appropriate? a. Have the client flex their neck onto their chest and cough while the nurse palpates the anterior neck with fingertips. b. Place the nurse's hands around the client's neck, with the thumbs in the front of the neck, and gently massage the anterior neck. c. Encircle the client's neck with both hands, have the client slightly extend their neck, and ask them to swallow. d. Have the client hyperextend their neck and take slow, deep inhalations while the nurse palpates their neck with the fingertips.

c. When palpating the thyroid gland, the nurse should encircle the client's neck with both hands, have the client slightly extend their neck, and ask them to swallow. As the client swallows, the gland is palpated for enlargement as the tissue rises and falls. Having the client flex their neck wouldn't allow for palpation. Massaging the area or checking during inhalation doesn't allow for the movement of tissue that swallowing provides.

A client with a history of angina and intermittent claudication reports pain in both legs with a need to stop and rest after ambulating down the hall. Which statement by the nurse best addresses this concern? a. "You are experiencing leg pain because of venous congestion." b. "You are experiencing pain due to inadequate removal of carbon dioxide from the tissues in the legs." c. "The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs." d. "The pain is related to atherosclerosis that is the same problem causing your angina."

c. When there is a history of atherosclerosis affecting the heart and resulting in intermittent claudication, there is arterial insufficiency. This results in inadequate provision of oxygenated blood to the muscles when there is an increase in muscle demand. This results in the pain of intermittent claudication. The other choices refer to problems with venous congestion rather than arterial perfusion. That the pain is related to atherosclerosis does not explain the specific reason for the pain.

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin. Client teaching about this drug should include which instruction? a. "Discontinue this medication after you've been seizure-free for 2 weeks." b. "Don't drive a car or operate machinery while taking this medication." c. "Schedule follow-up visits with your physician for blood tests." d. "Be aware that this drug may make your heart beat faster."

c. A client taking phenytoin to control seizures must undergo routine blood testing to monitor for therapeutic serum phenytoin levels. Typically, the client takes the medication for 1 year after the original seizure, then is reevaluated for continued therapy. During phenytoin therapy, the client may drive and operate machinery. This drug may cause a decreased heart rate and hypotension.

A client is newly diagnosed with pernicious anemia. The nurse is teaching the client to increase the vitamin B12 intake. Which is the most effective way for this client to increase vitamin B12 intake? a. increasing dietary intake of vitamin B12 b. taking an oral vitamin B12 replacement c. taking vitamin B12 injections or nasal spray replacement d. using chelation therapy

c. The client with pernicious anemia will require lifelong supplementation of vitamin B12, available through injection or nasal spray administration. It must be given in these forms to ensure absorption. Oral vitamin B12 would not be absorbed because the client lacks the intrinsic factor in the stomach necessary for absorption. Chelation therapy is used to extract metals at toxic levels such as in lead poisoning.

A staffing agency is assigning a licensed practical/vocational nurse (LPN/VN) to cover a shift on a pediatric unit. Because the unit manager is unfamiliar with the nurse's skill level, what assignment is best for the LPN/VN? a. 8-year-old child admitted that morning with suspected meningitis b. 9-year-old child receiving subcutaneous insulin for diabetes mellitus c. 10-year-old child who had a tonsillectomy that morning d. 9-year-old child with Legg-Calve'-Perthes disease

c. The unit manager should assign the LPN/VN to the child with diabetes mellitus. Because the client is receiving subcutaneous insulin rather than IV insulin, the diabetes is likely stable. Meningitis is an acute condition with the potential to progress into respiratory depression and seizures; this child will require frequent nursing assessments. The child who had a tonsillectomy remains at risk for hemorrhage during the first 24 hours following surgery. Legg-Calve'-Perthes disease is associated with impaired circulation to the femoral capital epiphysis; the child with this condition requires aggressive monitoring.

When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into the nurse's eyes. What should the nurse do next? a. Rinse their eyes with water, record the incident on the client's chart, and see Employee Health. b. Wash their hands, complete an incident report, and see a physician as soon as possible. c. Rinse their eyes with water, report the incident, and go to Employee Health. d. Rinse their eyes, contact Employee Health and document their findings.

c. Transmission of the AIDS virus can occur through contact with mucous membranes, so it's vital that the nurse immediately flush their eyes with water. The nurse should properly report and document the incident in an incident report and seek follow-up care with a medical professional. The nurse shouldn't record this incident on the client's care record. A nurse who fails to rinse their may allow viral transmission through contact with the mucous membranes.

A nurse is caring for a client who is anxious to know her baby's due date. The nurse instructs the client on how to determine the baby's due date according to Nägele's rule. The client is correct to state which comment when discussing the use of the rule? Select all that apply. a. "I need to know the date of intercourse when fertilization may have occurred." b. "I will calculate 9 months from my last menstrual period." c. "Nägele's rule provides a good approximation of the due date." d. "I will add 7 days to the first day of my last menstrual period and count back 3 months." e. "Nägele's rule may be used in conjunction with other assessment findings."

c., d., and e.

A client is hospitalized following a report of dizziness, shortness of breath, and chest pain. Based on the ECG rhythm, the client is scheduled for a transesophageal echocardiogram (TEE) today. Which nursing intervention would be appropriate at this time? a. Initiate a heparin drip. b. Encourage deep breathing exercises. c. Prepare the client for immediate electrical cardioversion. d. Administer oxygen via nasal cannula as prescribed.

d. After analyzing the waveform, it is noted that the client is experiencing atrial fibrillation and is symptomatic; therefore, because of the client's symptoms, the nurse would administer oxygen. Initiating a medication such as a heparin requires a health care provider order. Deep breathing exercises assist to open airways and reestablish lung function following surgery. A TEE is sometimes prescribed before electrical cardioversion to ensure that there are no clots in the atria; if none are found, then the cardioversion can be safely performed.

Atropine sulfate is included in the preoperative prescriptions for a client undergoing a modified radical mastectomy. What is the expected outcome of this drug? a. Promote general muscular relaxation. b. Decrease pulse and respiratory rates. c. Decrease nausea. d. Inhibit oral and respiratory secretions.

d. Atropine sulfate, a cholinergic blocking agent, is given preoperatively to reduce secretions in the mouth and respiratory tract, which assists in maintaining the integrity of the respiratory system during general anesthesia. Atropine is not used to promote muscle relaxation, decrease nausea and vomiting, or decrease pulse and respiratory rates. It causes the pulse to increase.

The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation? a. standard or routine precautions b. contact precautions c. airborne precautions d. droplet precautions

d. Bacterial meningitis is caused by one of three organisms, Haemophilus influenzae type b, Neisseria meningitidis, or Streptococcus pneumoniae. All three organisms may be transmitted through contact with respiratory droplets. These droplets are heavy and typically fall within 3 feet (91.4 cm) of the client. Droplet precautions require, in addition to standard (routine) precautions, that HCPs wear masks when coming into close contact with the client. Standard or routine precautions, previously referred to as universal precautions, are general measures used for all clients. Contact precautions are used when direct or indirect contact with the client causes disease transmission. Gowns and gloves are needed but not masks. Airborne precautions differ from droplet in that the particles are smaller and may stay suspended in the air for longer periods of time. These clients require negative pressure rooms, and all heath care workers must wear respirators.

A client with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use? a. reverse isolation b. strict hand washing c. standard precautions d. respiratory isolation

d. Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use respiratory isolation. This type of isolation involves wearing a gown and gloves during direct client care and ensuring that everyone who enters the client's room wears a mask. Reverse isolation is unnecessary because it's used for immunosuppressed clients who are at high risk for acquiring infection. Strict hand washing and standard precautions are insufficient for this client because they don't require the use of a mask.

A nurse is preparing a client for bronchoscopy. Which instruction is appropriate for the nurse to give to the client? a. "You will need to stay flat after the procedure." b. "Don't cough after the procedure." c. "You will not be able to talk for 4 hours following the procedure." d. "Don't eat for 6 hours prior to the procedure."

d. Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent ASPIRATION of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. The client will need to be in a semi-Fowler's position after the procedure. It isn't necessary for the client to avoid talking or coughing.

The nurse is teaching the client to self-administer insulin. Which approach to establishing learning goals will likely be most effective? When the goals are established by the: a. nurse and client because both need to be responsible for teaching. b. health care provider and client because the health care provider is the manager of care and the client is the main participant. c. client because the client is best able to identify his or her own needs and how to meet those needs. d. client, nurse, pharmacist, and health care provider so the client can participate in planning care with the entire team.

d. Learning goals are most likely to be attained when they are established mutually by the client and members of the health care team, including the nurse, pharmacist, and health care provider. Learning is motivated by perceived problems or goals arising from unmet needs. The perception of the unmet needs must be the client's; however, the nurse, pharmacist, and health care provider help the client arrive at his or her own perception of the need or reason to learn.

When a client is recovering as expected from spinal anesthesia the nurse should assess: a. level of consciousness. b. rate and depth of respirations. c. rate of capillary refill in the toes. d. degree of response to pinpricks in the legs and toes.

d. Return of sensation in the toes and legs marks recovery from spinal anesthesia. Because the client receiving spinal anesthesia is conscious, he will not ordinarily be disoriented. The client's respiratory status is not affected by spinal anesthesia. Capillary refill time is an indicator of circulatory status, not neurologic status.

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first? a. Administer the prescribed preanesthetic medication. b. Note this new allergy prominently on the medical record. c. Contact the scrub nurse in the operating room. d. Inform the anesthesiologist.

d. The anesthesiologist who administers the anesthetic agent and monitors the client's physical status throughout the surgery must have knowledge of all known allergies for client safety. The completed record (with the preoperative checklist) must be available to all members of the surgical team, and any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the medical record. The preanesthetic medication can cause light-headedness or drowsiness. The nurse in the scrub role provides sterile instruments and supplies to the surgeon during the procedure.

A client is taking clozapine and complains of a sore throat. This symptom may be an indication of which adverse reaction? a. extrapyramidal reaction b. tardive dyskinesia c. Reye's syndrome d. agranulocytosis

d. The complaint of a sore throat may indicate an infection caused by agranulocytosis, a depletion of white blood cells. Although extrapyramidal reaction and tardive dyskinesia may occur, a sore throat isn't an indication of these conditions. Reye's syndrome is caused by a virus unrelated to clozapine.

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? a. floor exercises b. stretching c. running d. walking

d. The best exercise for females who are on long-term corticosteroid therapy is a low-impact, weightbearing exercise such as walking or weight lifting. Corticosteroids effect the metabolism of calcium, Vitamin D, and bone which can lead to osteoporosis. 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 prescription has just been received for a 72-year-old client with gastrointestinal hemorrhage to have two blood transfusions. The registered nurse caring for the client is a pediatric nurse temporarily assigned to the unit who has never administered blood before. The best action of the charge nurse is to: a. ask the nurse to read the policy book before administering the blood. b. give a thorough explanation of the procedure for blood administration to the nurse. c. ask the nurse to determine how confident he or she is to administer the blood safely. d. reassign the client to another nurse who is experienced in blood administration.

d. The best option in this situation is to reassign the client to a nurse with experience in blood administration.The policy book and explanation are resources, but the nurse is a pediatric nurse who has never administered blood before, and therefore, an unsafe situation is created.An explanation is insufficient teaching for safe and proper blood administration, and reading policy book may be a resource, but having an experienced nurse administer the blood is a safer decision.Asking about the nurse's confidence is not sufficient evidence that the nurse can administer the blood. Asking an experienced nurse to administer the blood is a safer option.

A client is receiving chemotherapy for the diagnosis of brain cancer. When teaching the client about contamination from excretion of the chemotherapy drugs within 48 hours, what should the nurse tell the client? a. A bathroom can be shared with an adult who is not pregnant. b. Urinary and bowel excretions are not considered contaminated. c. Disposable plates and plastic utensils must be used during the entire course of chemotherapy. d. Any contaminated linens should be washed separately and then washed a second time, if necessary.

d. The client may excrete the chemotherapeutic agent for 48 hours or more after administration. Blood, emesis, and excretions may be considered contaminated during this time, and the client should not share a bathroom with children or pregnant women. Any contaminated linens or clothing should be washed separately and then washed a second time, if necessary. All contaminated disposable items should be sealed in plastic bags and disposed of as hazardous waste.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The health care provider (HCP) is notified because the nurse suspects which complication? a. phimosis b. hydrocele c. epispadias d. hypospadias

d. The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy.

One hour after receiving nalbuphine for pain during labor, a primigravida gives birth to a full-term neonate with symptoms of respiratory depression. The nurse anticipates that the neonate will require the administration of which drug? a. betamethasone b. naltrexone c. promethazine d. naloxone

d. The drug of choice to reverse opioid-induced respiratory depression in a neonate is naloxone, which reverses the effects of opioids. Betamethasone is administered to enhance surfactant production in preterm neonates. Naltrexone is used to relieve pruritus from epidural narcotics. Promethazine is used to control nausea and vomiting in the mother.

A physician orders a single dose of trimethoprim/sulfamethoxazole by mouth for a client diagnosed with an uncomplicated urinary tract infection. The pharmacy sends three unit-dose tablets. The nurse verifies the physician's order. What should the nurse do next? a. Administer the three tablets as the single dose. b. Call the physician to verify the order. c. Give one tablet, three times per day. d. Call the hospital pharmacist and question the medication supplied.

d. The nurse should call the hospital pharmacy and question the medication supplied. The hospital pharmacist should be able to tell the nurse whether three tablets are necessary for the single dose or whether a dispensing error occurred. It isn't clear whether the three tablets are the single dose because they were packaged as a unit-dose. The physician's order was clearly written, so clarifying the order with the physician isn't necessary. Administering the tablets without clarification might cause a medication error.

What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block? a. "Avoid drinking liquids until the gag reflex returns." b. "Avoid eating milk products for 24 hours." c. "Notify a nurse if you experience blood in your urine." d. "Remain supine for the time specified by the physician."

d. The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria.

After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when she says that which hormone is produced by the placenta? a. estrogen b. progesterone c. human chorionic gonadotropin (hCG) d. testosterone

d. The placenta does not produce testosterone. Human placental lactogen, hCG, estrogen, and progesterone are hormones produced by the placenta during pregnancy. The hormone hCG stimulates the synthesis of estrogen and progesterone early in the pregnancy until the placenta can assume this role. Estrogen results in uterine and breast enlargement. Progesterone aids in maintaining the endometrium, inhibiting uterine contractility, and developing the breasts for lactation. The placenta also produces some nutrients for the embryo and exchanges oxygen, nutrients, and waste products through the chorionic villi.

A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place them closer to the nurses' station because of their tendency to a. forget to eat. b. not change their position often. c. exhibit acquiescent behavior. d. wander.

d. A client with Alzheimer's disease is at risk for injury because of their tendency to wander. Placing them closer to the nurses' station makes it easier to monitor them and better ensures their safety if the client begins to wander. Placing the client closer to the nurses' station won't help the client remember to eat, change position often, or modify their behavior.

When teaching a group of adolescents about anorexia nervosa, the nurse should describe this disorder as being characterized by which factor? a. excessive fear of becoming obese, near-normal weight, and a self-critical body image b. obsession with the weight of others, chronic dieting, and an altered body image c. extreme concern about dieting, calorie-counting, and an unrealistic body image d. intense fear of becoming obese, emaciation, and a disturbed body image

d. An intense fear of becoming obese, emaciation (being abnormally thin or weak), and a disturbed body image all are considered to be characteristic of anorexia nervosa. Near-normal weight is not associated with anorexia. The weight of others is not a primary factor. "Concern about dieting" is not strong enough language to describe the control of food intake in the individual with anorexia nervosa.

Important teaching for a client receiving risperidone should include advising the client to: a. maintain a therapeutic level by doubling a dose if the client misses a dose. b. be sure to take the drug with a meal because it can severely irritate the stomach. c. discontinue the drug if the client gains weight. d. notify the physician if the client notices an increase in bruising.

d. Bruising may indicate blood dyscrasias, so notifying the physician about increased bruising is very important. The client shouldn't double the drug dose. This drug doesn't irritate the stomach, and weight gain isn't an adverse effect of risperidone therapy.

A client has a nursing diagnosis of fluid volume deficit. Which nursing assessment finding would support this diagnosis? a. leathery, pliable skin b. pretibial pitting edema c. pedal pulses of 4+ d. orthostatic blood pressure changes

d. Fluid volume deficit is characterized by hypotension, tachycardia, increased body temperature, and weakness. Leathery, pliable skin may not demonstrate fluid deficit; it may reflect diabetes. Pitting edema and pedal pulses of 4+ demonstrate localized edema and potential fluid excess.

A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. What should the nurse tell the client to expect when following this diet? The diet will: a. act as a diuretic. b. reduce demands on the liver. c. help maintain urine acidity. d. prevent the development of ketosis.

d. High-carbohydrate foods meet the body's caloric needs during acute renal failure. Protein is limited because its breakdown may result in accumulation of toxic waste products. The main goal of nutritional therapy in acute renal failure is to decrease protein catabolism. Protein catabolism causes increased levels of urea, phosphate, and potassium. Carbohydrates provide energy and decrease the need for protein breakdown. They do not have a diuretic effect. Some specific carbohydrates influence urine pH, but this is not the reason for encouraging a high-carbohydrate, low-protein diet. There is no need to reduce demands on the liver through dietary manipulation in acute renal failure.

A primigravid adolescent client at approximately 15 weeks' gestation is visiting the prenatal clinic to undergo maternal quad screening. What information should the nurse include in the teaching plan for this client? a. Ultrasonography usually accompanies maternal quad screen testing. b. Results are usually very accurate until 20 weeks' gestation. c. A clean-catch midstream urine specimen is needed. d. Increased levels of alpha fetoprotein are associated with neural tube defects.

d. Increased alpha fetoprotein (AFP) is one of the four laboratory values in a maternal quad screen. The labs are human chorionic gonadotropin, estriol, and inhibin-A. Increased AFP levels are associated with neural tube defects, such as spina bifida, anencephaly, and encephalocele. Ultrasonography is used to confirm a neural tube defect only when AFP levels are increased. Because AFP levels are usually highest at 15 to 18 weeks' gestation, this is the optimum time for testing. Performing the test after this time leads to inaccurate results. The client's blood, not urine, is used for the sample.

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

d. Leucovorin is administered with methotrexate to protect normal cells, which methotrexate could destroy if given alone. Probenecid should be avoided in clients receiving methotrexate because it reduces renal elimination of methotrexate, increasing the risk of methotrexate toxicity. Cytarabine and thioguanine aren't used to treat osteogenic carcinoma.

Which statement indicates that the client understands the home care of a colostomy? a. "I can attach my colostomy pouch directly to my skin as long as it is not irritated." b. "I can anticipate some pain around my stoma when I clean it." c. "I can expect to see some blood in my stool on occasion." d. "I should be able to establish a regular pattern of elimination with my colostomy."

d. Many colostomies, especially those located in the descending colon, can be regulated to evacuate on a schedule. All ostomy appliances should be applied using a peristomal skin barrier. There should be no pain associated with touching the stoma. After the immediate postoperative period, it is not normal for blood to be present in the stool. Bleeding should be reported to the client's health care provider.

A neonate born 2 hours ago has just arrived in the nursery. Which nursing measure will prevent the neonate from losing heat by evaporation? a. keeping the neonate away from drafts b. putting a blanket between the neonate and cold surfaces c. putting a cap on the neonate's head d. drying the neonate thoroughly after a bath

d. Neonates lose heat through evaporation as liquid is converted to a vapor. Drying a neonate after birth and following a bath prevents heat loss by evaporation. Keeping a neonate away from drafts prevents heat loss through convection. Keeping a neonate off a cold surface, such as a scale, prevents the loss of heat through conduction. Placing a cap on the neonate's head preserves heat and prevents heat loss from radiation.

The daughter of a client with Alzheimer's disease tells the nurse that her mother thinks someone is stealing her things. Which response by the nurse would be most helpful? a. "That behavior is typical of people with Alzheimer's disease and will become worse." b. "Your mother has problems with remembering where she puts things." c. "We have checked her room and nothing was missing?" d. "We asked the health care provider to evaluate your mother for paranoid delusions, which are common in people with Alzheimer's disease."

d. The best response addresses the daughter's concern and explains that paranoia and delusions are common in Alzheimer's disease. Stating that the behavior is typical of someone with Alzheimer's disease dismisses the daughter, is not helpful, and does not increase the daughter's knowledge about the disease. While it is important to share the information that the client's perceptions are not based in reality, telling the daughter that nothing is missing doe not address the underlying client problem. These are not delusions or her imagination but a reaction to not being able to remember.

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging the I.V. access device. The client's scheduled to receive amphotericin B I.V. Which action would be most appropriate for the nurse to take? a. Place bilateral wrist restraints on the client. b. Ask the physician to order sedation for the client. c. Delay giving the drug until the client's confusion disappears. d. Tell a nursing assistant to stay with the client during the infusion.

d. The client needs the medication to combat the protozoal infection. Because the client has been dislodging the I.V. access devices, a staff member should remain with with the client during the infusion. Bilateral wrist restraints are a poor choice for managing this situation, and using them doesn't ensure that the client will receive the medication. Giving sedation to a confused client is risky, and it's a poor alternative to having a staff member remain with the client. Administering the drug shouldn't be delayed; appropriate nursing action allows for the drug's administration.

A client is diagnosed with thrombophlebitis. What nursing action would demonstrate the appropriate level of activity for this client? a. bed rest with the affected extremity in the dependent position b. bed rest with all normal activities as long as there no increased pain on the affected site c. bed rest with the affected extremity flat d. Bed rest with the affected extremity elevated

d. Thrombophlebitis is an inflammatory process that causes a blood clot to form and block one or more veins, usually in your legs. Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Other answers are incorrect based on appropriate level of activity needed to assist the diagnosis. Bed rest with normal activity is incorrect because pain is not always experienced with a thrombophlebitis.

After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of a. sterile water. b. glucose water. c. standard infant formula. d. iron-fortified infant formula.

d. To prevent iron deficiency anemia

A multiparous client at 14 weeks' gestation has such severe morning sickness that she has "not been able to keep anything down for a week." The nurse should review the results of the urinalysis for which value? a. white blood cells b. albumin c. glucose d. ketones

d. When a client is not able to eat, the intake of carbohydrates is dramatically reduced, causing fat to be burned for energy. Improper fat metabolism results in ketones in the urine from the starvation this client is experiencing. Presence of white blood cells in the urine would suggest a possible urinary tract infection. Albumin in the urine is associated with kidney or heart disease. Glucose in the urine is associated with diabetes mellitus.

A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first? a. Prepare to administer a whole blood transfusion b. Prepare to administer a plasma transfusion c. Perform active range-of-motion (ROM) exercise on the affected part d. Elevate the affected part

d. Bleeding into the joint is the most common type of bleeding episode in the more severe forms of hemophilia. Elevating the affected part and applying pressure and cold are indicated. The nurse should anticipate transfusing the missing clotting factor rather than whole blood or plasma, which won't stop the bleeding promptly, and may pose a risk of fluid overload. Active ROM exercises are contraindicated because they may cause more bleeding, injury, and pain.

In preparation for discharge, the nurse teaches the mother of an infant diagnosed with bronchiolitis about the condition and its treatment. Which statement by the mother indicates successful teaching? a. "I need to be sure to take my child's temperature every day." b. "I hope I do not get a cold from my child." c. "Next time my child gets a cold I need to listen to the chest." d. "I need to wash my hands more often."

d. Handwashing is the best way to prevent respiratory illnesses and the spread of disease. Bronchiolitis, a viral infection primarily affecting the bronchioles, causes swelling and mucus accumulation of the lumina and subsequent hyperinflation of the lung with air trapping. It is transmitted primarily by direct contact with respiratory secretions as a result of eye-to-hand or nose-to-hand contact or from contaminated fomites. Therefore, handwashing minimizes the risk for transmission. Taking the child's temperature is not appropriate in most cases. As long as the child is getting better, taking the temperature will not be helpful. The mother's statement that she hopes she does not get a cold from her child does not indicate understanding of what to do after discharge. For most parents, listening to the child's chest would not be helpful because the parents would not know what they were listening for. Rather, watching for an increased respiratory rate, fever, or evidence of poor eating or drinking would be more helpful in alerting the parent to potential illness.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect a. pallor and coolness of the left foot with decreased sensation. b. a decrease in the left dorsalis pedis and posterior tibial pulses. c. loss of hair on the lower portion of the left leg and foot. d. left calf circumference 1" (2.5 cm) larger than the right.

d. Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased sensation, decreased pulses, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.

Possible causes of respiratory acidosis (excess CO2 retention)?

pH < 7.35 HCO3- > 26 PaCO2 > 45 - CNS depression from drugs - asphyxia - hypoventilation due to pulmonary, cardiac, musculoskeletal, or neuromuscular disease. - obesity - postoperative pain - abdominal distention