NCLEX review Practice Exam 1
A short time after administering pain medication to a client, the nurse returns to the client's room and finds the client difficult to arouse. The nurse realizes that 25 ml of the liquid medication was administered instead of the ordered 25 mg, which is contained in 5 ml. How could the nurse have prevented this error?
Carefully review the order and medication label, then calculate the ordered dose. Explanation: The nurse should always take the time to identify the client, carefully review the medication order, read the medication label, and calculate the ordered dose. Consistently following these steps helps prevent medication administration errors. The nurse should double check calculations with another nurse, not ask another nurse to double check all medications. The nurse can use non-pharmacological pain therapies, but as an adjunct to pain medications and not a last resort. Using non-pharmacological therapies only delays treatment and places the client at risk for intensified pain. Highlighting dosage instructions can lead to errors if done inconsistently. It is best to carefully review each order.
When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by which method?
Pulling the ear pinna back, up, and out Explanation: Pulling the pinna back, up, and out helps straighten an adult's ear canal so the nurse can properly place a tympanic thermometer probe. Pulling the ear pinna back, down, and out straightens a child's ear canal. Pulling the ear pinna only out or back does not straighten the ear canal for probe placement.
A nurse caring for a client with schizophrenia goes into the client's room to administer medication. While looking out the window at the trees, the client remarks, "That school across the street has creatures in it that are waiting for me." Which of the following is the most appropriate response by the nurse?
"How do you feel when you see the creatures?" Explanation: The most appropriate response by the nurse is "How do you feel when you see the creatures?" The client is experiencing a delusion, a false belief that has no basis in reality. When the client experiences a delusion, it is important to acknowledge the delusion and to ask the client to describe it and how it makes them feel. These actions help identify the type of delusions so that the correct intervention can be implemented while establishing trust. If asked, the nurse should point out that they are not experiencing the same stimuli but should not argue with the client.
A client is evaluated for type 1 diabetes. Which client comment correlates best with this disorder?
"I'm thirsty all the time. I just can't get enough to drink." Explanation: Classic signs and symptoms of diabetes mellitus are polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive appetite). Decreased appetite, lingering cough and cold, and pain on urination are not related to diabetes. Decreased appetite reflects a GI disorder; clients with Type 1 diabetes have increased appetite. Urination increased, but the urine does not necessarily smell bad. Dry skin is not uncommon, however the thirst is usually the first sign.
A nurse is caring for a 14-year-old adolescent who states, "No one understands me." Which of the following statements by the nurse best demonstrates empathy?
"It is difficult being a teenager. Tell me more." Explanation: Empathy is the ability to put oneself in another's place and experience a feeling as that person is experiencing it. The correct answer acknowledges the child's feelings and conveys an understanding without intimidating the child.
The mother of an infant being admitted to the hospital is crying and very upset. What would be the nurse's best response?
"What is it that is making you cry right now?" Explanation: The nurse's best response is an open-ended question that gives the mother an opportunity to verbalize fears, share concerns, and ask for information.
The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse?
A urinary output of 50 mL in the past 3 hours Explanation: Sepsis can cause the release of myoglobin from the cells which will directly block the renal tubules causing decreased urinary output. If it is not treated with hydration and antibiotics, the client could develop renal failure. A high white blood cell count is expected with sepsis. Temperature can be elevated or below normal, in clients with sepsis. The elevated pulse and respirations are normal in the presence of infection and should be monitored. The saturated oxygen level is within normal limits as is the blood pressure.
A nurse is preparing to teach a 13-year-old adolescent with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session?
Adolescents are worried about appearing different from their peers. Explanation: Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this information will help the nurse construct an effective teaching plan. Adolescents are capable of following detailed instructions. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. Fine motor coordination is well developed by adolescence. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives to establish a sense of identity; identity isn't already well-developed.
A neonate with multiple congenital defects is ready for discharge. The parents express concern about caring for the neonate at home. How can the nurse best help the parents?
Arrange a meeting between the health care team and the parents to develop a care plan. Explanation: A multidisciplinary team meeting with the parents to develop a care plan can help the parents meet the neonate's needs at home. The neonate will also require visits from the community nurse; however, a multidisciplinary approach is needed to prepare the parents for discharge. Written instruction should supplement teaching, not replace it. The parents should schedule a follow-up appointment with the pediatrician; however, the parents need help before discharge.
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?
Check the equipment. Explanation: A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.
When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis?
Improved muscle strength after I.V. administration of edrophonium chloride. Explanation: Extreme muscle weakness is present in both cholinergic crisis and myasthenic crisis. In cholinergic crisis, I.V. edrophonium chloride, a cholinergic agent, does not improve muscle weakness; in myasthenic crisis, it does. Diaphoresis and increased salivation are not present in cholinergic crises.
After insertion of bilateral tympanostomy tubes in a toddler, which instruction should the nurse include in the child's discharge plan for the parents?
Insert ear plugs into the canals when the child bathes. Explanation: Placing ear plugs in the ears will prevent contaminated bathwater from entering the middle ear through the tympanostomy tube and causing an infection. Inserting cotton swabs into the ear canal is not recommended. It is not necessary to administer antibiotics continuously to a child with a tympanostomy tube. Antibiotics are appropriate only when an ear infection is present. Drainage from the ear may be a sign of middle ear infection and should be reported to the health care provider (HCP).
A client was diagnosed with AIDS several years ago. He now has a CD4 T-lymphocyte count of 110 units/L. Which of the following is an appropriate outcome for this client?
No development of opportunistic infections Explanation: The CD4 count is low, indicating a risk for opportunistic infections. It does not alter risk for bleeding or bruisng. CD4 count does not affect weight loss or gain. Breaks in skin integrity would be potential sources of infection, but not the opportunistic infections that result from a decrease in immunity, as represented by a low CD4 count.
A physician orders acetaminophen elixir, 160 mg every 4 hours, for a 14-month-old child who weighs 20 lb (9.08 kg). This drug, supplied in a bottle labeled 160 mg/tsp, has a safe dosage of 10 mg/kg/dose. The nurse should administer how many milliliters?
None because this isn't a safe dose Explanation: For this client, the safe dose of this drug is 90.8 mg (9.08 kg × 10 mg/kg = 90.8 mg). This dose is equivalent to 2.8 ml. Therefore, the ordered dose isn't safe.
The nursing instructor is working with a student in a pre-operative unit. The student notices that the informed consent has not been signed. Which is the best action taken by the student nurse for obtaining informed consent?
Notifying the physician involved with the procedure that the consent has not been signed Explanation: The physician involved with the procedure is responsible for obtaining the client's informed consent. The primary nurse or the nurse working with the physician may witness the client's signature. The social worker may not obtain informed consent.
A student nurse requires additional teaching if which of the following factors is identified as contributing to a client's Risk for infection?
Proper nutrient intake Explanation: Malnutrition, rather than proper nutrient intake, would put the client at risk for infection. Inadequate secondary defenses, impaired primary defenses, and chronic disease put the client at risk by lowering the body's ability to fight infection.
The nurse is planning with a client who has cancer to improve the client's independence in activities of daily living after radiation therapy. What should the nurse do?
Provide positive reinforcement for skills achieved. Explanation: The positive reinforcement builds confidence and facilitates achievement of rehabilitation goals. Community support may or may not be applicable after discharge. Although family support is an important component of rehabilitation, reinforcing the skills the client has acquired is of greater importance when regaining independence. Rehabilitation plans should include the client, family, or both.
A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case?
Restrain the client, as he is harmful to the other clients. Explanation: The nurse should restrain the client because he is potentially harmful to other clients in the psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however. The nurse should inform the physician about the client, but sometimes it may not be logical to wait for orders to restrain a violent client.
The nurse collects a urine specimen from a client for a culture and sensitivity analysis. What should the nurse do next?
Send the specimen to the laboratory immediately. Explanation: A specimen for culture and sensitivity should be sent to the laboratory promptly so that a smear can be taken before organisms start to grow in the specimen.
An emergency room nurse concerned about the emotional health of a child who has been in a motor vehicle accident should collaborate with which of the following disciplines?
Social services Explanation: The nurse should collaborate with the social services to provide care for the child who has been in a motor vehicle accident. After such a traumatic life event, this child's care will involve dealing with his emotional health as well as his physical recovery. Pharmacy, nutritional services, and infectious disease services are not indicated at this time.
The nurse is making team assignments and is assigning tasks to the unlicensed assistive personnel (UAP). unit. What information should the nurse know before delegating tasks to the UAP?
The UAP's level of knowledge and comfort level in performing specific nursing activities should be considered. Explanation: The RN is responsible for providing, delegating, and at times supervising others to ensure safe nursing care. They remain responsible when delegating nursing tasks to other members of the health care team. The nurse should delegate tasks in collaboration with the UAP, considering their knowledge level and comfort when performing various aspects of care, regardless of whether the UAP has previously completed these activities.
A client was admitted to the behavioral health unit with a diagnosis of severe depression. The client was started on buproprion. Forty-eight hours after initiating the drug therapy, the client has recovered from depression, is laughing, singing, and dancing in the hallway and in the sitting room. How should the nurse interpret this behavior?
The client is most likely bipolar rather than depressed, and the healthcare provider should be notified of the behavior. Explanation: This behavior is often seen in clients who are bipolar when placed on an antidepressant. A mood stabilizer, such as lithium or lamotrigine, is needed to balance emotional states. The medication has affected the depression, but the client is bipolar and needs a mood stabilizer instead. These side effects occur in a person who is bipolar rather than someone suffering from depression.
A dying patient requests that the nurse pray with him. The nurse is not accustomed to praying aloud but is comfortable praying silently. What is the best approach for this nurse to follow to pray with this patient?
The nurse should select a formal prayer or Bible passage to use to pray aloud. Explanation: A nurse unaccustomed to praying aloud or in public may find it helpful to have a Bible passage or formal prayer readily available for praying. If the nurse is not comfortable praying with the patient, he or she should call the hospital chaplain or find another individual who is comfortable.
A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis?
Tripod position Explanation: The child being in the tripod position (sitting up and leaning forward) supports the diagnosis of epiglottitis because this position facilitates breathing. Epiglottitis presents with a sudden onset of signs and symptoms, such as high fever, muffled speech, inspiratory stridor, and drooling.
Which client is at greatest risk for Buerger's disease?
a 29-year-old male with a 14-year history of cigarette smoking. Explanation: Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic, inflammatory vasoocclusive disorder. The disorder occurs predominantly in younger men less than 40 years of age, and there is a very strong relationship with tobacco use. Diagnosis is based on age of onset, history of tobacco use, symptoms, and exclusion of diabetes mellitus.
When assessing a client with left-sided heart failure, the nurse expects to note:
air hunger. Explanation: With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.
When obtaining a nursing history from parents who are suspected of abusing their child, which characteristic about the parents should the nurse particularly assess?
difficulty with controlling aggression Explanation: Parents of an abused child have difficulty controlling their aggressive behaviors. They may blame the child or others for the injury, may not ask questions about treatment, and may not know developmental information
To prevent external rotation of the client's hips while lying on the back, it would be best for the nurse to place:
trochanter rolls alongside the legs from ilium to midthigh.
A client has an ileal conduit. Which solution will be useful to help control odor in the urine collecting bag after it has been cleaned?
vinegar Explanation: A distilled vinegar solution acts as a good deodorizing agent after an appliance has been cleaned well with soap and water. If the client prefers, a commercial deodorizer may be used. Salt solution does not deodorize. Ammonia and bleaching agents may damage the appliance.
The label of a drug package reads "meperidine hydrochloride, 50 mg/ml." How many milliliters should a nurse give a client for a 30-mg dose?
0.6 ml
Clients receiving a monoamine oxidase inhibitor must avoid tyramine, a compound found in which foods?
Aged cheese and Chianti wine Explanation: Aged cheese and Chianti wine contain high concentrations of tyramine. Green, leafy or yellow vegetables, figs, cream cheese, and fruit are low in tyramine.
A laboring client's membranes rupture, and the nurse notes that the amniotic fluid is meconium stained. Which of the following activities should the nurse immediately perform?
Begin continuous fetal heart rate monitoring. Explanation: Meconium staining in the amniotic fluid is not always a sign of fetal distress but is correlated with its occurrence. It reveals that the fetus has had an episode of loss of sphincter control. This clinical situation requires further investigation with fetal heart rate monitoring. There is no indication that birth is imminent. Changing the client to left lateral position may enhance uteroplacental exchange, allowing more oxygen to reach the fetus; however, it is most critical to assess the fetal heart rate, as this provides immediate information surrounding the health and safety of the fetus.
Which client has a greater risk for latex allergies?
a woman who is admitted for her seventh surgery Explanation: Clients who have had long-term multiple exposures to latex products, such as would occur with six previous surgeries and recoveries, are at increased risk for latex allergies. The nurse should explore what types of surgeries these were, how involved the client's recoveries were, and whether signs of latex allergies have occurred in the past. Working as a sales clerk, having type 2 diabetes, and undergoing laser surgery do not expose a client to latex or increase the risk of latex allergy.
After the nurse administers haloperidol 5 mg PO to a client with acute mania, the client refuses to lie down on her bed, runs out on the unit, pushes clients in her vicinity out of the way, and screams threatening remarks to the staff. What should the nurse do next?
Seclude the client and use restraints if necessary. Explanation: The client is visibly out of control, and other measures have not helped. Therefore, the nurse needs to seclude the client and use restraints if necessary to protect the client and others from harm. Following the client and asking her to calm down or telling the client to lie down on the sofa is not helpful because the client's level of anxiety is too high for her to attempt to calm down on her own and she cannot control her behavior. Telling the staff to ignore the client's remarks is not helpful because the client needs external means of control to protect the client, other clients on the unit, and the staff. Safety is the priority.
A preschool-age child refuses to take ordered medication. Which nursing strategy is most appropriate?
Showing trust in the child's ability to cooperate even with an unpleasant procedure Explanation: To gain a preschooler's cooperation, the most appropriate strategy is for the nurse to show trust and express faith in the child's ability to cooperate even with an unpleasant procedure. Hiding the medication in milk may foster mistrust. The nurse should provide simple, not detailed, explanations and should use terms the child can understand. Shaming the child is inappropriate and may lead to feelings of guilt.
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?
The client voids 500 mL of urine. Explanation: 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.
A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. When assessing the client on admission, the nurse should first ask the client:
if he is thinking about hurting himself.
When assessing for signs of a blood transfusion reaction in a client with dark skin, the nurse should assess for:
diaphoresis. Explanation: The nurse should assess for signs of impending shock such as diaphoresis. The client would have hypotension, dysuria, and cool skin.
When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be:
administering pain medication. Explanation: In Maslow's hierarchy of needs, pain relief is on the first layer. Love and belonging, as in allowing family members to visit are on the fourth layer. Activity, as in ambulation, is on the second layer. Safety, as in placing wrist restraints on the client, is on the third layer.
When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in:
cardiac arrhythmias. cardiac arrhythmias. Explanation: Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue.
The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal birth. The nurse should next:
apply an ice pack to the perineal area. Explanation: The client has a hematoma. During the first 24 hours postpartum, ice packs can be applied to the perineal area to reduce swelling and discomfort. Ice packs usually are not effective after the first 24 hours. Although vital signs, including temperature, are important assessments, taking the client's temperature is unrelated to the hematoma and would provide no additional information about swelling. After 24 hours, the client may obtain more relief by taking a warm sitz bath. This moist heat is an effective way to increase circulation to the perineum and provide comfort. Usually, hematomas resolve without further treatment within 6 weeks. Additionally, the nurse should measure the hematoma to provide a baseline for subsequent measurements and should notify the HCP of its presence. An antibiotic is not warranted at this point because the client is not exhibiting any signs or symptoms of infection.
A client is scheduled for oral cholecystography. Prior to the test, the nurse should:
ask the client about possible allergies to iodine or shellfish. Explanation: Iodine compounds used as radiographic contrast agents, such as iopanoic acid),, should not be administered to the client with iodine and seafood allergies, because anaphylaxis may occur. Drinking large amounts of water is indicated for certain kidney or urinary bladder studies, not gallbladder studies. The contrast agent is administered orally 10 to 12 hours before the test. The client is NPO after administration of the contrast agent. Enemas are not required for cholecystography.
The nurse is facilitating a group of clients with schizophrenia when one client says, "I like to drive my car, bar, tar, far." This client is exhibiting:
clang association. Explanation: Linking words together based on their sounds rather than their meanings is called clang association. Echolalia is the involuntary parrot like repetition of words spoken by others. Echopraxia refers to meaningless imitation of others' motions. Neolgisms are words that a person invents.
When taking a diet history from the mother of a 7-year-old child with phenylketonuria, a report of an intake of which food should cause the nurse to gather additional information?
diet cola Explanation: Foods with low phenylalanine levels include vegetables, fruits, and juices. Foods high in phenylalanine include meats and dairy products, which must be restricted or eliminated. Diet colas contain more phenylalanine than the fruits listed.
The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated?
droplet precautions Explanation: Meningococcal infections are spread through close mucous membrane or respiratory contact with large respiratory droplets. Meningococcal infections are not spread by small airborne organisms or contact with a person's skin or contaminated items. Standard precautions, used when touching body fluids, are not sufficient to prevent the spread of meningitis.
A health care provider (HCP) has been exposed to hepatitis B through a needlestick. Which drug should the nurse anticipate administering as postexposure prophylaxis?
hepatitis B immune globulin Explanation: Hepatitis B immune globulin is given as prophylactic therapy to individuals who have been exposed to hepatitis B. Interferon has been approved to treat hepatitis B. Hepatitis B surface antigen is a diagnostic test used to detect current infection. Amphotericin B is an antifungal.
A client states the following to the nurse: "I am a failure, and I wish I had died." Which of the following statements by the nurse demonstrates a therapeutic response?
"You feel like a failure; would you like to talk more about the way you feel?" Explanation: Acknowledging the client's feelings by repeating what the client states is therapeutic. It is also therapeutic for the nurse to offer to discuss the client's feelings further. The other options are incorrect because they dismiss the client's feelings.
A nurse is attending a seminar at the local senior center. The nurse knows the presenter has a good understanding of genitourinary changes in the elderly when the client makes which of the following statements?
"You should leave a light on in your bathroom at night." Explanation: Urinary incontinence, although common in the elderly is not a normal part of aging. Not drinking after lunch can lead to dehydration. Stress incontinence is related to detrusor muscle weakness and not dementia or Alzheimer's disease. Leaving a light on in the bathroom at night appropriately addresses possible safety/fall concerns.
A nurse prepares to administer medication by the buccal route. Where should the nurse place this medication?
Between the client's cheek and gum Explanation: The nurse should place medication administered by the buccal route in the client's upper or lower buccal pouch, between the cheek and gum. She should apply a topical medication to the client's skin; place a sublingual medication under his tongue on the floor of the mouth; and administer an eye (ocular) medication in the conjunctival sac.
During each prenatal checkup, a nurse obtains a client's weight and blood pressure and measures fundal height. What is another essential part of each prenatal checkup?
Evaluating the client for edema Explanation: During each prenatal checkup, the nurse should evaluate the client for edema, a possible sign of gestational hypertension. If edema exists, the nurse should assess for high blood pressure and proteinuria — other signs of gestational hypertension. Hb is measured during the first prenatal visit and again at 24 to 28 weeks' gestation and at 36 weeks' gestation. The pelvis is measured and the Rh factor is determined during the first prenatal visit.
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?
Fever, decreased level of consciousness (LOC), and impaired liver function Explanation: 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.
Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client?
a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance Explanation: Using the Morse fall scale, risk factors for this client include history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, weak gait/transfer, and forgetting limitations (100 points). Client no. 1 is also high risk with a secondary diagnosis, history of falling, IV access, and confusion but is on bed rest (75 points). Client no. 2 risks include IV access and secondary diagnosis (35 points). Client no. 4 is at risk due to his IV access only (20 points).
Which of the following is the most important consideration when performing tracheotomy suctioning?
The client should be hyperoxygenated, then suctioned for the duration of 10 to 15 seconds. Explanation: The most important aspect is to ensure the client is hyperoxygenated to increase oxygen saturation levels. Then suctioning should be limited to 10-15 seconds. This helps to prevent desaturation so that breathing is not compromised. It is not enough to apply oxygen if desaturation occurs. Suctioning should be done when necessary, not as a routine. Fluid intake is increased to help liquefy the secretions.
A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin 500 mg, the nurse notices that the pharmacy sent cefazolin. What should the nurse do? Select all that apply.
• Request that cephalexin be sent promptly. • Verify the medication order as written by the by the health care provider. (HCP). • Contact the pharmacy and speak to a pharmacist. • Return the cefazolin to the pharmacy.
A client is admitted to the Emergency Department with a full thickness burn to the right arm. Upon assessment, the arm is edematous, fingers are mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10. The nurse should:
call the health care provider (HCP) to report the loss of the radial pulse. Explanation: Circulation can be impaired by circumferential burns and edema, causing compartment syndrome. Early recognition and treatment of impaired blood supply is key. The HCP should be informed since an escharotomy (incision through full-thickness eschar) is frequently performed to restore circulation. Pain management is important for burn clients, but restoration of circulation is the priority. Assessments should be performed every 15 minutes while there is absence of the radial pulse. Exercise will not restore the obstructed circulation.
A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The nurse should first:
inquire about the onset, duration, severity, and precipitating factors of the heaviness. Explanation: Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the HCP.
A nurse is teaching a client about taking antihistamines. Which information should the nurse include in the teaching plan? Select all that apply.
• Operating machinery and driving may be dangerous while taking antihistamines. • Increase fluid intake to 2,000 mL/day. • Do not use alcohol with antihistamines.
An obese diabetic client has bilateral leg aching is to start a cardiac rehabilitation with an exercise program. Using which exercise equipment will be most helpful to the client?
stationary bicycle Explanation: The stationary bicycle is the most appropriate training modality because it is a non-weight-bearing exercise. The time that the individual exercises on the stationary bicycle is increased with improved functional capacity. The other exercise equipment requires exercising while standing.
A client who has apnea during sleep would require which of the following interventions? Select all that apply.
• Refer to primary healthcare provider • Have client keep a sleep diary • Assess sleep routine/hours Explanation: The client with periods of apnea may require a more thorough assessment including a sleep routine/hour and sleep diary as well as a referral to a primary healthcare provider. Pursed-lip breathing has no influence on sleep apnea. Family may sleep in the same room.
A client and her boyfriend of 5 months are celebrating the birth of a healthy baby boy when the client's estranged partner arrives to visit the baby he believes is his son. The nurse caring for the client knows that the estranged partner has the right to:
hold the neonate after the mother gives permission. Explanation: The neonate's mother has legal control over the neonate. Therefore, the mother must grant permission for her estranged partner to hold him. The neonate commonly stays in the mother's room, not in the nursery. Therefore, looking through the nursery window isn't an option. The estranged partner can't ask to have the boyfriend removed because the client wants him to remain. The mother must sign the consent for circumcision
A nurse is assessing a client with bone cancer pain. Which part of a thorough pain assessment is most significant for this client?
intensity Explanation: Intensity is indicative of the severity of pain and is important for evaluating the efficacy of pain management. The cause and location of the pain cannot be managed, but the intensity of the pain can be controlled. The nurse and client can collaborate to reduce aggravating factors; however, the goal will ultimately be to reduce the intensity of the pain.
As an angry client becomes more agitated while talking about his problems, the nurse decides to ask for staff assistance in taking control of the situation when the client demonstrates which behavior?
picking up a pool cue stick and telling the nurse to get out of his way Explanation: Asking the staff for assistance is appropriate when the client demonstrates behaviors that involve the direct threat of violence. Holding a stick and telling the nurse to move is the most direct threat of violence. Swearing and pounding on a table may be disturbing, but these actions are less of a threat. Coming out of his room may indicate noncompliance with directions. However, further assessment is needed to determine whether this behavior was a direct threat of violence.
A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:
profound neuromuscular irritability. Explanation: Hypoparathyroidism may slow bone resorption, reduce the serum calcium level, and cause profound neuromuscular irritability (as evidenced by tetany). Hypoparathyroidism doesn't alter blood pressure or affect the thirst mechanism, which usually is triggered by fluid volume deficit. Gastritis doesn't cause or result from hypoparathyroidism.
The nurse is caring for an elderly client who has hip pain related to rheumatoid arthritis. The client is practicing appropriate self-care activities when the client chooses to sit in which type of chair?
straight-back chair with elevated seat Explanation: It is important that clients with rheumatoid arthritis maintain proper posture and body alignment to support joints and decrease pain and stiffness. Clients with hip pain will be most comfortable when sitting in a straight-back chair with an elevated seat. Elevated seats avoid excessive hip flexion and place less stress on the hip joints.
When preparing a client for electroconvulsive therapy (ECT), the nurse should make sure that:
the client has undergone a thorough medical evaluation. Explanation: Before an ECT treatment, the nurse should ensure that the client has had a medical evaluation that includes an electrocardiogram, a chest X-ray, neurologic and laboratory tests, and spinal X-rays, if indicated. Although making sure that the client sees family members immediately before the procedure would be appropriate, it's unnecessary (unless the client requests this). A brain scan isn't required after ECT because such a scan can't evaluate the therapeutic effects of this treatment. The client should be NPO for at least 8 hours before the treatment to decrease the risk of aspiration and vomiting
A client has a tumor of the posterior pituitary gland. The nurse planning his care would include which interventions? Select all that apply.
• Assess urine specific gravity. • Monitor intake and output. • Take daily weight. Explanation: Tumors of the pituitary gland can lead to diabetes insipidus because of a deficiency of antidiuretic hormone (ADH). Decreased ADH reduces the ability of the kidneys to concentrate urine, resulting in excessive urination, excessive thirst, and excessive fluid intake. To monitor fluid balance, the nurse would weigh the client daily, measure urine specific gravity, and monitor intake and output. The nurse would encourage fluids to keep intake equal to output and prevent dehydration. Coffee, tea, and other fluids that have a diuretic effect would be avoided.
A stable older adult client is comatose following a cerebral vascular accident. The primary healthcare provider believes a gastrostomy tube should be placed for long-term nutrition. No family members have been located. Which of the following should be done to obtain informed consent for the procedure?
The nurse should contact the person identified as the healthcare power of attorney. Explanation: Clients may have several types of legal documents regarding healthcare decisions. A healthcare power of attorney is a document that authorizes a person to make healthcare decisions if the client is unable. A DNR order designates when to withhold life support but does not include food or fluids. A client may have a living will to state what sort of treatment they want at the end of life, but it may not be legally binding in all states, provinces, or territories. A last will and testament allocates the client's possessions but does not address healthcare needs.
An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of:
myxedema coma. Explanation: Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.
When fluids by mouth are appropriate for the infant after surgery to correct intussusception, the nurse most likely would initiate feeding with:
oral electrolyte solution. Explanation: When a child is ready to take fluids by mouth postoperatively, clear liquids are given initially. If clear liquids are tolerated, the concentration and amount of oral feedings are gradually increased. This means advancing to half-strength and then to full-strength formula while increasing the amount given with each feeding.
The amount of air inspired and expired with each breath is called:
tidal volume. Explanation: Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways.
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for:
hypotension. Explanation: When a client receives an epidural anesthetic, sympathetic nerves are blocked along with the pain nerves, possibly resulting in vasodilation and hypotension. Other adverse effects include bladder distention, prolonged second stage of labor, nausea and vomiting, pruritus, and delayed respiratory depression for up to 24 hours after administration. Diaphoresis and tremors are not usually associated with the administration of epidural anesthesia. Headache, a common adverse effect of many drugs, also is not associated with administration of epidural anesthesia.
The mother of a 28-year-old client who is taking clozapine states, "Something is wrong. My son is drooling like a baby." What response by the nurse would be most helpful?
"Excess saliva is common with this drug; here is a paper cup for him to spit into." Explanation: Telling the mother that excess saliva is a common adverse effect of the drug is most helpful because it gives her information about the problem, thereby helping to decrease her anxiety about what is occurring with her son. By offering the paper cup, the nurse also demonstrates concern for the client, thereby leading to increased trust. Saying, "I wonder if he is having an adverse reaction to the medicine," shows the nurse's lack of knowledge about the drug, decreases confidence in the nurse, and indicates poor judgment. Saying, "Do not worry about it, it is only a minor inconvenience compared to its benefits," or telling the mother that the nurse has seen this happening to other clients is insensitive and does not assuage the mother's anxiety.
A client with known coronary artery disease reports intermittent chest pain, usually on exertion. The physician diagnoses angina pectoris and orders sublingual nitroglycerin to treat acute angina episodes. When teaching the client about nitroglycerin administration, which instruction should the nurse provide?
"Be sure to take safety precautions because nitroglycerin may cause dizziness when you stand up." Explanation: Nitroglycerin commonly causes orthostatic hypotension and dizziness. To minimize these problems, the nurse should teach the client to take safety precautions, such as changing to an upright position slowly, climbing up and down stairs carefully, and lying down at the first sign of dizziness. To ensure the freshness of sublingual nitroglycerin, the client should replace tablets every 3 to 6 months, not every 9 months, and store them in a tightly closed container in a cool, dark place. Many brands of sublingual nitroglycerin no longer produce a burning sensation. The client should take a sublingual nitroglycerin tablet at the first sign of angina. He may repeat the dose every 5 minutes for up to three doses; if this intervention doesn't bring relief, the client should seek immediate medical attention.
The parent of a toddler hospitalized for episodes of diarrhea reports that when the toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I do not know what to do!" After teaching the parent about ways to manage this behavior, which statement indicates that the nurse's teaching was successful?
"Next time she screams and throws her legs, I'll ignore the behavior." Explanation: The child is demonstrating behavior associated with temper tantrums, which are relatively frequent normal occurrences during toddlerhood as the child attempts to develop a sense of autonomy. The development of autonomy requires opportunities for the child to make decisions and express individuality. Ignoring the outbursts is probably the best strategy. Doing so avoids rewarding the behavior and helps the child to learn limits, promoting the development of self-control. However, the mother should intervene in a temper tantrum if the child is likely to injure herself. Allowing the child to have what she wants occasionally would typically add to the problems associated with temper tantrums because doing so rewards the behavior and prevents the child from developing self-control. Toddlers do not possess the capacity to understand explanations about behavior. Expressing disappointment in the child's behavior or telling her that she is being a bad girl reinforces feelings of guilt and shame, thus interfering with the child's ability to develop a sense of autonomy.
The nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy?
Partial thromboplastin time, 1.5 to 2.5 times the normal control. Explanation: The nurse should adjust the heparin dose to maintain the client's partial thromboplastin time between 1.5 and 2.5 times the normal control. The prothrombin time and International Normalized Ratio are used to maintain therapeutic levels of warfarin, oral anticoagulation therapy. The thrombin clotting time is used to confirm disseminated intravascular coagulation.
