NCLEX Review

The nurse cares for the client diagnosed with asthma. The physician orders neostigminenIM. Which of the following actions by the nurse is MOST appropriate? 1. Administer the medication. 2. Check the blood pressure and pulse. 3. Ask the pharmacy if the medication can be given orally. 4. Notify the physician.

Question: Can neostigmine be administered to a client with asthma? Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. Needed Info: Neostigmine (Prostigmin) is a cholinergic (parasympathomimetic) used to treat myasthenia gravis and is an antidote for nondepolarizing neuromuscular blocking agents; side effects include nausea, vomiting, abdominal cramps, respiratory depression, bronchoconstriction, hypotension, and bradycardia. Nursing considerations include monitoring vital signs frequently, having atropine injection available, taking with milk, potentiates the action of morphine. (1) causes bronchoconstriction; notify physician (2) assessment; neostigmine causes hypotension and bradycardia; important to monitor vital signs, but priority is to notify the physician (3) medication used cautiously in clients with asthma. (4) CORRECT - cholinergics can cause bronchoconstriction in asthmatic clients; may precipitate an acute asthmatic attack

The nurse cares for the client receiving phenytoin intravenously. The nurse recognizes that the medication is administered in which of the following fluids? 1. 5% dextrose in water (D5W). 2. Lactated Ringer's solution. 3. 10% dextrose in water (D10W). 4. Normal saline.

Question: Dilantin should be mixed with which type of fluid? Strategy: Determine the outcome of each answer. Needed Info: Phenytoin (Dilantin) is an anticonvulsant; side effects include drowsiness, ataxia, nystagmus, blurred vision, gingival hypertrophy; give medication with meals to minimize GI irritation, inform client that red-brown or pink discoloration may occur; instruct about proper oral hygiene; never mix with other drugs. (1) may precipitate in any fluid containing dextrose (2) body can convert to glucose, which will precipitate med (3) may precipitate in any fluid containing dextrose (4) CORRECT - phenytoin may precipitate in any fluid containing dextrose; clear IV tubing with normal saline prior to administering to remove all traces of dextrose

The nurse cares for the multipara who comes to the hospital at 29 weeks gestation with reports of backache and pelvic pressure "on and off all day." Which of the following assessments, if made by the nurse, is MOST important in determining if the patient is in premature labor? 1. The patient's history of her subjective symptoms. 2. The cervix is 50% effaced, 1 centimeter dilated. 3. The presenting part is at -1 station. 4. Regular contractions are noted on a monitor tracing.

Question: How can you tell if the patient is in true labor? Strategy: Establish priorities. When a question includes words such as "MOST important" or "FIRST," this indicates that more than one answer choice may be correct but one choice is more important than the others. Narrow the answer choices to those that are correct and then put them in order of priority. The highest priority will be the correct answer. Needed Info: Effacement: shortening and thinning of the cervix. Dilation: enlargement of opening of cervix from a few mm to an opening large enough to allow for passage of infant. Station: indicates progress of labor; relationship of presenting fetal part to imaginary line between ischial spines of pelvis in the mother. S/S premature labor: abdominal pain resembling menstrual cramps, dull backache, pelvic pressure. (1) not most important information; must differentiate regular contractions of labor from Braxton-Hicks contractions (do not occur on a regular basis, do not cause cervical dilation) (2) common occurrence especially in multiparas (women who have carried 2 or more pregnancies to viability) (3) presenting part is 1 cm above ischial spines of the pelvis; does not indicate true labor (4) CORRECT - most important; if contractions are regular (occur at least every 10 min for 1 hour), would indicate premature labor

The nurse on the medical unit is performing a physical assessment on a newly admitted patient. To locate the point of maximum impulse (PMI) of the patient's heart, the nurse's hand (fingertips) should be placed over which of the following locations? 1. The fifth intercostal space directly over the sternum. 2. The second intercostal space to the right of the sternum. 3. The second intercostal space to the left of the sternum. 4. The fifth intercostal space at the midclavicular line.

Question: How do you locate the PMI? Strategy: Picture the anatomy of the heart and its position in the body. Needed Info: PMI: forward thrust of L ventricle during systole produces normal pulsation on chest wall; indicates size and position of heart; should be felt in 1 intercostal space; if larger, indicates ventricular enlargement. (1) position of R ventricle (2) best for aortic valve sounds (3) best for pulmonic valve sounds (4) CORRECT

The nurse cares for the 4-year-old diagnosed with a fractured pelvis due to an auto accident. The nurse prepares the child for the application of a hip spica cast. The nurse recognizes that it is MOST important to include which of the following in the child's plan of care? 1. Obtain a doll with a hip spica cast in place. 2. Tell the child that the cast will feel cold when it is put on the skin. 3. Reassure the child that the cast application is painless. 4. Introduce the child to another child who has a hip spica cast.

Question: How do you prepare a 4-year-old for the procedure? Strategy: "MOST important" indicates that discrimination is required to answer the question. Needed Info: Preschool children (age 36 months - 6 years) fear injury, mutilation, and punishment; allow child to play with models of equipment; encourage expression of feelings; spica cast immobilizes the hip and knee. (1) CORRECT - preschoolers need to see and play with dolls and equipment; explain procedure in simple terms and explain how it will affect the child (2) may feel a warm or burning sensation under cast while it dries, due to chemical reaction between the plaster and the water (3) will be placed on special cast table that holds the child's body; turning to apply the cast may be painful (4) more important to allow child to play with doll with a hip spica cast; viewing the cast may be frightening.

The nurse plans care for the adult with pneumonia. The patient is to be suctioned PRN. Which of the following techniques, if used by the nurse, MOST accurately describes proper suctioning? 1. Apply suction with rotation, for no more than 20 seconds, as the catheter is inserted. 2. Apply suction, for no more than 10 seconds, as the catheter is both inserted and withdrawn. 3. Apply suction, for no more than 10 seconds, as the catheter is withdrawn. 4. Apply suction each time the patient inhales.

Question: How do you suction an adult? Strategy: Think about the outcome of each answer choice. Needed Info: Pneumonia: infection of the lungs due to viruses/bacteria, aspiration of food/fluids or inhalation of toxic chemicals. S/S: fever, chills, hemoptysis, dyspnea, fatigue. Treatment: antibiotics. Nursing responsibilities: turn, cough, deep breath, Fowler's position; suction to remove secretions and provide open airway; use 12 - 14 French catheter; use suction pressure less than 120 mm Hg and gently rotate the catheter 360 degrees. Complications: infection, trauma, hypoxemia, dysrhythmias. (1) not done for that length of time or during insertion, which would cause trauma to the mucous membrane (2) no suction when inserted (3) CORRECT - short time of suctioning, when pulling out catheter; too long can cause hypoxia, dysrhythmias; hyperoxygenate before, during, and after (4) suctioning process not correlated with breathing pattern.

The nurse cares for the client who is to receive warfarin sodium. The nurse recalls that which of the following is the mechanism of action of this medication? 1. It inhibits prothrombin synthesis. 2. It prevents conversion of fibrinogen to fibrin. 3. It inactivates thrombin. 4. It inhibits platelet aggregation.

Question: How does Coumadin work? Strategy: Think about each answer choice. Needed Info: warfarin sodium (Coumadin): long acting anticoagulant that inhibits Vitamin K-dependent clotting factors. Side effects: excessive dosage may cause hemorrhage, rash, fever. Prothrombin time (PT) used to control dosage. Therapeutic range is 1.5 - 2 times normal level. Antidote vitamin K (phytonadione: Mephyton). May eat consistent amounts of green leafy vegetables containing vitamin K. (1) CORRECT (2) action of heparin (3) action of heparin (4) action of aspirin and dipyridamole (Persantine).

The nurse cares for the client receiving lansoprazole. The nurse recognizes that lansoprazole has which of the following effects on the gastrointestinal system? 1. It increases bowel motility. 2. It reduces bowel motility. 3. It neutralizes gastric acid secretion. 4. It decreases gastric acid secretion.

Question: How does lansoprazole work? Strategy: Think about the actions of lansoprazole. Needed Info: Lansoprazole (Prevacid) is a protein pump inhibitor used to treat and prevent stomach and intestinal ulcers. It reduces gastric acid production. Prevacid 24HR should be taken only once every 24 hours for 2 weeks. May take 4 days to work. (1) no effect on bowel motility; laxatives (bisacodyl: Dulcolax) increase motility, these are contraindicated for pt with abdominal pain (2) no effect on bowel motility (3) effect of antacids such as aluminum hydroxide with magnesium hydroxide (Maalox) or aluminum hydroxide with magnesium hydroxide and simethicone (Mylanta) (4) CORRECT

The nurse cares for the patient with Parkinson's disease who is receiving levodopa. The nurse recalls that levodopa works by which of the following actions? 1. It blocks central cholinergic receptors. 2. It restores dopamine levels in extrapyramidal centers. 3. It releases dopamine and other catecholamines from neuronal storage sites. 4. It activates dopaminergic receptors in the basal ganglia.

Question: How does levodopa work? Strategy: Think about each answer choice and how it relates to Parkinson's disease. Needed Info: Parkinson's disease: caused by impairment of dopamine-producing cells in the brain. Levodopa is converted to dopamine in the body to supply the extrapyramidal centers in the brain. Side effects: hemolytic anemia, aggressive behavior, dystonic movements, depression, hallucinations, dizziness, orthostatic hypotension. (1) action of benztropine mesylate (Cogentin) used with levodopa; side effects: urinary retention, dry mouth, constipation; takes 2 - 3 days before effects are seen (2) CORRECT - don't take with vit B6 or fortified cereals: will block effects (3) action of amantadine (Symmetrel) used with levodopa; side effects: irritability, insomnia, dizziness; take after meals (4) action of bromocriptine (Parlodel) used with levodopa; side effects: dizziness, HA, orthostatic hypotension, abdominal cramps, pleural effusion; take with meals.

The nurse cares for the patient on the telemetry unit. The patient's orders include nifedipine 10 mg PO TID. The patient asks the nurse how the medication works. Which is the BEST response by the nurse? 1. "It constricts the coronary arteries." 2. "It increases myocardial contractility." 3. "It decreases myocardial oxygen demand." 4. "It promotes coronary artery spasms."

Question: How does nifedipine work? Strategy: Determine the outcome of each answer choice. Is it desirable? Needed Info: nifedipine (Procardia): antianginal medication that is a calcium channel blocker (inhibits calcium ion flow across cardiac and smooth muscle). Side effects: light-headedness, HA, hypotension, hypokalemia. Nursing responsibilities: monitor BP and potassium levels. (1) dilates coronary arteries (2) decreases myocardial muscle contractility; digoxin increases myocardial contractility (3) CORRECT - antianginal (4) inaccurate.

The client is admitted to the hospital for surgery on a ruptured anterior cruciate ligament in the right knee. Following surgery, the physician prescribes morphine sulfate to be administered using a patient-controlled analgesia (PCA) pump. Which explanation by the nurse BEST describes this method of pain medication administration? 1. "You will contact your nurse when you feel pain, and the nurse will bring pain medication to add to your intravenous pump." 2. "You will receive a large dose of pain medication continually from an intravenous pump." 3. "You will be able to self-administer a preset dose of pain medication as needed by pressing a button connected to the intravenous pump." 4. "You will be able to self-administer an unlimited amount of pain medication as needed by pressing a button connected to the intravenous pump.

Question: How is a PCA pump used? Strategy: "BEST" indicates that there may be more than one correct response. Each part of the answer choice must be correct. Needed Info: PCA amount allows patients to control administration of IV analgesics; preloaded pump system administers preset amount of medication when button is pushed by patient; predetermined lock-out time interval; amount of medication is displayed on front of machine; reduces pulmonary complications, and patient is more alert. (1) contact with a nurse is not required (2) client does not get a large amount of medication continuously, which might lead to an unintentional drug overdose (3) CORRECT - client is able to pace the rate of medication being dispensed by taking responsibility for when it is administered; provider continues to take responsibility for the amount administered at any one time (4) client gets only a pre-set amount of medication at any one time.

The client is admitted for evaluation of a convulsive disorder. An electroencephalogram (EEG) is scheduled. The client asks the nurse how an EEG is performed. Which of the following explanations by the nurse is MOST accurate? 1. "Several small electrical shocks are given that feel like pinpricks." 2. "Electrodes are attached to the head and the electrical activity of the brain is evaluated." 3. "A radiopaque substance is injected into an artery and x-rays are taken." 4. "A radioactive material is injected intravenously followed by a brain scan."

Question: How is an EEG performed? Strategy: Picture the test being performed. Needed Info: EEG: measurement of the electrical activity of the brain to evaluate seizure disorders. Nursing responsibilities: keep awake night before test; shampoo client's hair; stimulants (coffee, tea, cigarettes, cola), antidepressants, tranquilizers, anticonvulsants held for 24 - 48 hours before test to avoid alteration (particularly lowering) of the seizure threshold. (1) not accurate; no shocks given; painless procedure (2) CORRECT -readings taken awake, asleep, while hyperventilating, viewing flickering lights (3) cerebral angiography; nursing responsibilities: check for allergies to contrast medium and iodine; prep: NPO 6 - 8 hours, will feel heat sensation when dye injected; post-test: bed rest 6 - 24 hours, pressure dressing over insertion site 6 - 12 hours, force fluids for 24 hours to excrete contrast medium (4) brain positron emission tomography (PET) scan: preparation: empty bladder; isotope injected, takes 2 hours to be absorbed in brain; post-test: force fluids, urine does not need special care.

The nurse cares for the client receiving pain medication via a patient controlled analgesia pump (PCA). The syringe contains hydromorphone 6 mg in 30 mL. The client is prescribed hydromorphone 0.2 mg/hour IV per the PCA pump. How many milliliters per hour does the client receive?

Question: How much hydromorphone is needed an hour on this PCA pump? Strategy: Utilize the correct equation to figure out the answer in mL per hour. Needed Info: Set the answer up as a ratio proportion. The answer is being calculated from the concentration of hydromorphone (Dilaudid) available in order to figure out the hourly rate to be set on the pump. CORRECT ANSWER: 1 mL / hour. (0.2 mg / 6 mg) x 30 mL = 1 mL/hour

The nurse teaches the group of men about testicular cancer and testicular self-examination. The nurse instructs the men to perform testicular self-examination at which frequency? 1. Weekly. 2. Monthly. 3. Yearly. 4. Biannually.

Question: How often should men do a testicular exam? Strategy: Think about each answer choice. Needed Info: Testicular cancer most common in men 15 - 34 years old; best to do after a shower when the body is warm and relaxed; hold scrotum in the palm of hand; roll each testicle between thumb and fingers. Symptoms of cancer: painless enlargement or heaviness in testicle. (1) too often (2) CORRECT (3) too infrequent (4) too infrequent.

The father of the day-old infant tells the nurse that he will be driving his wife and infant home from the hospital. It is MOST important for the nurse to make which of the following recommendations for how the infant should be transported? 1. In a front-facing infant car seat in the back seat. 2. In a rear-facing infant car seat in the back seat. 3. In an infant seat on the wife's lap in the passenger seat. 4. In the wife's arms in the back seat.

Question: How should a newborn be transported in a car? Strategy: Think about the outcome of each answer choice. Needed Info: The American Academy of Pediatrics recommends that children under 2 years of age use a rear-facing infant car seat. Children should ride in the rear of a vehicle until they are 13 years old. (1) bone structure inadequate to handle motor vehicle accidents (2) CORRECT - until a minimum age of 2 years, can be longer if the child is small for age (3) unsafe (4) unsafe.

The nurse cares for the postoperative patient who is to receive psyllium. When administering psyllium, the nurse uses which of the following techniques? 1. Mix with 6 ounces of orange juice; let stand for 1 minute, then administer it. 2. Mix with 8 ounces of water; administer it immediately followed by another 8 ounces of water. 3. Sprinkle on the patient's food; add 4 ounces of water and mix until well blended. 4. Pour into 8 ounces of milk; let it stand for 1 minute, then administer it.

Question: How should you mix psyllium? Strategy: Think about the outcome of each answer choice. Needed Info: psyllium (Metamucil): bulk-forming laxative used to treat constipation; on contact with water it forms a bland, gelatinous bulk that promotes peristalsis; can be mixed with water, milk, or fruit juice. (1) do not let stand; use 8 oz fluid (2) CORRECT (3) should not be chewed (4) do not let stand.

The patient with peripheral vascular disease is returned to the room following a right below-the-knee amputation (BKA). During the first 24 hours postoperatively, how does the nurse position the patient's residual limb? 1. Elevates the stump by raising the foot of the bed on blocks. 2. Dangles the stump over the side of the bed. 3. Abducts the stump by placing pillows between the legs. 4. Places the stump in correct anatomical alignment.

Question: How should you position a patient after a BKA? Strategy: Determine the outcome of each answer choice. Needed Info: Common complication after amputation is hip flexion contracture, resulting from elevation of stump on pillows. (1) CORRECT - increases venous return, prevents edema, promotes comfort (2) increases edema (3) legs should be adducted, not abducted (4) after 24 hours.

The pregnant woman is given an epidural anesthetic in preparation for cesarean section. Following administration of the epidural, the patient's blood pressure falls from 120/84 to 94/50. The nurse recognizes that it is ESSENTIAL to assist the patient into which of the following positions? 1. Supine. 2. Sitting. 3. Side-lying. 4. Trendelenburg.

Question: How should you position the patient? Strategy: "Essential" indicates that this is a priority question. Think about the outcome of each answer choice. Needed Info: Spinal anesthetic: local anesthetic injected into the lumbar intervertebral space beyond the dura mater into the subarachnoid space, which blocks pain sensations and movement. Epidural: local anesthetic injected into the lumbar intervertebral space outside the dura mater, which blocks pain sensations only, not movement. Complication of regional anesthetics: sympathetic nerve fibers blocked, hypotension due to loss of vasoconstrictor ability. Prehydrate before regional anesthetic to ensure adequate blood volume. (1) position impedes blood return to maternal heart due to pressure of fetus on vena cava; worsens hypotension (2) causes greater pooling of blood in legs, contributing to hypotension (3) CORRECT - optimizes blood return from lower extremities; displaces heavy uterus from inferior vena cava (4) weight of uterus against diaphragm impedes respirations.

The nurse in the well child clinic receives a call from a parent stating the parent's child attended a birthday party the day before with a child who had a facial rash and was diagnosed with erythema infectiosum (fifth disease). The parent is concerned that the parent's child may develop the disease. Which of the following responses by the nurse is BEST? 1. "Your child will not develop the disease." 2. "Look for a rash in 4 to 14 days." 3. "Bring your child into the clinic this afternoon." 4. "Does your child have a facial rash now?

Question: Is a child with a rash due to fifth disease contagious? Strategy: Think about the outcome of each answer. Needed Info: Erythema infectiosum (fifth disease) is a virus caused by human parvovirus B19; symptoms include erythema on face, lacy red rash on trunk and limbs. May have cold-like symptoms prior to onset of rash; treatment includes antipyretics, analgesics, and anti-inflammatory drugs. (1) CORRECT - fifth disease is a virus that is found in respiratory secretions; not contagious after the rash develops (2) incubation period is 4 to 14 days but may be as long as 20 days; an infected person is contagious prior to development of rash, whereas the child at the party already had a rash; (3) no reason for child to come to clinic (4) no reasons to assess for a rash.

The nurse performs discharge teaching for the patient with chronic renal failure. The nurse recognizes that teaching has been successful if the patient makes which statement? 1. "I will weigh myself every morning, before I eat breakfast." 2. "I will restrict my sodium and protein intake." 3. "I will take my antivomiting pills right after I eat." 4. "I will avoid between-meal snacks."

Question: What are appropriate self-care activities for a patient with chronic renal failure? Strategy: Recall the pathophysiology of chronic renal failure. Needed Info: Chronic renal failure is the slow progressive loss of renal function; gain of 2 pounds or more in 24 hours indicates fluid retention; antiemetics can be taken 30 to 60 minutes before meals; to increase nutritional balance, sodium and protein are not restricted, and between-meal snacks are encouraged. (1) CORRECT - most accurate measurement (2) not useful approach (3) need to be taken before the meal (4) less likely to prompt nausea.

The nurse cares for children in the pediatric clinic. After assessing a 3-year-old, the nurse instructs the child's parent about safety precautions. The nurse determines teaching is effective if the parent states which of the following? Select all that apply. 1. "My child wears a helmet while riding in the bike seat on the back of my bike." 2. "Our cleaning products at home are in a closed cabinet below the kitchen sink." 3. "Our medications are kept in childproof containers in a locked cabinet." 4. "My child sits in a forward-facing seat with a harness while riding in the car." 5. "Since we call vitamins 'candy,' our child eagerly takes them each day." 6. "The number to poison control is posted on our refrigerator."

Question: What are correct child safety precautions? Strategy: Consider each answer as a child safety precaution. More than one answer will be correct. Needed Info: Unintentional injury is the leading cause of death among children aged 1 - 4 years, accounting for about one-third of their deaths. (1) CORRECT - bike helmets prevent concussions if the child falls off the bike (2) need for locked cabinet, not just closed door (3) CORRECT - the locked cabinet is key to preventing accidental poisoning; childproof containers are not sufficient by themselves (4) CORRECT - the American Academy of Pediatrics in June 2011 recommended using a backward-facing seat for children under 2 years of age; use a forward-facing seat with a harness for children over 2 years (5) does not give child idea of possible danger of taking more. (6) CORRECT - posting an emergency contact in a visible spot allows faster response when time is critical.

The nurse prepares to change the central line dressing on the child. Arrange the following steps of the procedure in the correct order from first to last. All options must be used. 1. Open sterile towel to create a field. 2. Apply nonsterile gloves. 3. Apply an occlusive dressing. 4. Remove old dressing and wash hands. 5. Cleanse the area with acetone and alcohol swabs in a circular motion. 6. Cleanse the area with 1% povidone-iodine swabs. 1. 1, 2, 4, 5, 6, 3 2. 1, 4, 2, 6, 5, 3 3. 2, 4, 1, 5, 6, 3 4. 2, 4, 1, 6, 5, 3

Question: What are the steps of a central line dressing change for a child? Strategy: Be careful! Arrange the steps of the dressing change in the correct order in which to perform the task. Needed Info: The central line dressing needs to be changed regularly, at least every 48 hours using sterile technique. The site must be cleansed properly, and signs of infection need to be assessed. CORRECT ANSWER: 2, 4, 1, 5, 6, 3 (2) The first step is to apply nonsterile gloves. (4) The second step is to remove old dressing and wash hands. (1) The third step is to open sterile towel to create a field. (6) The fourth step is to cleanse the area with 1% povidone-iodine swabs. (5) The fifth step is to cleanse the area with acetone and alcohol swabs in a circular motion. (3) The sixth step is to apply an occlusive dressing.

The nurse cares for the patient who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings does the nurse recognize as consistent with this diagnosis? 1. Increased urine output; decreased serum sodium. 2. Decreased urine output; increased serum sodium. 3. Increased urine output; increased serum sodium. 4. Decreased urine output; decreased serum sodium.

Question: What are the symptoms of SIADH? Strategy: Think about how the disease affects the body. Needed Info: SIADH: seen with head injury, encephalitis, lung cancer, myxedema. Excessive amounts of antidiuretic hormone (ADH) from posterior pituitary results in water imbalance; water intoxication occurs due to fluid retention; opposite of diabetes insipidus. S/S: decreased LOC (cerebral edema, increased intracranial pressure), seizures, coma, sodium less than 120 mEq/L. Treatment: fluid restriction (500 - 600 mL/24 hr), sodium replacement, diuretics. Nursing responsibilities: daily weight, neuro checks, I + O, check electrolytes, position flat in bed. (1) decreased urine output (2) in SIADH, the serum sodium is washed out, resulting in a decreased level (3) diabetes insipidus due to lack of ADH; S/S: polyuria, polydipsia; treatment: vasopressin (Pitressin) (4) CORRECT - alderosterone is suppressed, causing hyponatremia with normal or increased plasma volume

The nurse administers morphine sulfate as ordered to the patient reporting severe pain. The nurse recognizes that which of the following signs indicates morphine toxicity? 1. The patient has blurred vision. 2. The patient's pupils are pinpoint. 3. The patient's pupils are unequal. 4. The patient's pupils are dilated.

Question: What are the symptoms of morphine toxicity? Strategy: Think about what causes each symptom. Does it relate to morphine? Needed Info: Morphine: narcotic analgesic used for severe pain. Side effects: sedation, hypotension, N + V, urinary retention, and physical dependence. Nursing responsibilities: check pupils and respirations. (1) inaccurate (2) CORRECT - indicators of morphine toxicity include pinpoint pupils and/or respirations less than 13 per min (3) not seen (4) not seen.

The nurse observes the behavior of the patient seen in the emergency room. Which of the following indicates to the nurse that the patient is experiencing a panic level of anxiety? 1. Reduced sensory input, distorted perception, behavioral disorganization. 2. Behavioral disorganization, inability to negotiate simple life demands, increased ability to concentrate. 3. Heightened sensory awareness, impaired cognitive function, distorted perception. 4. Increased pulse, increased muscle tension, rate of speech and volume are adequate for communication.

Question: What behaviors indicate a panic level of anxiety? Strategy: All symptoms must be correct in order for the answer to be correct. Needed Info: Anxiety is feeling of dread or fear in the absence of external threat, or disproportionate to the nature of the threat. In panic level anxiety, the patient is unable to see, hear, or function. Assess level of anxiety, decrease environmental stimuli, use unhurried approach, and stay with the patient. (1) CORRECT - reduced sensory input, distorted perception, behavioral disorganization are indicators of panic (2) will have decreased ability to concentrate with panic (3) sensory input is decreased with panic (4) pulse, muscle tension, rate of speech and volume all increase with panic.

The nurse performs screening on a group of older adult males. The nurse recognizes that which of the following is the MOST frequent cause of their urinary problems? 1. Degeneration of the renal arteries. 2. Degeneration of prostatic tissue. 3. Hyperplasia of the renal arteries. 4. Hyperplasia of the prostate gland.

Question: What causes urinary problems in elderly males? Strategy: Think about the answers. Needed Info: Symptoms of benign prostatic hypertrophy (BPH) include dysuria, frequency, urgency, decreased urinary stream, hesitancy, and nocturia; later symptoms may include cystitis, hydronephrosis, or urinary calculi. (1) renal blood vessels become thickened and more rigid, rather than degenerated (2) prostate enlarges, rather than degenerates, due to aging (3) blood vessels become thickened and more rigid, but they do not cause the manifestations of BPH (4) CORRECT - prostate enlargement (hyperplasia) causes urethral obstruction

The nurse cares for the emaciated patient admitted with Crohn's disease (regional enteritis). The nurse expects the patient to be placed on which of the following diets? 1. High-calorie, high-protein, high-residue. 2. Low-calorie, low-protein, low-residue. 3. High-calorie, high-protein, low-residue. 4. Low-calorie, low-protein, high-residue.

Question: What diet is used for Crohn's disease? Strategy: Think about Crohn's disease. Needed Info: Crohn's disease (regional enteritis): inflammatory bowel disease involving segments of the terminal ileum and proximal colon. The entire wall of the colon is affected. Restricts absorption of nutrients. S/S: right lower quadrant abdominal pain, diarrhea, weight loss, low-grade fever. Remissions and exacerbations seen. Treatment: meds: antidiarrheals (loperamide), antispasmodics, anticholinergics, sulfonamides (sulfasalazine), steroids. (1) high residue; may cause diarrhea (2) nutritional deficiencies (3) CORRECT - nonirritating, high in nutrients and minerals (4) nutritional deficiencies and high residue; may cause diarrhea.

The nurse conducts a physical assessment of the newly admitted client on the medical unit. When auscultating breath sounds over the trachea, the nurse normally expects to hear sounds that can be BEST characterized as which of the following? 1. Soft and low pitched. 2. Coarse and rumbling. 3. Fine and crackling. 4. Loud and high pitched.

Question: What do breath sounds sound like over the trachea? Strategy: "Best categorized" indicates that there may be more than one correct response. Think about what causes each breath sound. Needed Info: Use diaphragm of stethoscope, have patient take slow, deep breaths through the mouth. If crackles or wheezes are heard, ask patient to cough to see if sound changes. (1) inaccurate; vesicular: peripheral parts of lungs (2) inaccurate; rhonchi/wheezes: air over mucus; abnormal (3) inaccurate; rales: air over fluid; abnormal (4) CORRECT - hollow, harsh sounding; air passing through a tube

The woman is brought to the emergency room complaining of severe left lower quadrant pain. She tells the nurse that she performed a home pregnancy test and believes she is 8 weeks pregnant. On admission the patient's vital signs are pulse 90, blood pressure 110/70, respirations 20. A half-hour later her vital signs are pulse 120, blood pressure 86/50, respirations 26. The nurse recognizes that the change in the patient's vital signs indicates which of the following? 1. The patient's pain may have increased. 2. The patient may be bleeding internally. 3. The patient may be frightened. 4. The patient may have an infection.

Question: What do the changes in vital signs mean? Strategy: Think about the significance of each assessment. Needed Info: Ectopic pregnancy: fetus implanted outside of uterus, usually the fallopian tube. (1) usually BP increases with pain increase (2) CORRECT - increased P, decreased BP = decreased intravascular volume; shock (3) usually BP + P increases with fear (4) usually won't change BP unless in septic shock.

The nurse cares for the newly admitted patient who reports abdominal cramping and generalized weakness. When the nurse sends a stool sample to the lab for a guaiac test, what positive finding could be expected? 1. White blood cells. 2. Red blood cells. 3. Ova and parasites. 4. Mucus.

Question: What does a guaiac test indicate? Strategy: Think about each answer choice. Needed Info: Guaiac fecal occult blood test (G-FOBT): occult means hidden, often done as a screening test for colon cancer. Positive indicates need for further studies. (1) not accurate (2) CORRECT - none usually found (3) not accurate (4) not accurate.

The patient visits the physician for HIV testing. The physician notifies the patient that the results are positive. The patient asks the nurse what this means. The nurse's response should be based on recognition of which of the following? 1. The patient has AIDS. 2. The patient will develop AIDS within the year. 3. The patient has been exposed to the HIV virus. 4. The patient has been infected with the HIV virus.

Question: What does it mean if a person is HIV positive? Strategy: Think about each answer choice: Is it true about AIDS? Needed Info: AIDS (acquired immunodeficiency syndrome): caused by human immunodeficiency virus (HIV). Alters the functioning of immune system. Transmission: contact with blood and body fluids (semen). Test that detects presence of antibodies: enzyme-linked immunosorbent assay (ELISA). Test that confirms presence of virus: Western blot. (1) not true; AIDS: defined as presence of complications (such as opportunistic infections--Pneumocystis pneumonia) from HIV virus (2) not completely certain; AIDS Related Complex (ARC) has symptoms (fever, drenching night sweats, weight loss, fatigue, lymphadenopathy) without opportunistic infections (3) no test determines exposure; only detects infection. (4) CORRECT - HIV virus is considered infected and infectious

The nurse cares for the woman who has just delivered her first child, a boy weighing 6 lb 2 oz. The Apgar scores at one and five minutes are 8 and 9. The nurse recognizes that these scores indicate which of the following? 1. An isolette should be ready in the nursery for close observation of this infant. 2. The newborn is making an optimal transition to extrauterine life. 3. The parents will need emotional support to deal with a less than perfect infant. 4. Apgar scores correlate well with future emotional and intellectual development.

Question: What does this Apgar mean? Strategy: Think about each answer choice. Is it true about Apgar score? Needed Info: Apgar scores, checked at 1 and 5 min, are used to assess a newborn's initial adaptation to extrauterine life. There are five categories, each of which gets a score of 0 - 2: heart rate, resp effort, muscle tone, reflex irritability, color. (1) not needed; radiant warmer (2) CORRECT - good Apgar (3) Apgar score is fine (4) no relationship.

The parent of the adolescent being admitted to the psychiatric unit reports that the adolescent has become increasingly withdrawn at home. During the admission interview with the nurse, the patient says, "When I look in the mirror, I cannot see myself." The nurse recognizes that the patient is experiencing which of the following? 1. Displacement. 2. Dissociation. 3. Denial. 4. Depersonalization.

Question: What does this describe? Strategy: Think about each answer choice. Needed Info: Adolescence provides a time for development of a healthy self-concept and discovering one's role in life. If the road to these discoveries is blocked, the person experiences depersonalization. (1) unconscious placing of emotions onto others (boss yelling at employee, person yelling at spouse) (2) splitting off anxiety producing experiences (multiple personalities) (3) refusal to acknowledge reality (will not accept bad news). (4) CORRECT - feelings of unreality concerning self or environment

The nurse teaches the client how to increase dietary potassium. The client knows bananas are high in potassium but she does not like their taste. What foods should the nurse recommend the client include in the diet? 1. Potatoes, spinach, raisins. 2. Rhubarb, tofu, celery. 3. Carrots, broccoli, yogurt. 4. Onions, corn, oatmeal.

Question: What foods are high in potassium? Strategy: Think about each food. Needed Info: Potassium functions in water balance in cells, protein synthesis, and heart contractility; primary sources include grains, meats, vegetables, and fruits. (1) CORRECT - potassium content: potatoes 610 mg, spinach 838 mg, raisins 1,089 mg, for a total of 2,537 mg (2) potassium content: rhubarb 548 mg, tofu 9 mg, celery 114 mg, for a total of 671 mg (3) potassium content: carrots 221 mg, broccoli 254 mg, yogurt 251 mg, for a total of 726 mg (4) potassium content: onions 318 mg, corn 192 mg, oatmeal 132 mg, for a total of 642 mg.

The 72-year-old parent is brought to the clinic as a patient by the adult child who reports that the patient is not eating well but is otherwise healthy. The patient is not taking any medications. The nurse determines that which of the following meals is the BEST choice for this patient's nutritional needs? 1. Grilled cheese sandwich, cookie, tea. 2. Broiled chicken, broccoli, skim milk. 3. Raisin toast, tapioca pudding, apple juice. 4. Liver and onions, decaffeinated coffee, jell-o.

Question: What foods are in a nutritionally well balanced diet? Strategy: Think about the type of diet that is needed for an elderly person. Needed Info: Patients with anorexia (poor appetite) need nutrient-dense, high-calorie diet. Nutritionally well-balanced diet contains foods from 6 basic food groups: bread, cereal, rice, and pastas (6 - 11 servings); vegetable group (3 - 5 servings); fruit (2 - 4 servings); milk, yogurt, cheese group (2 - 3 servings); meat, poultry, fish, dry beans, eggs, nuts group (2 - 3 servings); fats, oils, and sweets (use sparingly). (1) some protein, some carbohydrate, some fluid (2) CORRECT - source of protein, vegetable, milk (3) some carbohydrate, some fruit (4) source of iron and fluids.

The nurse cares for the client experiencing an episode of acute pain. Which of the following physiologic changes does the nurse expect to see in this client during this episode? 1. Decreased blood pressure. 2. Decreased heart rate. 3. Decreased skin temperature. 4. Decreased respirations.

Question: What happens to the vital signs when a client is in pain? Strategy: Think about the cause of each vital sign change. Is it consistent with pain? Needed Info: Pain causes increased blood pressure and heart rate, which leads to increased blood flow to the brain and muscles; rapid irregular respirations lead to increased oxygen supply to brain and muscles; increased perspiration removes excessive body heat; increased pupillary diameter leads to increased eye accommodation to light. (1) blood pressure increases to enhance alertness to threats (2) heart rate increases (3) CORRECT - skin cools due to diaphoresis (4) respirations increase.

The nurse cares for the patient 1 hour after a percutaneous liver biopsy. The nurse is MOST concerned if which of the following is observed? 1. The patient frequently coughs after deep breathing. 2. The patient lies on the right side with a pillow under the costal margin. 3. The LPN/LVN obtains the blood pressure and pulse every 15 minutes. 4. The patient reports mild pain radiating to the right shoulder.

Question: What indicates a complication of a liver biopsy? Strategy: "Nurse is MOST concerned" indicates a complication. Needed Info: Sampling of tissue by needle aspiration; preparation for procedure includes administer IM vitamin K, NPO morning of exam, instruct patient to hold breath; post-procedure nursing care includes position on right side for 1 - 2 hours, maintain bed rest for 24 hours, obtain frequent vital signs to monitor for hemorrhage. (1) CORRECT - avoid coughing or straining to prevent hemorrhage (2) prevents hemorrhage or escape of bile (3) vital signs monitored every 10 - 15 minutes during first hour and every 30 minutes for next 1 - 2 hours; assess for hemorrhage (4) referred pain often happens, associated with current liver problems.

The nurse in the same-day surgery department cares for the client after a sigmoidoscopy. Which of the following symptoms, if exhibited by the client an hour after the procedure, MOST concern the nurse? 1. The client reports fullness and pressure in abdomen. 2. The client reports grogginess and thirst. 3. The client reports lightheadedness and dizziness. 4. The client reports mild pain and cramping in abdomen.

Question: What indicates a complication of a sigmoidoscopy? Strategy: Think about what causes each symptom. Needed Info: Direct visualization of the sigmoid colon, rectum, and anal canal; laxative night before exam and enema or suppository morning of procedure; NPO at midnight. Post-procedure: allow client to rest; observe for hemorrhage, perforation; encourage fluids. (1) expected after this procedure (2) expected after this procedure; has been NPO since midnight before the procedure; midazolam (Versed) is used to aid in relaxation during procedure; atropine is used during procedure to decrease peristaltic activity (3) CORRECT - could signify hypovolemic shock due to bowel perforation (4) expected after this procedure.

The nurse cares for the patient after a traditional cholecystectomy. The patient has a nasogastric tube connected to suction, an IV of D5W infusing into the right arm, and a T-tube and Penrose drain in place. The nurse is MOST concerned by which of the following findings? 1. The systolic blood pressure is 10 mm Hg lower than it was preoperatively. 2. There is 250 cc of bloody drainage from the T-tube during the first 24 hours. 3. There is 30 cc of serosanguineous drainage in the Penrose drain during the first 24 hours. 4. The patient experiences a 2 degree temperature decrease in the evening after surgery.

Question: What indicates a complication? Strategy: Think about each answer. Needed Info: T-tube ensures drainage of bile from common bile duct until edema in area decreases; protect skin around incision from bile drainage irritation; observe for jaundice. (1) decrease could be due to position change or fluids lost during surgery (2) CORRECT - would expect drainage of 400 mL/day with gradual decrease in amount; will be bloody initially and change to greenish-brown; T-tube getting dislodged is most frequent cause of ineffective drainage (3) drainage is expected, prevents accumulation of fluid in the incision (4) expected outcome of taking temperature by a different method, as patient is now a mouth-breather.

The nurse educator presents an in-service for staff on family dynamics. The nurse educator identifies which behavior as being associated with a functional family process related to communication? 1. Acknowledgment of personal needs and role responsibilities. 2. Congruence between verbal and nonverbal messages. 3. Ability to meet emotional needs of family members. 4. Appropriate responsibility for other family members' needs.

Question: What indicates a functional family process? Strategy: Think about each answer. Needed Info: Family function is how individual members relate to each other; functional communication is characterized by clear direct messages and by requesting and receiving feedback; dysfunctional communication is characterized by double-bind communication, contradictions, inconsistencies, obscure speech, and misunderstandings. (1) indicates a functional family, but this is not necessarily related to communication (2) CORRECT - indicates a functional family; double-bind communication, by contrast, is an example of conflicting messages (3) one function of a family system is assisting members to meet their physical, emotional, and safety needs; dysfunctional families are unable to meet these needs, but this is not necessarily related to communication (4) indicates a functional family, but this is not necessarily related to communication.

The nurse evaluates the progress of the patient hospitalized with depression. The nurse considers which of the following statements by the patient as an indication of improvement? 1. "I slept well last night." 2. "I can't seem to stop eating." 3. "I feel tired." 4. "I am feeling sad."

Question: What indicates an improvement in a patient who has been depressed? Strategy: Think about each answer choice. How does it relate to depression? Needed Info: S/S: unkempt appearance, lack of energy, change in sleep pattern, weight loss, decreased concentration, slowed motor activity. (1) CORRECT - depression indicated by excessive sleeping or difficulty falling asleep, staying asleep, or awakening too early (2) sign of depression (3) sign of depression (4) sign of depression.

The nurse plans care for the patient admitted reporting fever, vomiting, and diarrhea. The nurse writes the following nursing diagnosis on the patient's care plan: "Fluid volume deficit." The nurse recognizes that which of the following changes in laboratory values BEST demonstrates improvement in the patient's condition? 1. Decreased specific gravity of urine, decreased hematocrit. 2. Increased specific gravity of urine, increased hematocrit. 3. Decreased specific gravity of urine, increased hematocrit. 4. Increased specific gravity of urine, decreased hematocrit.

Question: What indicates an improvement in fluid volume deficit? Strategy: Think about physiology. Needed Info: Urine specific gravity depends on hydration; normal: 1.010 - 1.030; will increase if patient is dehydrated. Hematocrit measures % volume of RBCs in whole blood; normal: men 42 - 50%, women 40 - 48%; increases in severe dehydration (volume). (1) CORRECT - specific gravity and hematocrit increase with dehydration (2) ongoing fluid volume deficit (3) does not best indicate improvement; specific gravity is decreased but hematocrit still increased (4) does not best indicate improvement; hematocrit is decreased but specific gravity still increased.

The nurse cares for the woman at 37 weeks gestation. The nurse is MOST concerned by which finding? 1. The patient reports right quadrant pain. 2. The patient's BP is 150/95. 3. The patient has 1+ proteinuria. 4. The patient has 3+ pitting edema of the ankles.

Question: What indicates impending eclampsia? Strategy: "MOST concerned" indicates a complication. Question unstated. Read answer choices for clues. Needed Info: Eclampsia is seizures in a pregnant woman not related to a pre-existing brain condition. Providers intervene before that advanced stage, when symptoms of impending eclampsia occur. Preeclampsia causes hypertension, proteinuria, and edema; symptoms of severe preeclampsia include BP of 150 - 160/100 - 110 mm Hg; 4+ proteinuria; headache, epigastric pain; treatment for severe preeclampsia includes bed rest, vital signs and fetal heart tones, monitor I + O, seizure precautions, and administer magnesium sulfate. (1) CORRECT - indicates impaired liver function, sign of impending eclampsia (2) elevated BP less than 160/110 considered moderate preeclampsia (3) indicates mild preeclampsia (4) dependent edema, indicative of mild preeclampsia.

The patient is admitted to the hospital for a myelogram using a water-soluble dye. What information is MOST important for the nurse to obtain about the patient's medication history? 1. Is the patient currently taking any antihypertensives? 2. Is the patient currently taking any nonsteroidal anti-inflammatory medications? 3. Is the patient currently taking any antibiotics? 4. Is the patient currently taking any antidepressants or antipsychotics?

Question: What information do you need from the patient's medication history? Strategy: Think about each medication given. How does it relate to a myelogram? Needed Info: Meds that lower the seizure threshold such as phenothiazines (chlorpromazine), MAO inhibitors (isocarboxazid, phenelzine), tricyclic antidepressants (imipramine, amitriptyline), CNS stimulants, psychoactive drugs (methylphenidate) should be held for 48 hours before and 24 hours after test. The reason to stop such meds is that their presence could increase the risk of seizures. (1) will not affect test (2) will not affect test (3) will not affect test. (4) CORRECT - need to hold any meds that lower seizure threshold

The 80-year-old patient is admitted to the hospital with a diagnosis of carcinoma of the colon. A hemicolectomy is scheduled. On admission, the patient appears disheveled and is restless and confused. It is MOST important that the nurse obtain the answer to which of the following questions? 1. Which prescription and/or over-the-counter medications is the patient taking? 2. What is the medical history of the patient's family? 3. What was the patient's previous occupation? 4. Has the patient smoked cigarettes in the past?

Question: What information is MOST important to get about the patient since he is confused? What is a frequent cause of confusion in the elderly? Strategy: Picture the patient as described. Needed Info: Polypharmacy, the taking of multiple medications, is common in elderly adults, accounting for the dispensing of one-third of prescribed medications. Decreases in kidney and liver functioning can allow a buildup of toxic chemicals. (1) CORRECT - confusion can be caused by drug toxicity (2) not most important (3) not most important (4) not most important.

The nurse cares for the patient during the acute phase of a cerebrovascular accident (stroke). The nurse gives the HIGHEST priority to which of the following? 1. Maintaining musculoskeletal function. 2. Maintaining nutritional status. 3. Maintaining respiratory function. 4. Maintaining skin integrity.

Question: What is MOST important for a patient right after a CVA? Strategy: Remember your ABCs: airway, breathing, circulation. Needed Info: Manifestations of stroke vary with the involved cerebral vessel and the area of the brain affected; women more likely to report nontraditional manifestations; manifestations always sudden in onset, focal, and usually one-sided. (1) ROM, positioning (2) soft diet due to possible dysphagia, or tube feedings (3) CORRECT - ABCs first (4) bed rest 48 - 72 hours during acute phase.

The patient is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. The nurse recognizes it is MOST important to include which goal on the patient's preoperative care plan? 1. Fluid replacement. 2. Pain relief. 3. Emotional support. 4. Respiratory therapy.

Question: What is MOST important for a patient with a ruptured ectopic pregnancy? Strategy: Remember Maslow's hierarchy of needs. Meet physical needs before addressing psychosocial needs. Needed Info: Dehydration can become a serious danger in a preoperative patient, especially if bleeding occurs. Fluid replacement prevents that complication. Pain relief can be well handled in the postoperative period. Emotional support, while important, is a lower priority than ensuring that the patient's life is not in danger. (1) CORRECT - physical need; IV fluids, blood transfusion (2) not most important (3) not most important (4) not a problem.

The nurse prioritizes the needs of the patient who has been raped. Which of the following is MOST important initially? 1. Emotional needs. 2. Physical needs. 3. Hygiene needs. 4. Legal responsibilities.

Question: What is MOST important for a person who has been raped? Strategy: Establish priorities. Remember Maslow's hierarchy of needs. Meet the physical needs before you address safety, love, belonging, esteem, and self-actualization needs. Needed Info: Major effort in working with the person raped concentrates on first collecting physical evidence, such as proof of injuries and possible specimens for DNA testing. Emotionally charged crime. (1) not most important initially (2) CORRECT - Maslow's hierarchy: physical is first (3) not most important initially (4) not most important initially.

Arterial blood gases (ABGs) are ordered for the patient following a myocardial infarction. After obtaining the ABGs, which of the following measures is MOST important for the nurse to implement? 1. Obtain ice for the specimen. 2. Apply a sterile dressing to the site. 3. Apply direct pressure to the site. 4. Observe the site for hematoma formation.

Question: What is MOST important for you to do after obtaining an ABG? Strategy: Picture yourself doing the procedure. Set priorities. Care for the patient first and the equipment or samples second. Needed Info: ABGs: measurement of partial pressure of oxygen, carbon dioxide, and pH of blood; assessment of acid-base status of body; use a heparinized syringe; needle inserted 45 - 60 degrees to skin surface and advanced into radial artery; apply pressure after needle removed; put specimen on ice. (1) should be done, but not most important; care for the patient first (2) bandage applied (3) CORRECT - prevents bleeding, hematoma; maintain for at least 5 min, 15 min if on anticoagulant (4) not highest priority; check for discoloration, numbness, tingling, temperature.

The nurse cares for the client after a ureterolithotomy. The nurse notes that the client has a left ureteral catheter in place. The nurse includes which of the following in the client's plan of care? 1. Clamp the catheter for short periods of time. 2. Irrigate the catheter every 2 hours. 3. Gently advance the catheter if no drainage is observed. 4. Instruct the client that urine from the catheter should be clear.

Question: What is a correct action for a client with a ureteral catheter? Strategy: Determine the outcome of each answer. Needed Info: Ureterolithotomy is surgical removal of calculus from the ureter; do not irrigate ureteral catheter, check incisional drain, check surgical dressing; encourage oral fluids. (1) due to small size of catheter, do not clamp (2) do not irrigate, since that would change the direction of the fluid flow; measure intake and output (3) do not advance catheter, may cause trauma (4) CORRECT - immediately after surgery, a small amount of blood-tinged urine is normal but then it becomes clear; increase fluid to promote flow of urine

The nurse reviews patient assignments made by the student nurse. The nurse determines that assignments are appropriate if a nursing assistant is assigned to which patient? 1. The patient scheduled for an MRI. 2. The unconscious patient who requires mouth care. 3. The patient admitted for uncontrolled seizures. 4. The patient with diabetes who requires foot care.

Question: What is a correct patient assignment for a nursing assistant? Strategy: Think about each answer. Needed Info: Delegate standard, unchanging procedures to a nursing assistant. (1) requires assessment and teaching (2) CORRECT - mouth care for an unconscious patient can be delegated to the nurse assistant; the nurse must first assess for a gag reflex (3) nurse must care for patient; assess for patent airway, adequate respirations, and circulatory status (4) nursing assistant can perform foot care for a nondiabetic patient.

The nurse performs teaching for the client being discharged with a new ileostomy. The nurse includes which of the following statements in the discharge teaching? 1. "Change the appliance every day." 2. "The ileostomy does not require irrigation." 3. "Decrease your fluid intake." 4. "Apply cream around the stoma."

Question: What is a correct statement about caring for an ileostomy? Strategy: Determine the outcome of each answer. Needed Info: Ileostomy is an opening into the ileum from the abdominal wall for evacuation of feces; drainage bag with pectin-based skin barrier must be worn at all times. (1) appliance should only be changed if there is a leak (2) CORRECT - no need to irrigate; stool remains loose and cannot be controlled with irrigation (3) maintain high fluid intake due to loss of fluids through the ileostomy (4) prevents the appliance from adhering to skin; increases the incidence of leaking.

The nurse has completed discharge instructions for the primigravida at 29 weeks gestation who is hospitalized for treatment of deep vein thrombosis (DVT). Which of the following statements, if made by the patient to the nurse, indicates that teaching has been successful? 1. "I will give myself heparin every day." 2. "I should check my leg once a week." 3. "I will massage my leg nightly." 4. "I can take Pepto-Bismol for diarrhea."

Question: What is a correct statement about deep vein thrombosis and pregnancy? Strategy: "Teaching has been successful" indicates a correct response. Needed Info: Pregnancy, immobility, obesity, and surgery are risk factors for deep vein thrombosis. Heparin is anticoagulant that blocks conversion of prothrombin to thrombin; side effects include hematuria and bleeding gums; monitor partial thromboplastin time (PTT). (1) CORRECT - heparin does not cross the placenta; considered safe during pregnancy (2) not an aspect of self-care (3) contraindicated with DVT; clot can be released (4) bismuth subsalicylate (Pepto-Bismol) increases the anticoagulant effectof heparin;, do not use together.

The patient is admitted to the unit for treatment of acute glomerulonephritis. The nurse teaches the patient about the disease and the treatment required. The nurse determines that teaching is successful if the patient makes which of the following statements? 1. "Who would have thought that a sore throat two weeks ago would cause this!" 2. "I am in the hospital because my grandmother receives dialysis three times per week." 3. "I'm glad that I don't have to restrict my activities." 4. "My roommate is going to bring me a double cheeseburger with bacon."

Question: What is a correct statement about glomerulonephritis? Strategy: Think about what the words mean. Needed Info: Acute glomerulonephritis is usually caused by beta hemolytic streptococcal infection; symptoms include fever, chills, hematuria, weakness, pallor, weight gain, lung rales, and fluid overload. (1) CORRECT - inflammatory reaction of the kidney to infection that occurs on skin or in the throat (2) no relationship; damage to glomerulus caused by an immunological reaction (3) bed rest ordered during acute phase to guard against hematuria and proteinuria; promotes diuresis (4) usually anorexic; protein and sodium limited until BUN, creatinine and BP normal.

The nurse performs discharge teaching for the client receiving trifluoperazine. The nurse determines that teaching is successful if the client verbalizes which of the following? 1. "I should take two pills at night if I have difficulty sleeping." 2. "I cannot breastfeed my baby while I am taking this medication." 3. "I may experience frequent tearing in my eyes." 4. "I will have to increase my calorie intake daily."

Question: What is a correct statement about trifluoperazine? Strategy: Think about each statement. Needed Info: Trifluoperazine (Stelazine) is an antipsychotic phenothiazine; side effects include pseudoparkinsonism, dystonia, akathisia, tardive dyskinesia; instruct client to avoid alcohol, report urine retention or constipation, use sunblock, and chew sugarless gum or suck on hard candy to relieve dry mouth. (1) cannot increase or decrease dosage without physician approval (2) CORRECT - breastfeeding is contraindicated because trifluoperazine is excreted in breast milk (3) side effect is dry eyes--use artificial tears (4) may have weight gain; should decrease calorie intake and exercise frequently.

The nurse teaches the patient who is lactose intolerant about alternative ways to obtain adequate amounts of calcium in the diet. Which of the following items, if selected by the patient, indicates understanding of which foods to eat? 1. Eggs and green leafy vegetables. 2. Instant breakfast mixes and skim milk. 3. Cottage cheese and yogurt. 4. Custard and mashed potatoes.

Question: What is a good source of calcium for a lactose intolerant patient? Strategy: Eliminate foods that contain milk. Needed Info: Lactose intolerance: inability of intestine to absorb milk due to deficiency in enzyme that breaks down milk sugar (lactase). Calcium: milk, seafood, orange juice, cereals, and dark green leafy vegetables such as spinach, kale, and mustard greens. Yogurt and hard cheeses may be tolerated because of how they are processed. (1) CORRECT - good sources of Ca (2) contain lactose (3) contain lactose; yogurt may be tolerated; cottage cheese is a soft cheese and would not be tolerated ( 4) made with milk, contains lactose.

The nurse counsels the client in the outpatient psychiatric clinic for treatment of a fear of water. The nurse recognizes that a phobia can BEST be described as which of the following? 1. A form of sublimation that is adaptive to the client. 2. A persistent fear that is excessive and unrealistic. 3. A persistent uncontrolled thought precipitated by anxiety. 4. A manipulative behavior used to achieve secondary gain.

Question: What is a phobia? Strategy: Think about each answer. Needed Info: Client feels apprehension, anxiety, helplessness when confronted with the feared object; nursing considerations include: avoid confrontation and humiliation, do not focus on trying to stop the client from being afraid, use systematic desensitization, try relaxation techniques. (1) sublimation is a defense mechanism; diversion of unacceptable, instinctual drives into socially acceptable outlets (2) CORRECT - phobia is a lasting and unreasonable fear caused by a specific object or situation that poses little or no danger (3) this is description of an obsession (4) this is when one person attempts to influence another person in order to meet one's own needs or desires.

The nurse conducts the admission interview of the client scheduled for surgical repair of an inguinal hernia. Which of the following client statements MOST concerns the nurse? 1. "I am allergic to bananas." 2. "I am allergic to shellfish." 3. "I am allergic to peanuts." 4. "I am allergic to milk."

Question: What is a potential complication to the surgery? Strategy: "MOST concerned" indicates something is wrong. Needed Info: Indication of latex allergy includes urticaria, rash, wheezing, rhinitis, conjunctivitis, bronchospasm, and anaphylactic shock; instruct client to avoid latex products. (1) CORRECT - latex products are used extensively during surgery; certain food allergies may indicate an allergy to latex; foods include apricots, cherries, grapes, kiwis, passion fruit, mangoes, bananas, avocados, chestnuts, tomatoes, and peaches (2) a concern if client going to be given a dye (3) can cause anaphylactic reaction; latex allergy is concern prior to surgery (4) can cause diarrhea; latex allergy is concern prior to surgery.

The nurse on the surgical unit is assigned to care for two patients in traction. The nurse recognizes that when caring for the patient in traction it is MOST important to take which of the following actions? 1. Allow the weight to hang freely at all times. 2. Encourage the patient to limit body movements. 3. Immediately remove the weights if the patient complains of discomfort. 4. Give pain medication regularly.

Question: What is a priority when caring for a client in traction? Strategy: Determine the outcome of each answer. Needed Info: Traction reduces fractures, alleviates pain and muscle spasms, prevents or correct deformities, and promotes healing; maintain straight alignment of ropes and pulleys, ensure that weights hang freely, frequently inspect skin for areas of breakdown, maintain position for countertraction. (1) CORRECT - necessary for proper pull of traction (2) twisting and turning may be prohibited, but movement of unaffected extremities is encouraged (3) weights should not be removed, changes pull of traction (4) pain should be investigated rather than routinely treated; pain may indicate circulatory impairment.

The nurse cares for clients being treated for narcotic abuse. The nurse recognizes that which of the following data obtained during a client history presents the HIGHEST risk for the client developing a disease process? 1. The use of multiple drugs. 2. Intravenous administration of narcotics. 3. Unsuccessful efforts to decrease drug use. 4. Legal difficulties encountered as a result of drug use.

Question: What is a risk factor for IV drug users? Strategy: Think about each answer. Needed Info: Symptoms of narcotic abuse include marked respiratory depression, hyperpyrexia, seizures, ventricular dysrhythmias, pinpoint pupils, stupor leading to coma. (1) associated with some increased risk of complications, but not as severe as IV use (2) CORRECT - IV drug use is associated with increased risk of developing HIV, septicemia, hepatitis, and respiratory failure (3) not directly linked to the development of disease processes (4) not linked to disease processes.

The nurse does discharge teaching with the parent of the child diagnosed with epilepsy. The child is going to be discharged on phenytoin. Which of the following statements, if made by the parent, indicates understanding of the potential side effects of phenytoin? 1. "My child's teeth may become discolored." 2. "My child may develop strange food cravings." 3. "My child may be more sensitive to x-rays." 4. "My child's urine may turn pink, red, or brown."

Question: What is a side effect of phenytoin? Strategy: Eliminate what you know to be wrong. Needed Info: 1) Epilepsy: uncontrolled abnormal discharge of electrical activity in the brain. 2) Sequence of seizures: prodromal stage: vague change in emotions, aura: brief sensation, epileptic cry, convulsion, postictal: change in consciousness. 3) Phenytoin (Dilantin): anticonvulsant and antiarrhythmic. Side effects: thrombocytopenia, leukopenia, ventricular fibrillation, nystagmus, diplopia, gingival hyperplasia, toxic hepatitis. (1) inaccurate (2) inaccurate (3) inaccurate, is more sensitive to ultraviolet rayS (4) CORRECT: harmless side effect

The nurse cares for the client after a below-the-knee amputation. The nurse assesses for infection and is MOST concerned if which of the following is observed? 1. The client appears restless. 2. The client reports a throbbing headache. 3. The client reports persistent pain at the operative site. 4. The skin feels cool proximal to the operative site.

Question: What is a symptom of infection at the operative site? Strategy: Determine what causes each symptom. Does it indicate infection? Needed Info: Major complications after amputation are hemorrhage, infection, and skin breakdown; monitor for bleeding; keep tourniquet placed in site at bedside; skin hygiene important to prevent skin breakdown; wash and dry residual limb twice per day. (1) restlessness indicates hypoxia (2) does not indicate infection (3) CORRECT - infection is frequent complication of amputation; assess for change in color, odor, and consistency of drainage, increased pain, elevated temperature; contact physician immediately (4) does not indicate infection.

The nurse cares for clients in the psychiatric unit. When administering antipsychotic medication, the nurse observes for tardive dyskinesia. The nurse recognizes that which of the following is characteristic of tardive dyskinesia? 1. Masklike face and shuffling gait. 2. Involuntary grimacing and protrusion of the tongue. 3. Motor restlessness and pacing. 4. Severe muscle contractions of the face.

Question: What is a symptom of tardive dyskinesia? Strategy: Think about each answer. Needed Info: Antipsychotics are major tranquilizers used to treat psychotic symptoms; examples are chlorpromazine (Thorazine), thioridazine (Mellaril), fluphenazine (Prolixin), haloperidol (Haldol), clozapine (Clozaril), and risperidone (Risperdal). (1) side effect that describes parkinsonism; notify physician; administer trihexyphenidyl (Artane) or benztropine (Cogentin) as prescribed (2) CORRECT - describes tardive dyskinesia; important to prevent this side effect by maintaining client on lowest possible dose of medication (3) describes akathisia; notify physician; requires reduction of the dose of antipsychotic or may receive benztropine or trihexyphenidyl (4) describes dystonic reaction; can compromise airway; administer diphenhydramine (Benadryl) or benztropine; provide quiet, nonstimulating environment; reassure client that symptoms will resolve.

The patient arrives at the health clinic with reports of dark urine, fever, and flank pain. The initial nursing assessment of the patient reveals which of the following EARLY symptoms of glomerulonephritis? 1. Polyuria. 2. Oliguria. 3. Polydipsia. 4. Enuresis.

Question: What is an EARLY symptom of glomerulonephritis? Strategy: Be careful! The question asks about early symptoms. Needed Info: Acute glomerulonephritis: group of kidney diseases resulting in inflammatory changes from immunological responses. S/S: edema, abdominal pain, hypertension, fever. Nursing responsibilities: restrict sodium and water, daily weight, I + O, bed rest, high-calorie, low-protein diet. (1) excessive output seen with diabetes mellitus, acute renal failure; normal output 1,200 - 1,500 mL/day (2) CORRECT - reduced urinary output (100 - 400/day); also hematuria (blood in urine), proteinuria (protein in urine) (3) excessive thirst seen with diabetes mellitus due to osmotic diuresis; normal intake 1,500 - 2,000 mL/day (4) bedwetting after age 5; not seen with glomerulonephritis.

The nurse assesses the 8 lb 4 oz newborn infant. Which of the following observations, if made by the nurse, requires an intervention? 1. The infant's respirations are 36, shallow and irregular in rate, rhythm, and depth. 2. Rapid pulsations are visible in the fifth intercostal space, left midclavicular line. 3. The infant's axillary temperature is 96.2°F (35.6°C). 4. There is asynchronous spontaneous movement of the infant's extremities.

Question: What is an abnormal finding for a newborn? Strategy: Think about cause of each answer. "Requires an intervention" indicates a complication. Needed Info: Important to assist newborn with heat regulation: wrap newborn to protect from cold, dry infant after birth, place fabric insulated cap on head. Cold stress: infant unable to increase activity and lacks a shivering response to cold; causes metabolic acidosis, hypoxia, and hypoglycemia. (1) normal due to immaturity of respiratory system (2) normal, site of apical pulse, normal rate 120 - 140 bpm (3) CORRECT - subnormal indicates prematurity, infection, low environment temperature, inadequate clothing, dehydration (4) normal, legs move in bicycle fashion, should have equal extension of all extremities.

The patient receives morphine sulfate postoperatively for complaints of pain. Since the patient is receiving morphine, which of the following medications is MOST important for the nurse to have available? 1. Naloxone. 2. Disulfiram. 3. Methadone. 4. Epinephrine.

Question: What is an antidote to morphine? Strategy: Think about each answer choice and how it relates to morphine. Needed Info: Remember that an overdose of morphine causes respiratory depression; need availability of the antidote in case of overdose. (1) CORRECT - narcotic antagonist; rapid onset, duration 3 - 5 hours; reverses respiratory depression (2) treatment for alcohol abuse; reacts with alcohol to cause flushing, HA, vomiting, palpitations, hypotension (3) treatment for drug abuse; narcotic analgesic used to detoxify addicts (4) nervous system stimulant; used in asthmatic attacks, anaphylactic reactions, cardiac arrest.

The nurse cares for the depressed client who frequently verbalizes a negative self-image. The nurse recognizes that which of the following nursing interventions is MOST appropriate for this patient? 1. Help the client identify areas of weakness. 2. Help the client identify unrealistic expectations. 3. Ask the client to identify goals for the next 2 years. 4. Tell the client to stop having negative thoughts.

Question: What is an appropriate nursing action for a client who is depressed? Strategy: Determine the outcome of each answer. Needed Info: Depression may be a response to a real or imagined loss; it may result from anger and aggression toward self that results from feeling of guilt about negative or ambivalent feelings; nursing considerations include being alert for signs of self-destructive behavior, promote eating and rest, support self-esteem. (1) action too negative; reinforces what client already feels (2) CORRECT - unrealistic expectations that client fails to meet reinforces feelings of low self-esteem; the first step is to help client identify what is unreasonable (3) time frame is too long (4) not most appropriate; altering negative thoughts can be helpful in improving self-esteem, but it is not simply a matter of telling a client to stop them; that has a punitive tone and is not realistic.

The nurse observes the student nurse caring for a patient with a tracheostomy tube. The nurse intervenes if which of the following is observed? 1. The student nurse uses clean gloves to remove the tracheostomy dressing. 2. The student nurse cleans the inner cannula by soaking it in hydrogen peroxide. 3. The student nurse removes the soiled trach ties and then reattaches clean ties. 4. The student nurse replaces the dressing with a folded gauze 4 x 4.

Question: What is an incorrect action when caring for a patient with a tracheostomy tube? Strategy: "Need for an intervention" indicates an incorrect action. Needed Info: Perform tracheostomy care every 8 hours and as needed; hyperoxygenate patient prior to suctioning trach tube; sterile procedure. (1) appropriate procedure; dispose of soiled dressing and gloves appropriately (2) appropriate procedure; clean with small brush or pipe cleaner; rinse well in normal saline (3) CORRECT - apply new ties prior to removing old ties to prevent dislodgment of the trach (4) use folded 4 x 4 or commercially prepared 4 x 4; in order to prevent aspiration, do not cut dressing.

The home care nurse assesses the client diagnosed with gout. The nurse is MOST concerned if the client makes which of the following statements? 1. "I drink at least 2 quarts of liquid each day." 2. "I am losing 3 pounds per week." 3. "I limit my protein intake to 3 to 4 ounces per meal." 4. "I have quit drinking beer."

Question: What is an incorrect statement about gout? Strategy: "MOST concerned" indicates an incorrect statement. Needed Info: Gout is overproduction or underexcretion of uric acid; causes joint pain, swelling, limitation of movement, nodules over bony prominences; treatment includes colchicine, analgesics, and anti-inflammatory drugs. (1) increase fluid intake to 2 - 3 quarts per day to promote uric acid excretion and dilute the urine (2) CORRECT - excessive weight loss may precipitate an attack of gout; if overweight, lose 0.5 - 1 pounds per week (3) limit foods high in purines--anchovies, dried peas and beans, and organ meats; cheese, eggs, milk, and vegetables are lower in purines (4) excessive alcohol reduces uric acid excretion.

The nurse instructs the client receiving levothyroxine 100 mcg daily. The nurse identifies that further teaching is necessary if the client states which of the following? 1. "If I have chest pain, I will call my doctor." 2. "If my hands shake, I will call my doctor." 3. "I will take my medication before I go to sleep." 4. "I will inform my other health care providers about this medication."

Question: What is an incorrect statement about levothyroxine? Strategy: Think about the action of the medication. Needed Info: Levothyroxine (Synthroid) increases metabolic rate of body and is used as a thyroid replacement; side effects include nervousness, tremors, insomnia, tachycardia, palpitations, dysrhythmias, and angina; instruct client to report chest pain, palpitations, sweating, nervousness, or shortness of breath. (1) appropriate action: indicates a potentially serious side effect; instruct client to report unusual cardiovascular symptoms (2) appropriate action: may indicate overdose (3) CORRECT - take thyroid replacement at the same time each day; morning is preferred to prevent insomnia (4) appropriate action.

The community health nurse conducts a prevention program at the high school and discusses high-risk groups for suicide. The nurse recognizes that further teaching is necessary if a student states which of the following? 1. "Adolescents are at high risk." 2. "Depressed people are at high risk." 3. "History of previous suicide attempts put people at high risk." 4. "Those who are grieving in response to a loss for 9 months are at high risk."

Question: What is an incorrect statement about suicide? Strategy: Think about each answer. Needed Info: Be alert for signs of self-destructive behavior; behavioral clues of impending suicide include any sudden change in behavior; client becomes energetic after period of severe depression, finalizes business or personal affairs, withdraws from social activities and plans, presence of weapon, razors, or pills, has a death plan. (1) suicide is the third leading cause of death among people 15 to 24 years old (2) symptoms of depression include social withdrawal, feelings of hopelessness, irritability, and difficulty sleeping (3) previous suicide attempts and easy access to lethal methods are risk factors; of those who commit suicide, 80% made previous attempts. (4) CORRECT - grieving is a normal human response that occurs in response to a loss and the entire process may take more than 1 year.

The nurse counsels the young parent about how the parent will know when the child is ready for toilet training. The nurse recognizes that further teaching is necessary if the parent makes which of the following statements? 1. "I can consider toilet training when my child's diaper is dry after naps." 2. "I can begin toilet training when my child begins to walk." 3. "My child must be able to sit for five to ten minutes before I can start toilet training." 4. "It is important that I have the time to spend in toilet training."

Question: What is an incorrect statement about toilet training? Strategy: "Further teaching is necessary" indicates an incorrect statement. Needed Info: Child must be able to control anal and urethral sphincters, recognize the urge to void and defecate, and be able to communicate the need to the parents; readiness occurs around 18 - 24 months; practice sessions should be limited to 5 - 10 minutes, and a parent should stay with the child. (1) staying dry for 2 hours or waking up dry after a nap indicates toilet training readiness (2) CORRECT - voluntary control of anal and urethral sphincters is required; usually occurs at 18 - 24 months; toddlers usually walk at 12 - 13 months (3) must be able to sit without getting up or fussing (4) parent must also recognize child's readiness; if major changes occurring in the family (divorce, moving, vacation) do not begin toilet training.

The nurse assesses the child diagnosed with attention deficit hyperactivity disorder (ADHD). The nurse expects to observe which of the following? 1. Feeding difficulties. 2. Head banging. 3. Easy distractibility. 4. Rigid arms and legs.

Question: What is an indication of ADHD? Strategy: Think about each answer. Needed Info: Characteristics of ADHD include distractibility, immaturity relative to chronologic age, impulsivity, and learning disabilities; nursing considerations include reducing frustration, providing safety and security, and administering medication. (1) exhibited by children diagnosed with failure to thrive (2) observed in children diagnosed with pervasive developmental disorders and mental retardation (3) CORRECT - major clinical manifestation is distractibility; child has difficulty attending to unwanted tasks such as chores or homework (4) side effect of antipsychotic medication.

The nurse manager observes the staff nurse assist the physician with a lumbar puncture. The manager determines that the care is appropriate if the staff nurse does which of the following? 1. The staff nurse instructs the patient to hyperventilate. 2. The staff nurse instructs the patient to maintain a full bladder. 3. The staff nurse explains to the patient that the procedure is always painless. 4. The staff nurse assists the patient into a fetal position.

Question: What is appropriate position for lumbar puncture? Strategy: Determine outcome of each answer. Needed Info: Lumbar puncture is the insertion of needle into subarachnoid space to obtain specimen, relieve pressure, inject dye or medication. Preparation for procedure: explain procedure, confirm that consent has been signed, position in lateral recumbent fetal position. Post-test nursing care: position flat for 4 - 12 hours; encourage PO fluids to 3,000 mL, neurological assessment every 15 - 30 min until stable. Oral analgesics for headache. (1) patient should breathe normally; hyperventilation may lower an elevated pressure (2) patient should empty bladder for comfort (3) patient will feel a needle prick or may feel pain in the leg. (4) CORRECT - the patient uses own arms to hold knees in place, head bent forward; increases space between vertebrae

The nurse cares for clients in the outpatient clinic. The client diagnosed with glaucoma experiences severe restrictions of peripheral vision and asks the nurse if the vision will improve. Which of the following statements by the nurse is BEST? 1. "If you continue to take your medication, the pressure in your eyes will decrease. Your vision will improve." 2. "The physician will perform surgery to remove the lens in your eyes. This will increase your vision." 3. "The current damage to your vision is permanent. Continued use of the eye drops will prevent further damage." 4. "After the eye pressure is stabilized, the physician will reevaluate your vision. Your vision can be corrected with glasses."

Question: What is correct information about glaucoma? Strategy: Think about each answer. Needed Info: Glaucoma is abnormal increase in intraocular pressure leading to visual disability and blindness; signs and symptoms include cloudy, blurry vision, or loss of vision; artificial lights appear to have rainbows or halos around them; decreased peripheral vision; pain, headache, nausea, and vomiting; treatment is miotics. (1) vision will not improve (2) lens is removed during cataract surgery (3) CORRECT - true statement about glaucoma (4) damage is permanent.

The nurse cares for the client who was admitted to the cardiac unit reporting retrosternal chest pain and severe anxiety. The client was diagnosed with arteriosclerotic heart disease (ASHD) and angina. The client is ready for discharge and nitroglycerin is prescribed. Which of the following statements does the nurse include in the discharge teaching? 1. "Store the nitroglycerin tablets in a special clear plastic pillbox with a bright lid." 2. "Take a nitroglycerin tablet before engaging in any activity that may produce chest pain." 3. "Swallow the nitroglycerin tablets, but do not take with water or any other liquids." 4. "You will not have to renew your prescription for nitroglycerin for the next 12 months."

Question: What is correct information about nitroglycerin? Strategy: Determine the outcome of each answer. Needed Info: Nitroglycerin is an antianginal that relaxes vascular smooth muscle; side effects include flushing, hypotension, headache, tachycardia, dizziness, and blurred vision. (1) nitroglycerin is very unstable and should be kept in a dark glass bottle which is securely capped; do not store in metal or plastic (2) CORRECT - prophylactic dose of nitroglycerin increases client's tolerance for stress and exercise (3) nitroglycerin is not swallowed; place under tongue, wet tablet with saliva; do not swallow saliva until tablet dissolves (4) nitroglycerin is unstable, volatile, and inactivated by moisture, air, light, heat, and time; renew supply every 3 months.

The nurse cares for the client who will be taking phenelzine sulfate following discharge. Which of the following is important information for the nurse to include in the teaching plan regarding this medication? 1. The client will see the effects of the medication immediately. 2. The client does not need to use sunblock during outside activities. 3. Drinking coffee or carbonated beverages will decrease the effectiveness of the medication. 4. Combining the medication with certain foods significantly increases blood pressure.

Question: What is correct information about phenelzine? Strategy: Think about the action of the drug. Needed Info: phenelzine sulfate (Nardil) is an MAO inhibitor; interacts with foods containing tyramine or drugs containing sympathomimetic substances to cause a hypertensive crisis. (1) takes 3 - 4 weeks for drug to begin working (2) sunblock is required (3) may precipitate hypertensive crisis (4) CORRECT - instruct client to avoid pickled herring, liver, dry sausage, sauerkraut, aged cheese, yogurt, yeast, and meat extracts, and other pickled, fermented, or smoked foods to prevent a hypertensive crisis

The nurse cares for the client in the outpatient clinic who has received a prescription for verapamil 80 mg TID. The nurse includes which of the following instructions when teaching the client about this medication? 1. "Drink lots of fluids during the day to prevent liver and kidney damage." 2. "When you awaken in the morning, sit on the side of the bed for a few minutes before standing." 3. "If you are feeling stress and develop symptoms, take an extra dose of verapamil." 4. "Take the medication before meals on an empty stomach."

Question: What is correct information about verapamil? Strategy: Determine the outcome of each answer. Needed Info: Verapamil (Calan): calcium-channel blocker; side effects include transient hypotension, dizziness, headache, constipation, elevated liver enzymes; instruct client to take medication with food, monitor vital signs, and instruct not to chew or divide sustained-release medication. (1) encourage client to increase fluid and fiber intake to counteract constipation side effect (2) CORRECT - medication causes transient hypotension; monitor blood pressure when first taking the medication and when dosage is adjusted (3) take medication as prescribed; given as an antihypertensive and antianginal (4) take with food; increase intake of fiber and fluids.

The nurse plans postoperative care for the patient scheduled for a stapedectomy. When the patient is returned to the room after surgery, the nurse expects to observe which of the following? 1. Patient's hearing is completely restored. 2. Patient is still drowsy from the general anesthesia. 3. Patient experiences vertigo, nausea, and vomiting. 4. Patient has drains in both ears.

Question: What is expected after a stapedectomy? Strategy: Think about each answer. Needed Info: Excision of stapes with or without prosthesis to correct hearing loss; during first 24 hours post-op position patient flat in bed with minimal head movement; instruct patient to not blow nose or sneeze; assess for facial nerve damage or muscle weakness or changes in taste. (1) hearing initially worse; improves after 6 weeks (2) local anesthetic used (3) CORRECT - close to inner ear; meclizine (Antivert) (anti-vertigo) and prochlorperazine (Compazine) (antiemetic) used; assist with ambulation, side rails up, change positions slowly (4) drains not used; gel foam (absorbent sponge) packing used to decrease bleeding

The patient with a history of heart failure (HF) is admitted to the hospital with flulike symptoms. When taking the history, the nurse learns that the patient has been taking digoxin 0.125 mg PO daily for 3 years. Last month the physician changed the prescription for digoxin to 0.25 mg PO daily and ordered furosemide 40 mg daily. The nurse expects the physician to order which of the following laboratory tests? 1. Serum electrolytes and digoxin level. 2. White blood cell count and hemoglobin and hematocrit. 3. Cardiac enzymes and an arterial blood gas. 4. Blood cultures and urinalysis.

Question: What is going on with the patient, and which tests will help identify the problem? Strategy: Think about what each test measures. Needed Info: Digoxin (Lanoxin): cardiac glycoside works by strengthening myocardial contraction and slowing conduction through the AV node. Furosemide (Lasix): acts at loop of Henle to inhibit reabsorption of sodium, chloride; side effects: agranulocytosis (decreased WBC), hypokalemia. Heart failure (HF): failure of heart to adequately pump blood. S/S: dyspnea; weight gain, edema, crackles. Treatment: cardiac glycosides (digoxin), diuretics, restricted sodium diet. Nursing responsibilities: promote rest, give oxygen, teach about meds. (1) CORRECT - check potassium; hypokalemia may precipitate dig toxicity: N + V, bradycardia, AV block, visual disturbances, PVCs (2) WBC indicates infection, inflammation; hemoglobin and hematocrit measure functioning of red blood cells, low values indicate anemia (3) CPK + LDH isoenzymes indicate cardiac damage; ABG indicates acid/base balance (4) blood cultures indicate infection; UA indicates urinary problems.

The nurse cares for the recently retired salesman who is brought to the psychiatric hospital by his spouse. The spouse states that since retirement, the patient has been listless and roams around the house complaining of nothing to do. The patient states, "Without a job I have no purpose in life." The spouse adds that the patient recently lost 10 pounds and sleeps for only 2 to 3 hours each night. In order to prioritize the patient's nursing care, the nurse assesses which of the following areas FIRST? 1. Suicidal ideation. 2. Level of insight into his problem. 3. Nutritional deficiencies. 4. Motivation to solve own personal problems.

Question: What is most important for a patient with depression? Strategy: Set priorities according to Maslow's hierarchy of needs. Needed Info: Symptoms of depression: regressive behavior, obsessive thoughts, unkempt appearance, insomnia, withdrawn behavior. Nursing responsibilities: check for possible suicide, report behavioral changes, meet physical needs, structure simple routines, use touch judiciously, encourage expression of feelings. Treatment: antidepressants; group, individual, and family therapy. (1) CORRECT - safety needs highest (2) safety needs higher priority (3) safety needs more important (4) later issue.

The nurse teaches the group of parents of toddlers how to prevent accidental poisoning. Which of the following suggestions does the nurse give regarding medications? 1. Lock all medications in a cabinet. 2. Childproof all the caps to medication bottles. 3. Store medications on the highest shelf in a cupboard. 4. Place medications in different containers.

Question: What is the BEST way to prevent accidental poisoning in children, especially toddlers? Strategy: Picture toddlers at play. Needed Info: Remember that no bottle's cap can be made totally childproof; only a locked cabinet can provide protection. Even the highest shelf is no barrier for some climbing toddlers. Changing the containers will only make life difficult for the parents; it will not prevent accidental poisoning. (1) CORRECT - improper storage most common cause of poisoning; highest incidence in 2-year- olds (2) children can open (3) toddlers climb (4) keep in original containers.

The nurse cares for the patient who is being treated for heart failure (HF) and atrial fibrillation. The physician orders digoxin 0.25 mg PO daily. Prior to administering the medication, the nurse assesses that the patient's heart rate is 98 and irregular. Which of the following actions should the nurse take FIRST? 1. Administer the digoxin and chart the rhythm. 2. Hold the digoxin until the patient's pulse slows down. 3. Hold the digoxin until the patient's pulse increases. 4. Call the physician for clarification of the medication order.

Question: What is the FIRST thing you should do? Strategy: Determine the outcome of each answer choice. Needed Info: Atrial fibrillation: rapid, irregular depolarization of atria. Results in irregular and rapid pulse. Treatment: digoxin (Lanoxin; strengthens the myocardial contraction and slows the rate of conduction), calcium channel blockers nifedipine (Procardia), quinidine, procainamide (Pronestyl), anticoagulants (heparin), cardioversion. (1) CORRECT - drug of choice for atrial fib and flutter; report to physician any increase, decrease, irregularity and/or change in regularity of pulse rate (2) needs digoxin to do (3) already is rapid; would increase myocardial demands (4) not necessary

The nurse cares for the patient receiving neomycin sulfate. The nurse recalls that this medication is given for which of the following reasons? 1. To increase digestive functioning by supporting intestinal bacteria. 2. To decrease postoperative wound infection by suppressing intestinal bacteria. 3. To serve as an adjunct to systemic antibiotic therapy. 4. To prevent the occurrence of ulcerative colitis.

Question: What is the action of neomycin? Strategy: Think about the action of the medication. Needed Info: Neomycin sulfate (Neo-fradin) is an aminoglycoside used to treat infections caused by Pseudomonas and E. coli, used to suppress intestinal bacteria, and as adjunct treatment for hepatic coma; side effects include ototoxicity and nephrotoxicity; nursing considerations include check hearing and renal function, encourage fluids, and offer small frequent meals. (1) no improved digestion (2) CORRECT - neomycin sulfate is an aminoglycoside used to suppress intestinal bacteria; acts as a bowel sterilizer; used to prevent wound and abdominal infections (3) used as adjunctive treatment of hepatic coma (4) sulfasalazine (Azulfidine), not neomycin, is helpful in preventing the recurrence of ulcerative colitis.

The nurse plans care for the patient diagnosed with Graves' disease. The nurse includes which of the following in the patient's plan of care? 1. Provide frequent rest periods. 2. Provide 2 meals per day. 3. Provide extra clothing for warmth. 4. Provide caffeinated beverages.

Question: What is the appropriate action? Strategy: Determine the outcome of each answer. Needed Info: Graves' disease is hyperthyroidism; assessment includes hyperactivity, sensitivity to heat, rest and sleep disturbance, increased perception of stimuli, weight loss, and tachycardia. (1) CORRECT - due to increased metabolic rate, provide for frequent rest periods and provide an environment that is free of stress (2) requires 6 meals per day that are high in calories due to high metabolic rate (3) suffers from heat intolerance; requires cool environment (4) has increased metabolic rate and caffeine would further increase it.

The nurse cares for the infant being evaluated for pyloric stenosis. The nurse recognizes that it is MOST important to offer which of the following feedings? 1. Clear fluids. 2. Continuous nasogastric feedings. 3. Intermittent nasogastric feedings. 4. Small, frequent feedings.

Question: What is the appropriate feeding for an infant with pyloric stenosis? Strategy: Determine the outcome of each answer. Needed Info: Pyloric stenosis is obstruction caused by hypertrophy and hyperplasia of pylorus, the muscular sphincter at the gastroduodenal juncture; projectile vomiting occurs 2 - 4 weeks after birth; postoperative care includes provide parenteral fluids as ordered, check incision site, monitor warmth, offer clear liquids with glucose or electrolyte solution first; if tolerated, infant begins formula or breast feeding. (1) clear fluids offered only in special situations, such as initial feeding after surgery or in preparation for surgery or diagnostic tests of the bowel (2) IV fluids will be given rather than NG tube feedings; exception--NG tube may be inserted prior to surgery for gastric decompression and may be continued immediately after surgery (3) if unable to tolerate oral feedings, infant is NPO and given IV fluids, not NG tube feedings, containing glucose and electrolytes (4) CORRECT - normal amounts of feeding may not be tolerated; may cause aspiration; position upright on right side after feedings

The nurse cares for clients in the outpatient clinic. Which of the following is the MOST important immediate nursing goal for the client just diagnosed with glaucoma? 1. Prepare for required surgery. 2. Prevent further deterioration of the vision. 3. Assist the client to deal with the inevitable effects of blindness. 4. Decrease the ocular pressure and improve vision.

Question: What is the appropriate goal for a client diagnosed with glaucoma? Strategy: Think about each answer. Needed Info: Glaucoma is an abnormal increase in intraocular pressure, leading to visual disability and blindness; signs and symptoms include cloudy, blurry vision or loss of vision; artificial lights appear to have rainbows or halos around them; decreased peripheral vision; pain, headache, nausea, and vomiting; treatment is miotics. (1) surgery is not always indicated (2) CORRECT - damage to vision cannot be corrected; further damage can be prevented with medication; client can complete a trial of medication before contemplating surgery or assuming blindness as an outcome (3) most important immediate goal is to prevent further loss of vision, possible with medication, so that client will not develop blindness, which is NOT inevitable (4) ocular pressure can be decreased, but vision cannot be improved.

The nurse cares for the patient admitted to the recovery room following a total left hip replacement. The nurse positions the patient in which of the following positions? 1. On the right side with the head of the bed slightly elevated and the left hip adducted. 2. On the left side with the head of the bed slightly elevated and the hips flexed 120 degrees. 3. Supine with the knee gatch elevated to 30 degrees and the left hip extended. 4. Supine with the head of the bed slightly elevated and a pillow between the legs.

Question: What is the appropriate position to place a client in after a total left hip replacement? Strategy: Determine the outcome of each answer. Needed Info: Nursing care includes abduction of affected extremity using splints, wedge pillow, or 2 - 3 pillows between legs, turn patient as ordered, ice to operative site, do not sleep on operative side, do not flex hip more than 45 - 60 degrees. (1) adduction should be avoided to prevent dislocation (2) do not flex more than 45 - 60 degrees to prevent dislocation (3) head of bed should be slightly elevated, knee gatch is never used (4) CORRECT - keeps legs abducted and prevents hip flexion; maintains alignment of the prosthesis and prevents dislocation

The nurse is performing a home care visit on the 3-year-old with a cast on the left arm due to a fracture of the radius. The nurse is MOST concerned when which of the following is observed? 1. The mother wraps the cast with plastic wrap prior to bathing the child. 2. The child elevates the arm on a pillow while watching television. 3. The child sits at the table playing with small toy figurines. 4. The mother encourages the child to wiggle the fingers on the left hand.

Question: What is the child doing wrong? Strategy: "MOST concerned" indicates an actual or potential complication. Needed Info: Immediate cast care includes avoid covering cast until dry, handle with palms, not fingertips, watch for danger signs such as blueness or paleness, pain, numbness or tingling sensations on affected area; intermediate cast care includes mobilize client, encourage isometric exercises, do not put anything inside cast, keep small items that might be placed inside the cast away from small children. (1) waterproofs cast against splashes; cast should be kept out of water (2) prevents swelling; can support with a sling or on pillow (3) CORRECT - possibility of child sticking small items down cast (4) indicates good circulation; also check for swelling, discoloration, or decreased sensation.

A neighbor calls the nurse stating that a piece of glass is embedded in the neighbor's child's eye. Which of the following instructions by the nurse is MOST important? 1. Irrigate the injured eye with warm normal saline and apply a dressing. 2. Place a pressure dressing on the injured eye and take the child to the emergency room. 3. Remove the piece of glass from the child's eye. 4. Put an eye patch over both eyes and immediately take the child to the emergency room.

Question: What is the correct action for an eye injury? Strategy: Determine the outcome of each answer. Needed Info: If nonpenetrating abrasion, patch eye for 24 hours; if nonpenetrating contusion, apply cold compresses and take analgesics; if penetrating injury, cover with patch and refer to surgeon. (1) appropriate for nonpenetrating foreign body that is causing an irritation (2) would lead to further eye injury (3) would lead to further eye injury; removal should be done only by a surgeon (4) CORRECT - minimize eye movement in order to prevent further injury

The nurse manager reviews infection prevention practices with the staff caring for clients with central venous catheters (CVCs). Which of the following statements by a staff member indicates the BEST understanding of the precaution required to prevent infections for these clients? 1. "If the dressing is wet or soiled, I will change it immediately." 2. "I will apply the antibiotic ointment as ordered by the physician." 3. "I will assess for swelling in the shoulder, neck, chest, and arm at least twice per shift." 4. "I will flush the catheter at regular intervals."

Question: What is the correct care to prevent infection? Strategy: Determine the outcome of each answer. Needed Info: Central venous catheter used to deliver parenteral nutrition; complications of insertion of central venous catheter include pneumothorax and infection. (1) CORRECT - prevents growth of microorganisms; use aseptic technique when changing dressing (2) relates to treatment, not prevention; if infection occurs, physician may order local antibiotic ointment and /or systemic antibiotic or antifungal (3) swelling indicates possible pneumothorax, which is not an infection (4) important to maintain patency of central venous catheter, but not expected to play a role in infection prevention.

The nurse evaluates care for the client with a diagnosis of vaginal cancer being treated with an internal radium implant. The nurse determines that the nursing care of the client is appropriate if which of the following is observed? 1. The nurse wears a dosimeter film badge when in the client's room. 2. The client uses the bedside commode. 3. The client's 10-year-old grandchild visits for 20 minutes. 4. The nurse stands at the foot of the bed to talk with the client.

Question: What is the correct procedure when caring for clients with an internal radium implant? Strategy: Determine the outcome of each answer. Needed Info: Internal radiation is a sealed source placed in a body cavity or tumor. Place client in private room; save all dressing, bed linens until source is removed; then discard dressing and linens as usual; rotate staff caring for client. (1) CORRECT - measures the amount of radiation that nurse is exposed to; each nurse should have individual badge (2) is on bed rest to prevent dislodgment of the implant (3) children under age of 16 and pregnant women not allowed to visit; limit time in room (4) do not stand in the direct line of the radiation source; limit time in room.

The nurse cares for the postoperative client receiving cephalexin monohydrate 500 mg PO QID. The nurse schedules the administration of this medication at which of the following times? 1. Prior to meals. 2. 9AM, 3PM, 9PM, 3AM. 3. 9AM, 1PM, 5PM, 9PM. 4. After administration of an antacid.

Question: What is the correct schedule to administer cephalexin monohydrate? Strategy: Determine the outcome of each answer. Needed Info: Cephalexin (Keflex) is a first-generation cephalosporin antibiotic; side effects include diarrhea, nausea, dizziness, abdominal pain, superinfection, allergic reactions; take with food, avoid alcohol while taking medication; assess for penicillin allergy (up to 20% have cross-allergy). (1) take with food or milk to avoid GI upset (2) CORRECT - blood level must be achieved and maintained for an antibiotic to be effective; medication should be given around-the-clock, every 6 hours (3) schedule medication around-the-clock, every 6 hours (4) antacids will reduce the effectiveness of the medication.

The nurse cares for clients in the orthopedic clinic. The nurse is MOST concerned if which of the following is observed? 1. The teenager who is 6'4" tall places the crutches about 6" to the side of the feet when ambulating with them. 2. The school-aged child who is 4'8" tall flexes the elbows about 20 degrees when ambulating with crutches. 3. The middle-aged adult who is 5'10" tall advances the crutches first when walking down the stairs. 4. The older adult who is 5'6" tall uses a 4-point gait when ambulating with crutches.

Question: What is the correct technique for crutch-walking? Strategy: "MOST concerned" indicates an incorrect action. Needed Info: To determine crutch height, measure 2 fingers below axilla; support weight on hand pieces, not on axilla; crutches should be kept 8 - 10 inches out to side. (1) CORRECT - taller person requires a broader base of support, at least 8 inches (2) elbows flexed 20 - 30 degrees enables correct hand placement on grips (3) appropriate technique, follow crutches with weak leg, then strong leg (4) provides maximum support, partial weight bearing, both feet required.

The nurse instructs the client about how to perform breast self-examination. The nurse should include which of the following instructions about examining the breasts in a mirror? 1. "Stand with your arms at your sides. Bend from the waist to the left side. Bend from the waist to the right side." 2. "Stand with both arms above your head. Lower the right arm and keep the left arm raised. Lower the left arm and raise the right arm." 3. "Stand with your hands on your hips. Clasp your hands behind your back." 4. "Stand with your arms at your sides. Clasp your hands behind your head and press your hands forward. Place your hands on your hips and bow slightly toward the mirror."

Question: What is the correct way to perform self-breast examination using a mirror? Strategy: Determine the outcome of each answer. Needed Info: Perform breast self-examination monthly beginning at age 20; after inspecting breasts in the mirror, client should palpate the breasts when standing and lying down. (1) should bend forward with hands on hips (2) raise arm to palpate breast to detect unusual growths (3) clasp hands behind head first and then place hands on hips. (4) CORRECT - stand before mirror to inspect breast for discharge from nipples, puckering, dimpling, or scaling of skin; placing hands behind head and on hips will show changes in shape and contour of the breast

The client in the clinic asks the nurse, "What is the difference between rheumatoid arthritis and osteoarthritis?" Which of the following responses by the nurse is BEST? 1. "Rheumatoid arthritis is quickly progressive, and osteoarthritis has periods of remission." 2. "Rheumatoid arthritis is a systemic disease, and osteoarthritis is deterioration of the synovial joints." 3. "Rheumatoid arthritis is often treated surgically, and osteoarthritis is treated by medication." 4. "There is very little clinical difference between rheumatoid arthritis and osteoarthritis."

Question: What is the difference between rheumatoid arthritis and osteoarthritis? Strategy: Think about each answer. Needed Info: Rheumatoid arthritis is a chronic systemic disease that causes inflammatory changes in joints; osteoarthritis is nonsystemic and degenerative; symptoms include joint pain, swelling, and limitation of movement; nursing care includes pain management, rest, activity, and exercise. (1) rheumatoid arthritis is progressive and has periods of remission and exacerbations; osteoarthritis is degenerative and there are no remissions (2) CORRECT - rheumatoid arthritis is a chronic systemic disease that causes inflammatory changes in joints; osteoarthritis is nonsystemic and degenerative affecting the synovial joints (3) both diseases can be treated with medication; both diseases may require joint replacement (4) untrue statement.

The nurse cares for the client who experiences severe panic attacks when planning to go grocery shopping. The nurse expects to administer which of the following oral medications? 1. Chlorpromazine. 2. Carbamazepine. 3. Flurazepam. 4. Imipramine.

Question: What is the drug of choice for clients experiencing panic-level anxiety? Strategy: Think about the action of each medication. Needed Info: Anxiety is feeling of dread or fear in the absence of external threat or disproportionate to the nature of the threat; in panic level anxiety, the client is unable to see, hear or function; assess level of anxiety, decrease environmental stimuli, use unhurried approach and stay with the client. (1) chlorpromazine (Thorazine): antipsychotic medication; not used to treat panic attacks (2) carbamazepine (Tegretol): anticonvulsant used to treat seizures and nightmares (3) flurazepam (Dalmane) : sedative-hypnotic, used to produce sleep. (4) CORRECT - imipramine (Tofranil): tricyclic antidepressant used to treat panic attacks

The patient with a history of alcoholism is brought to the emergency room in an agitated state. The patient is vomiting and diaphoretic. The patient had the last drink 5 hours ago. The nurse expects to administer which of the following medications? 1. Disulfiram. 2. Methadone hydrochloride. 3. Naloxone hydrochloride. 4. Chlordiazepoxide hydrochloride.

Question: What is the drug used to treat acute alcohol withdrawal? Strategy: Think about the action of each drug. Needed Info: Symptoms of acute alcohol withdrawal include tremors, being easily startled, insomnia, anxiety, anorexia, and alcoholic hallucinations. Nursing care includes administering sedation as needed, monitoring pulse, blood pressure, and temperature, seizure precautions, orienting frequently, and not leaving hallucinating, confused client alone. (1) disulfiram (Antabuse): used as a deterrent to impulsive drinking; contraindicated if patient drank alcohol in previous 12 hours (2) methadone hydrochloride (Dolophine): opioid analgesic, used to treat narcotic withdrawal syndrome; S/E seizures, respiratory depression (3) naloxone hydrochloride (Narcan): narcotic antagonist used to reverse narcotic-induced respiratory depression; S/E ventricular fibrillation, seizures, pulmonary edema. (4) CORRECT - chlordiazepoxide hydrochloride (Librium): antianxiety; used to treat symptoms of acute alcohol withdrawal; S/E lethargy, hangover, agranulocytosis

The nurse manager notes that one of the staff members is frequently absent, and this has adversely affected the quality of care given to patients on the unit. When INITIALLY counseling the staff member, which of the following approaches by the nurse manager is BEST? 1. Inform the staff member that the next missed day will be grounds for termination. 2. Talk with the staff member and remind the staff member of the standards of the agency. 3. Give the staff member a written reminder of the standards of the agency. 4. Document the staff member's absenteeism.

Question: What is the first action the nurse manager should take? Strategy: Determine the outcome of each answer. Needed Info: If the staff member does not clearly understand what is expected, the staff member may feel role strain, which might cause withdrawal from the work situation. (1) important to clarify the staff member's role; give oral and written reminders before terminating employee (2) CORRECT - first action is to give employee an oral reminder of the agency's standards; do not threaten discipline; purpose is to clarify role expectation (3) if absenteeism continues to be a problem after the verbal reminder, the staff member is given the same reminder in writing (4) should be documented, but the nurse's first action should be to give the staff member a verbal reminder.

At midnight, 2 days following a hemicolectomy, the patient awakens frightened and agitated. The patient climbs out of bed, removes the indwelling urinary drainage catheter, and runs down the hall screaming. Which of the following actions is most appropriate for the nurse to take INITIALLY? 1. Call the physician and request a sedative for the patient. 2. Return the patient to bed and restrain the patient immediately. 3. Replace the patient's indwelling urinary drainage catheter. 4. Return the patient to bed and assess the patient's condition.

Question: What is the first thing you should do in this situation? Strategy: Establish priorities. Remember the steps of the nursing process. Needed Info: Hemicolectomy: removal of half or less of the colon in order to remove tumors. (1) assessment needed first (2) last resort; needs assessment and reorientation (3) not first priority. (4) CORRECT - assessment first step

The woman in her second trimester of pregnancy tells the clinic nurse that her 5-year-old child has been asking questions "about sex." The client asks the nurse what she should tell her child. Which of the following statements, if made by the nurse, is BEST? 1. "Buy a book about sex designed for young children and read it with your son." 2. "Have your child touch your abdomen and tell him about your pregnancy." 3. "Tell your child that this subject is complicated, and you will discuss it as the child gets older." 4. "Answer your child's questions in a matter-of-fact manner, in words that the child will understand."

Question: What is the most appropriate response? Strategy: "BEST" indicates discrimination is required. Needed Info: Important to determine what the child knows and thinks and to offer honest explanations. (1) not best action, may provide more information than child is seeking (2) does not answer particular questions child has; assumes that questions are about pregnancy (3) questions should be answered as they are asked, not postponed or ignored. (4) CORRECT - helps child understand his concerns, allows for answering exact question that is being asked

The nurse cares for the patient with a diagnosis of chronic obstructive pulmonary disease (COPD) and bronchitis. The patient constantly rings the call bell and rattles the bed rails. Which of the following actions by the nurse is MOST appropriate? 1. Check the patient's pulse oximetry. 2. Send a nursing assistant to sit with the patient. 3. Sit the client in a chair next to the nurses' station. 4. Request that the patient's family order the TV for the patient.

Question: What is the most important action for this patient? Strategy: Remember to assess before implementing. Needed Info: COPD is a group of conditions associated with obstruction of air flow entering or leaving the lungs; indications include change in skin color, weakness and weight loss, dyspnea, use of accessory muscles to breathe, cough, abnormal ABGs. (1) CORRECT - decreased oxygenation will cause confusion; assess before implementing (2) assess before implementing (3) obtain pulse oximetry reading before determining appropriate intervention (4) assess before implementing.

The client is brought to the community mental health center by the spouse. One year ago the client's youngest child was killed in a car accident. The graduation of the child's high school class triggered feelings of sadness and guilt. As a result, the client has been having severe headaches, insomnia, and poor appetite. In planning care for this client, the nurse recognizes that the symptoms are MOST likely an example of which of the following? 1. Turning aggression inward. 2. Receiving inadequate support from her family. 3. Displacement of anger. 4. Delayed grief reaction.

Question: What is the most likely cause of these symptoms in this patient? Strategy: Think about each action. Needed Info: At the one-year time point, a client would often be moving toward the stage of grief called acceptance. However, the stages are not sequential and do not have a guaranteed timeframe. The client has faced a major anniversary, reminding client of the loss. (1) partial possible explanation (2) assumption (3) not accurate; no evidence of displacement (4) CORRECT - anniversaries of loss can trigger symptoms of grief

The patient diagnosed with multiple myeloma is admitted to the unit after developing pneumonia. When the nurse enters the patient's room wearing a mask, the patient says in an irritated tone of voice, "Why are you wearing that mask?" Which of the following responses by the nurse is BEST? 1. "The chest x-ray taken this morning indicates you have pneumonia." 2. "What have you been told about the x-rays that were taken this morning?" 3. "You have been placed on contact precautions due to your infection." 4. "I am trying to protect you from the germs in the hospital."

Question: What is the most therapeutic response? Strategy: Remember to assess before implementing. Needed Info: Multiple myeloma is a neoplastic disease that infiltrates bone and bone marrow, causes anemia, renal lesions, and high globulin levels in blood. Pneumonia is inflammatory process resulting in edema of lung tissue and extravasation of fluid into alveoli, causing hypoxia. (1) does not assess what client knows; physician responsible for telling patient the medical diagnosis (2) CORRECT - assessment; determines what client knows before responding; allows client to verbalize (3) pneumonia requires droplet precautions (4) pneumonia requires droplet precautions.

The nurse has just given a client a subcutaneous injection. What immediate follow-up action does the nurse take? 1. The nurse removes and discards gloves in the designated receptacle. 2. The nurse performs hand hygiene, to protect both the nurse and the client. 3. The nurse discards the uncapped needle with the syringe in the designated receptacle. 4. The nurse caps the needle before discarding the syringe in the designated receptacle.

Question: What is the next step after giving an injection? Strategy: Think about each answer choice. Needed Info: Capping a needle can lead to a needlestick injury. Gloves kept on until syringe disposal, as a safety precaution. Hand hygiene after all other steps. (2) hand hygiene after syringe and gloves disposal (3) CORRECT - the Centers for Disease Control and Prevention (CDC) recommends not capping the needle before disposal (1) discard gloves after syringe disposal (4) violates CDC recommendation

The school nurse observes the group of school-aged children playing on the playground. A child begins to cry and reports being stung by a bee. Which of the following actions should the nurse take FIRST? 1. Inject IM epinephrine. 2. Remove the stinger. 3. Apply a warm compress. 4. Wash with soap and water.

Question: What is the nurse's priority for a bee sting? Strategy: All answers are implementation; determine the outcome of each answer. Needed Info: Hymenopteran stings (bees, wasps, hornets, yellow jackets, fire ants) inject venom through a stinging apparatus; local reaction includes small red area, wheal, itching, and heat. Assess for systemic reaction and instruct client about how to avoid contact. (1) appropriate for hypersensitive individuals or if the client demonstrates a severe life-threatening response (2) CORRECT - remove stinger by scraping skin until stinger is removed; remove the stinger as quickly as possible to avoid injection of venom (3) apply cool compress after removing stinger and clean the bee sting (4) cleanse wound after removing stinger; apply paste made with baking soda or meat tenderizer.

The nurse cares for the 19-year-old client admitted to the emergency department after an auto accident. Even though the client denies drinking alcohol, the nurse notes that the client's breath smells of alcohol, speech is slurred, reflexes are diminished, and the client has difficulty recalling the events of the evening. The physician orders an MRI. Which of the following actions should the nurse take FIRST? 1. Inform the client that since he is of the age of consent, he can sign the consent form for the MRI. 2. Instruct the client to remove his watch. 3. Contact the client's parents to give consent for the MRI. 4. Restrict food and fluids for 4 hours.

Question: What is the nurse's priority in this situation? Strategy: Determine the outcome of each answer. Needed Info: In most states, young adults (18 years and older) can legally give consent; a client cannot give informed consent if s/he has been drinking or is premedicated. (1) cannot give consent since client has apparently been drinking and has altered mental status (2) appropriate action; however, health care provider must obtain consent prior to an MRI (3) CORRECT - MRI provides detailed pictures of body structures; procedure requires consent, and client unable to give informed consent due to probable drinking and altered mental status (4) no food or fluid restrictions for adults.

The nurse auscultates the abdomen of the pregnant woman at 38 weeks gestation to determine fetal heart rate. If the fetal heartbeat is located in the right lower quadrant, which of the following is MOST likely the presenting part? 1. Shoulder. 2. Head. 3. Feet. 4. Buttocks.

Question: What is the position of the fetus? Strategy: Map out the abdomen and picture the position of the fetus. Needed Info: Lower quadrant heartbeat indicates vertex or head/cephalic presentation; fetal heartbeat is best heard over the fetus's back. (1) only 1% of births; uncommon (2) CORRECT - right lower quadrant heartbeat indicates occiput of fetal head is on the right side of the mother's body and facing the front (anterior) of the mother's body; (ROA) (3) breech; would hear FHT in upper quadrant (4) breech; would hear FHT in upper quadrant.

The home care nurse cares for the child diagnosed with hemophilia A recovering from the acute phase of spontaneous bleeding into the joints. It is MOST important for the nurse to give the parents which of the following instructions? 1. Administer ibuprofen for pain. 2. Apply ice to the joint. 3. Decrease the risk of injury. 4. Encourage active range-of-motion exercises.

Question: What is the priority nursing action after the acute phase of spontaneous bleeding? Strategy: "MOST important" indicates a priority. Determine the outcome of each answer. Needed Info: Hemophilia is a bleeding disorder caused by deficiency of factor VIII (most common) or factor IX; symptoms include easy bruising, joint pain with bleeding, prolonged internal or external bleeding. (1) use ibuprofen (Advil) with caution because it inhibits platelet aggregation; offer acetaminophen (Tylenol) at home to control pain (2) appropriate action during bleeding episode; rest, ice, compression, and elevation to prevent excessive blood loss; administer factor VIII concentrate (3) important to prevent bleeding episodes; encourage age-appropriate exercises that strengthen muscles and joints (4) CORRECT - active range-of-motion encouraged after bleeding episode to prevent crippling effects of bleeding; active range-of-motion allows the child to control the amount of exercise according to the pain level; do not perform passive range-of-motion

The nurse cares for the client after an above-the-knee amputation. The client has a closed rigid cast dressing in place. Several days after surgery, the nurse enters the client's room and finds that the cast has come off. Which of the following actions does the nurse take FIRST? 1. Wrap the residual limb with an elastic compression bandage. 2. Observe the residual limb for swelling. 3. Contact the physician. 4. Ask the client how the cast came off.

Question: What is the priority nursing action if the rigid cast dressing comes off an above-the-knee amputation? Strategy: Determine the outcome of each answer. Needed Info: Observe for signs of oozing; elevate residual limb for 24 hours; turn client prone to prevent contractures; client ambulates early with rigid cast dressing because it functions as a socket for fitting of a prosthetic immediately post-op. (1) CORRECT - will prevent edema from developing; edema will delay the rehabilitation process (2) important to prevent edema; if residual limb not wrapped immediately, significant swelling will occur (3) notify surgeon so that a new cast dressing can be applied; wrap residual limb before notifying the physician (4) more important to prevent edema from developing.

The nurse cares for clients in the labor and delivery unit. The nurse notes that a client's membranes have ruptured and the amniotic fluid is meconium-stained. The nurse determines that there is no prolapsed cord. Which of the following actions does the nurse take NEXT? 1. Contact the health care provider. 2. Assess fetal heart tones. 3. Start an intravenous line. 4. Obtain the client's pulse and blood pressure.

Question: What is the priority nursing action when a client passes meconium-stained amniotic fluid? Strategy: Determine whether it is appropriate to assess or implement. Needed Info: Amniotic fluid is straw-colored and pale; meconium-stained fluid (greenish-brown) indicates fetus has probably experienced recent hypoxic episode; meconium-stained fluid may be normal finding in breech presentation. (1) assess for nonreassuring fetal heart tone patterns before contacting health care provider (2) CORRECT - meconium-stained amniotic fluid may be an ominous sign; assess for the nonreassuring fetal heart tone patterns of fetal bradycardia, fetal tachycardia, irregular FHR, late, severe, variable, and prolonged deceleration patterns; if fetal distress, turn client to left side, give supplemental oxygen, start IV (3) assess fetus first (4) no reason to assess mother; meconium-stained fluid might indicate fetal distress.

The nurse cares for the 6-year-old child placed in Russell's traction due to a fracture of the left tibia. After repositioning the child, it is MOST important for the nurse to take which of the following actions? 1. Administer pain medication. 2. Offer the child a book. 3. Check the position of the left hip. 4. Assess the pin site for infection.

Question: What is the priority nursing action when caring for a child in Russell's traction? Strategy: "MOST important" indicates priority. Answers are a mix of assessment and implementation. Needed Info: Skin traction is used on the lower leg and a padded sling is placed under the knee; "pulls" contracted muscles; elevate foot of bed with shock blocks to provide countertraction; check popliteal pulse; do not turn from waist down; lift patient, not leg, to provide assistance. (1) analgesics and muscle relaxants are administered due to discomfort caused by traction pull; offer at regular intervals (2) important to offer children an opportunity for play; explain to child what is happening (3) CORRECT - hip is flexed at a prescribed angle to prevent fracture malalignment; after moving child, assess that the prescribed amount of hip flexion is maintained (4) Russell's traction is a form of skin traction; no pins are used.

The staff nurse observes the newly licensed LPN/LVN prepare to administer iron dextran IM to a patient with iron deficiency anemia. It is MOST important for the staff nurse to give which of the following instructions to the LPN/LVN? 1. "Massage the injection site for one minute after the injection of the medicine." 2. "Tap out the air bubble prior to administering the medication." 3. "Release the skin prior to withdrawing the needle." 4. "Change the needle after drawing up the medication."

Question: What is the priority when administering iron dextran? Strategy: Determine the outcome of each answer. Needed Info: Iron dextran (DexFerrum) is a hematinic used to treat iron deficiency anemia; administer using Z-track method; select large, deep muscle; pull skin and subcutaneous tissue 1.5 inches to the side; release skin after withdrawing needle. (1) causes medication to leak into subcutaneous tissue, staining skin (2) draw up 0.2 mL of air to create an airlock (3) release skin after withdrawing the needle. (4) CORRECT - ensures that no solution remains on outside of needle

The home care nurse visits the client diagnosed with non-Hodgkin's lymphoma who is receiving chemotherapy. After the second round of chemotherapy, the client reports a sore mouth and loss of taste. Which of the following actions does the nurse take FIRST? 1. Examine the client's mouth. 2. Instruct the client to use a saline rinse. 3. Obtain a diet history from the client. 4. Instruct the client to avoid spicy foods.

Question: What is the priority when client is complaining of a sore mouth? Strategy: Assess before implementing. Needed Info: Chemotherapy causes stomatitis; assess frequently; good oral hygiene; use soft-bristled toothbrush; avoid dental floss, water pressure gum cleaners, and mouthwashes containing alcohol or glycerin. (1) CORRECT - assess every 4 hours; instruct client about good oral hygiene (2) implementation; important to rinse mouth with water or saline rinse every 12 hours (3) assessment; encourage client to avoid spicy foods or hard foods (4) implementation; correct action, but assess first.

The home care nurse visits the client who has been receiving lithium carbonate for 3 weeks. The client reports to the nurse experiences of blurred vision and intense dizziness. Which of the following actions does the nurse take FIRST? 1. Encourage the client to increase fluid intake. 2. Notify the physician. 3. Instruct the client to breathe into a paper bag. 4. Teach the client about relaxation techniques.

Question: What is the priority when the client is complaining of adverse effects of lithium? Strategy: Determine the outcome of each answer. Needed Info: Lithium used to treat bipolar disorder; has a narrow therapeutic range (1 - 1.5 mEq/L); side effects include dizziness, headache, impaired vision, fine hand tremors, and reversible leukocytosis; nursing considerations include monitor blood levels frequently, encourage 2,500 - 3,000 mL fluids daily. (1) intake should be 2,500 - 3,000 mL daily; more important to contact physician (2) CORRECT - important to confirm lithium level; levels over 2.0 mEq/L may cause lithium intoxication, agitation, ataxia, blurred vision, confusion, tinnitus, vertigo, hyperreflexia, and myoclonic twitching (3) appropriate action if client hyperventilating (4) not priority; symptoms indicate adverse side effects; need physician management.

The home care nurse is visiting the 82-year-old client living with the client's adult child. The client appears malnourished and has multiple bruises on the body. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Place a home health aide with the patient to document incidents of abuse. 2. Discuss the nurse's observation with the client's children. 3. Report the situation to the nursing supervisor. 4. Request that another nurse visit the patient to assess the situation.

Question: What is the priority when the nurse suspects elder abuse? Strategy: Determine the outcome of each answer. Needed Info: Indications of elder abuse include battering, fractures, bruises, overmedicated or undermedicated, poor nutritional status, dehydration; nursing care includes providing for the client's safety, providing for physical needs, and reporting to appropriate agency. (1) must report suspected cases (2) report to the nursing supervisor (3) CORRECT - required by state law (4) no reason to involve another nurse.

The male patient is admitted to the hospital for evaluation of hematuria. An intravenous pyelogram (IVP) is ordered. The patient asks the nurse to explain what will happen to him during the IVP. Which of the following explanations, if made by the nurse, is MOST accurate? 1. "An intravenous line will be inserted, dye injected into it, and then x-rays will be taken of your kidneys, ureters, and bladder." 2. "A scope will be inserted into your penis so that the inside of your bladder can be visualized." 3. "A catheter will be inserted into your penis, dye injected into it, and then x-rays will be taken of your bladder and ureters." 4. "A small incision is made in the kidney, dye injected into it, and then x-rays will be taken of your kidneys, ureters, and bladder."

Question: What is the procedure for an IVP? Strategy: Form a mental image of the procedure. Needed Info: Hematuria: blood in the urine. IVP: radiographic exam of the kidney, ureter, bladder. Prep: check for sensitivity to contrast medium, iodine, shellfish; prep bowel (laxatives, enemas); may be NPO or allowed fluids. Post-test: force fluids. (1) CORRECT - describes procedure (2) cystoscopy; prep: NPO, bowel prep (laxatives, enemas), general or local anesthesia used; post-test: check for bleeding and infection (3) cystourethrogram; prep: none; post-test: check for infection (4) inaccurate.

The nurse cares for the 1-year-old patient who is admitted to the hospital with a fractured femur and is placed in Bryant's traction. The nurse recognizes that the child should be maintained in which of the following positions? 1. Buttocks slightly elevated off the bed. 2. Buttocks flat on the bed. 3. Knees slightly flexed. 4. Hips extended.

Question: What is the proper position for a child in Bryant's traction? Strategy: Picture the traction apparatus. Remember the concepts for effective traction. Needed Info: Bryant's traction: type of running traction used to reduce a fractured femur in a child; adhesive strips are applied to both legs and secured with elastic bandages wrapped from foot to groin; both legs are suspended by weights and pulleys. (1) CORRECT - child's weight provides countertraction (2) no countertraction (3) not possible; must be extended (4) must be flexed at 90 degree angle.

The nurse conducts the admission physical examination for the new clinic patient. Which of the following sequences represents the order in which the nurse performs the assessment of the patient's abdomen? 1. Observe, auscultate, percuss, palpate. 2. Auscultate, observe, percuss, palpate. 3. Palpate, percuss, auscultate, observe. 4. Percuss, palpate, auscultate, observe.

Question: What is the proper sequence of steps to take to assess a patient's abdomen? Strategy: Remember to look and listen before you feel. Needed Info: Percussion and palpation alter the mobility of the bowel and heighten bowel sounds. Use the diaphragm of a stethoscope because sounds are high pitched. Percuss, checking for tympany (hollow sound) and dullness (high-pitched sound). To palpate, depress abdominal wall 1 cm using the pads of your fingers. (1) CORRECT (2) inaccurate; look first (3) inaccurate; look first (4) inaccurate; look first.

The nurse cares for the postoperative client who had an abdominal resection for colon cancer, including the insertion of a Jackson-Pratt drain. The nurse recognizes that which of the following is the PRIMARY purpose of the drain? 1. To irrigate the incision with a saline solution. 2. To prevent bacterial infection of the incision. 3. To prevent accumulation of drainage in the wound. 4. To measure the amount of fluid lost after surgery.

Question: What is the purpose of a Jackson-Pratt drain? Strategy: Think about each answer. Is it the primary purpose of a drain? Needed Info: Jackson-Pratt drain: tissue drain used postoperatively to prevent accumulation of fluid in wound. (1) not accurate (2) not best answer; prophylactic antibiotics and sterile technique used (3) CORRECT - portable wound suction; speeds wound healing; document color, odor, amount, consistency of drainage (4) not primary purpose.

The nurse cares for the patient who returns to the nursing unit in stable condition after having a myelogram using a water-soluble dye. An intravenous infusion is in progress. The nurse recognizes that which of the following is the PRIMARY purpose of the intravenous fluid? 1. To replace blood lost during the procedure. 2. To enhance excretion of the dye. 3. To restore cerebrospinal fluid levels. 4. To increase blood flow to the brain.

Question: What is the purpose of administering IV fluids after a myelogram using a water-soluble dye? Strategy: Think about each answer choice. Does it make sense? Needed Info: In a myelogram, contrast dye is injected into the spinal column. This causes the tissue under study to be visible. The spinal cord, subarachnoid space, and other surrounding structures can be visualized more clearly than in standard x-rays. After the procedure is completed, an intravenous infusion enhances renal excretion of the dye. (1) no blood loss (2) CORRECT - dilutes dye and enhances excretion by kidneys (3) none lost (4) not purpose.

The unconscious patient is admitted to the hospital for treatment of an injury sustained in an automobile accident. The patient has a cuffed tracheostomy tube and mechanical ventilation in progress. The nurse recalls that the purpose of the cuff on a tracheostomy tube is to accomplish which of the following? 1. Prevent displacement of the tracheostomy tube. 2. Maintain the alignment of the trachea with the lungs. 3. Separate the upper and lower airways. 4. Maintain the patency of the trachea.

Question: What is the purpose of the cuff on a trach tube? Strategy: Form a mental image of a tracheostomy tube with a cuff inserted into a trachea. Needed Info: Cuff: plastic balloon that encircles the tracheal tube to form a seal between the outer cannula and the trachea. (1) action of twill tapes tied at side of neck; need 2 people to change, or leave in place till new ties on; allow for 2 finger spaces between tie and neck (2) does not change position of trachea (3) CORRECT - seals off lumen; prevents aspiration (4) purpose of trach tube, not cuff.

The patient is admitted to the hospital after sustaining a severe head injury in an automobile accident. When the patient dies, the nurse observes the patient's spouse comforting other family members. Which of the following interpretations of the spouse's behavior is MOST justifiable? 1. The spouse has already moved through the stages of the grieving process. 2. The spouse is repressing anger related to the patient's death. 3. The spouse is experiencing shock and disbelief related to the patient's death. 4. The spouse is demonstrating resolution of the patient's death.

Question: What is the reason for the spouse's behavior? Strategy: "MOST justifiable" indicates that there may be more than one correct response. Think about each answer choice. Is it true? Needed Info: Stages of grief, popularly known as DABDA: 1) denial, 2) anger, 3) bargaining, 4) depression, 5) acceptance. The stages can be experienced in any order; they are not sequential. Acute period: 4 - 8 weeks, usual minimum time for resolution: 1 year. (1) usually takes a minimum of 1 year (2) anger is a possible stage, but the spouse's behavior does not support this interpretation (3) CORRECT - denial is the inability to comprehend reality of situation (4) too soon.

The nurse conducts the family therapy session with the patient being treated for depression. During the therapy session, the patient verbally expresses love toward the mother, but has an angry facial expression and pounds the table with a fist. The nurse understands that the discrepancy between the patient's body language and spoken language is BEST characterized as which of the following? 1. Ambivalence. 2. Scapegoating. 3. Double-bind communication. 4. Loose associations.

Question: What is this behavior called? Strategy: "Best categorized" indicates that there may be more than one correct response. Needed Info: Double-bind communication is characterized by simultaneous communication of two mutually conflicting verbal and nonverbal messages. (1) mixed feelings; confusing emotional experience (2) others blamed for problems (3) CORRECT - emotions communicated verbally are opposite of emotions communicated physically (4) disordered thought processes.

The patient admitted for treatment of bronchitis reports an allergy to sulfa drugs and to penicillin to the nurse. The nurse recognizes that which of the following medications is MOST appropriate for this patient? 1. Co-trimoxazole. 2. Sulfisoxazole. 3. Cephalexin. 4. Ciprofloxacin.

Question: What medication can be given to a patient with a sulfa and penicillin allergy? Strategy: Think about each answer choice. Needed Info: Patients with a sensitivity to penicillin should take cephalosporin medications cautiously due to a cross-allergy. Patients with an allergy to sulfa drugs should not take any sulfa-containing medications. (1) co-trimoxazole (Septra): sulfa medication; used for treatment of traveler's diarrhea, Pneumocystis jiroveci; used prophylactically for women with recurrent UTI; side effects: agranulocytosis, anemia, N + V, diarrhea, toxic nephrosis, rash, photosensitivity (2) sulfisoxazole (Gantrisin): sulfa medication; side effects: aplastic anemia, toxic nephrosis; force fluids (3,000 - 4,000/day) to prevent crystalluria; keep urine alkaline (3) cephalexin (Keflex): cephalosporin medication; side effects: diarrhea, rash, urticaria; take with food/milk (4) CORRECT - ciprofloxacin (Cipro): quinolone antibiotic; side effects: dizziness, seizures, HA, abdominal pain, rash, photosensitivity; give PO 2 hours after meals or 2 hours before or after antacids or medications continuing iron; avoid caffeine; force fluids 3,000 mL/24 hours

The nurse cares for the client with schizophrenia. The nurse recognizes that the patient has developed parkinsonian side effects of chlorpromazine. The nurse expects which of the following medications will be prescribed for the patient? 1. Diazepam. 2. Haloperidol. 3. Amitriptyline. 4. Benztropine.

Question: What medication is given to treat the parkinsonian side effects of chlorpromazine? Strategy: Think about the action of each drug. Needed Info: benztropine: anticholinergic, antiparkinsonian agent; side effects include drowsiness, blurred vision, nausea, constipation, urinary retention, dry mouth, agitation; nursing considerations include monitor intake and output, monitor for muscle weakness or inability to move certain muscle groups, monitor for central nervous system depression or stimulation, provide sugarless gum or lozenges for dry mouth. (1) diazepam: antianxiety medication; side effects: drowsiness, ataxia, cardiovascular collapse (2) haloperidol: antipsychotic medication; would exacerbate symptoms; side effects: extrapyramidal reactions, blurred vision, dry mouth, tardive dyskinesia (3) amitriptyline: antidepressant medication; side effects: drowsiness, dizziness, orthostatic hypotension, blurred vision, dry mouth, urinary retention, photosensitivity (4) CORRECT- benztropine: antiparkinsonian medication; manages extrapyramidal symptoms; side effects: sedation, dry mouth, urinary retention

The nurse cares for the client admitted to the hospital reporting fatigue and weight loss. Physical examination reveals pallor and multiple bruises on the arms and legs. The results of the client's test reveal acute lymphocytic leukemia and thrombocytopenia. Which of the following nursing diagnoses MOST accurately reflects the client's condition? 1. Potential for injury. 2. Self-care deficit. 3. Potential for self-harm. 4. Alteration in comfort.

Question: What nursing diagnosis is seen with acute lymphocytic leukemia and thrombocytopenia? Strategy: Think about each answer choice. Needed Info: Thrombocytopenia: decreased platelet count increases the client's risk for injury, normal count: 150,000 - 350,000 per mm3. Leukemia: group of malignant disorders involving overproduction of immature leukocytes in bone marrow; this shuts down normal bone marrow production of erythrocytes, platelets, normal leukocytes; causes anemia, leukopenia, and thrombocytopenia leading to infection and hemorrhage. Symptoms: pallor of nail beds and conjunctiva, petechiae (small hemorrhagic spots on skin), tachycardia, dyspnea, weight loss, fatigue. Treatment: chemotherapy, antibiotics, blood transfusions, bone marrow transplantation. Nursing responsibilities: private room, no raw fruits or vegetables, small frequent meals, oxygen, good skin care. (1) CORRECT - low platelet count increases risk of bleeding from even minor injuries; safety measures: shave with an electric razor, use soft toothbrush, avoid subcutaneous or IM medications and invasive procedures (urinary drainage catheter or a nasogastric tube), side-rails up, remove sharp objects, frequently assess for signs of bleeding, bruising, hemorrhage (2) may feel weak; does not most address condition (3) implies risk for purposeful self-injury; not given any information, assumption (4) client is not comfortable, and comfort measures would address problem; does not most address condition.

The nurse cares for the patient in the labor unit. During the transitional phase of labor, the umbilical cord becomes prolapsed. The nurse places the patient in which of the following positions? 1. Lithotomy. 2. Side-lying. 3. Semi-Fowler's. 4. Trendelenburg.

Question: What position should you place a patient in if there is a prolapse of the umbilical cord? Strategy: Picture the situation as described. Needed Info: Prolapsed cord: obstetrical emergency in which the umbilical cord is below the presenting part of the fetus. Compression of the cord causes fetal hypoxia resulting in CNS damage. (1) lying on back with thighs flexed on abdomen, legs separated and knees bent with feet in stirrups; used for examination of vagina or rectum (2) used to remove weight from vena cava to prevent maternal hypotension; does not help with prolapsed cord (3) aggravates prolapsed cord pressure. (4) CORRECT - supine on incline with head lower than hips and legs; or put finger against presenting part and shift weight off cord

The nurse cares for the patient who is being discharged after having a transurethral prostatectomy (TURP) for benign prostatic hypertrophy (BPH). The nurse's discharge teaching plan reinforces adherence to which of the following measures? 1. Avoiding vigorous exercise for 3 weeks. 2. Avoiding cold foods for 1 week. 3. Avoiding hot baths for 1 month. 4. Avoiding high-residue foods for 2 weeks.

Question: What should a patient be told to do after discharge for a TURP? Strategy: Think about the outcome of each answer choice. Needed Info: Hemorrhage most common complication after a TURP. During first 3 weeks post-op avoid: lifting more than 8 lbs, mowing lawn, riding in car more than 25 min, climbing stairs quickly, sexual intercourse, engaging in sports. (1) CORRECT - due to danger of bleeding (2) no dietary restrictions (3) no need to avoid; comforting (4) no dietary restrictions.

The nurse develops a care plan for the patient with dementia. The nurse recognizes that it is MOST important to include which of the following measures in the plan? 1. Leave the television on in patient's room all day. 2. Frequently orient patient to surroundings. 3. Provide patient with newspapers and magazines. 4. Assign a staff member to stay with patient while patient is awake.

Question: What should be done for a patient with dementia? Remember to establish priorities. It is necessary to meet physical needs and safety needs before addressing psychosocial needs. Strategy: Determine the outcome of each answer choice. Needed Info: Dementia: progressive loss of cognitive function. Decline in memory, learning, attention, judgment, orientation and language skills. Most common type is Alzheimer's disease. Affects 5 million people in US. Usually lasts between 7 and 15 years, before death. (1) provides sensory stimuli but no orientation (2) CORRECT - provides for safety needs (3) does not address safety needs or orientation (4) provides company but not orientation.

The patient is admitted to the hospital complaining of right-sided weakness and difficulty speaking. The patient reports a fall while at home. It is MOST important for the nurse's initial assessment of the patient to include evaluation for which of the following? 1. Nutritional deficiencies. 2. Ambulation problems. 3. Hearing difficulties. 4. Head injury.

Question: What should the nurse assess for in this situation? Strategy: Establish priorities. Remember your ABCs. Needed Info: Cerebrovascular accident (stroke): caused by thrombosis, embolism, ischemia, or hemorrhage. S/S: loss of movement, thought, memory, speech, or sensation. Aphasia: inability to use or comprehend language, due to damage in cerebral hemisphere. Dysarthria: problem with rate, rhythm, or articulation of speech due to loss of motor function of muscles for speech. Expressive aphasia: difficulty speaking. Nursing responsibilities: repeat directions, break down tasks into components, face patient, and speak clearly and slowly. Give patient time to respond. Assist with facial muscle exercises. (1) not highest priority (2) not highest priority; on bed rest during first 48 - 72 hours (3) not highest priority (4) CORRECT - safety most important

The home care nurse performs an assessment of the elderly client diagnosed with type 2 diabetes and hypertension. The client is following an 1,800-calorie ADA diet and takes furosemide 40 mg PO daily. The client's adult child tells the nurse that the parent has been complaining of dizziness. Which of the following actions does the nurse take FIRST? 1. Instruct the client to change positions slowly. 2. Advise the client to drink more fluids. 3. Obtain the client's blood pressure when lying or sitting, and then when standing. 4. Check the client's blood sugar.

Question: What should the nurse do if the client complains of dizziness? Strategy: "FIRST" indicates priority. Assess before implementing. Needed Info: Hypertension is persistent elevation of systolic blood pressure of 140 or higher mm Hg and diastolic blood pressure of 90 or higher mm Hg; furosemide (Lasix) is a loop diuretic that causes hypotension, hypokalemia, hyperglycemia, GI upset, and weakness. (1) appropriate action if client has postural hypotension due to diuretic therapy; assess before implementing (2) appropriate action if client has fluid volume deficit; assess before implementing (3) CORRECT - dizziness may indicate hypotension; elderly may be more sensitive to fluid loss due to diuretic therapy; obtain blood pressure in lying/sitting and standing positions to determine if client has postural hypotension (4) dizziness is symptom of hypoglycemia; after assessing for postural hypotension, a check of whether the dizziness is related to low blood sugar readings is warranted.

The nurse cares for the patient admitted to the intensive care unit (ICU) with a diagnosis of adult respiratory distress syndrome (ARDS) after a drug overdose. Positive end-expiratory pressure (PEEP) is initiated. Because the patient fights the ventilator, the physician orders vecuronium bromide. After administering the medication, it is MOST important for the nurse to take which of the following actions? 1. Administer analgesia as ordered. 2. Explain all procedures to the patient. 3. Maintain airborne precautions. 4. Administer complete eye care.

Question: What should the nurse do to prevent complications of vecuronium bromide? Strategy: Think Maslow. Needed Info: Adult respiratory distress syndrome (ARDS) is characterized by dyspnea and tachypnea followed by progressive hypoxemia despite oxygen therapy; positive end-expiratory pressure (PEEP): positive pressure is exerted during the expiratory phase of ventilation; vecuronium bromide (Norcuron) is a neuromuscular blocking agent used to provide skeletal relaxation during mechanical ventilation. (1) psychosocial; important because patient unable to communicate pain or discomfort; caring for eyes more important (2) psychosocial; client will be anxious due to mechanical ventilation; even though there is temporary paralysis due to drug, client is still able to hear; explain all care to client (3) physical; universal precautions used; no need for airborne (4) CORRECT - physical; client unable to blink due to vecuronium; eye care will prevent corneal abrasion

The patient is scheduled for a myelogram. The patient asks the nurse if there will be any discomfort during the test. Which of the following responses, if made by the nurse, is MOST accurate? 1. "No, this procedure will not hurt at all." 2. "Yes, this is one of the most painful procedures that you can have." 3. "This is an uncomfortable procedure, but you will receive general anesthesia so you will not be aware of the pain." 4. "This is an uncomfortable procedure, but you will be given medication before the test to lessen the discomfort."

Question: What should the nurse say about pain during a myelogram? Strategy: "MOST accurate" indicates that there may be more than one correct response. Needed Info: Myelogram: insertion of contrast medium into the subarachnoid space of spine via a lumbar puncture in order to visualize the vertebral column. Pretest: encourage fluids, check allergies. Antipsychotics, antidepressants, and anticoagulants may be withheld for several days. Diazepam (Valium) can be given during pre-op. Post-test: position the patient in a supine position with the head slightly elevated for several hours. (1) some discomfort involved (2) inaccurate and nontherapeutic (3) local anesthesia given to decrease discomfort. (4) CORRECT - usually given sedative

The nurse cares for the patient being treated for a myocardial infarction. The patient is receiving heparin 5,000 units subcutaneously every 12 hours. The nurse should assess the patient for which of the following? 1. Pallor or cyanosis. 2. Areas of ecchymosis and petechiae. 3. Varicose veins. 4. Edema and weight gain.

Question: What should you assess in a patient receiving heparin? Strategy: Think about the cause of each symptom and how it relates to heparin. Needed Info: Heparin: anticoagulant that inactivates thrombin and prevents the conversion of fibrinogen to fibrin. Side effects: hemorrhage, thrombocytopenia, hypersensitivity. Nursing responsibilities: check partial thromboplastin time (PTT) to monitor effect: 1.5 - 2 times control. Give subcutaneous into abdomen. Leave needle in place for 10 sec. Do not massage. Rotate sites. Never "piggyback" with other meds. Protamine sulfate is antagonist. Terminology: ecchymosis = bruise; petechiae = pinpoint hemorrhages; melena = black, tarry stool; epistaxis = nosebleed; hematuria = blood in urine. (1) unoxygenated blood in circulation (2) CORRECT - ecchymosis and petechiae can indicate hemorrhage; contact provider (3) incompetent valves appear as tortuous skin veins (4) not seen.

The nurse cares for the patient being treated for injuries sustained in a hunting accident. The patient has a tracheostomy tube in place. The nurse enters the patient's room and discovers that the tracheostomy tube has become dislodged and assesses that the patient is having difficulty breathing through the stoma. Which of the following actions does the nurse take FIRST? 1. Performs mouth to stoma breathing. 2. Hyperextends the patient's neck. 3. Places the patient in high-Fowler's position. 4. Administers oxygen.

Question: What should you do FIRST? Strategy: Remember your ABCs: airway, breathing, circulation. Needed Info: Tube extubation may occur during change of ties or coughing. (1) needs airway first (2) CORRECT - provides patent airway; call for help; place in semi-Fowler's (30 - 45 degrees), then check breath sounds; use hemostat to open airway (3) high-Fowler's position (90 degrees) is too upright; needs airway first (4) needs airway first.

The child is brought to the emergency department by the parents, who state the child fell off a bicycle. Upon examination, the nurse notes several bruises, lacerations, and burns in various stages of healing on the child's body, and the child is hypervigilant to touch. The nurse suspects child abuse. Which of the following statements MOST accurately reflects the nurse's responsibility in cases of suspected child abuse? 1. The nurse should not report child abuse without actual proof. 2. The nurse should report a case of suspected child abuse to proper authorities. 3. The nurse should not report suspected child abuse without discussing it with the child's parents first. 4. The nurse should confirm suspicions of child abuse with at least two other staff members before reporting it.

Question: What should you do if you suspect child abuse? Strategy: "Most accurate" indicates that there may be more than one correct response. Think about the outcome of each answer choice. Needed Info: Each state has laws that specify the individuals who are "mandated reporters." Nurses are in this category. The laws also direct the nurse to the relevant place to make a report. Ongoing education by hospitals makes this responsibility clear. (1) must report suspected cases (2) CORRECT - state law (3) inaccurate (4) inaccurate.

In the dining room of the mental health center, the nurse observes the formerly homeless and malnourished patient diagnosed with chronic schizophrenia putting food into a plastic bag. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Reprimand the patient immediately. 2. Ask the patient why the food is being put into a plastic bag. 3. Inform the patient that snacks will be available later. 4. Distract the patient and redirect to another activity.

Question: What should you do in this situation? Strategy: "MOST appropriate" indicates that there may be more than one correct response. Determine the outcome of each answer choice. Needed Info: The behavior of the patient is consistent with a distorted view of reality. Concern about food availability leads to storing a personal cache of food. Way of coping with fear. (1) judgmental (2) nontherapeutic; "why" questions make patient defensive, feel threatened (3) CORRECT - reality orientation; talk with patient in nonthreatening way about the patient's needs (4) misses opportunity to reality test and reorient.

The nurse cares for the patient with moderate hearing loss. The nurse teaches the patient's family to use which of the following approaches when speaking to the patient? 1. Raise your voice until the patient is able to hear you. 2. Face the patient and speak quickly using a high voice. 3. Face the patient and speak slowly using a slightly lowered voice. 4. Use facial expressions and speak as you would normally.

Question: What should you do to communicate with a person with a moderate hearing loss? Strategy: Think about the outcome of each answer choice. Needed Info: Presbycusis: age-related hearing loss due to inner ear changes; decreased ability to hear high sounds. (1) would result in high tones patient unable to hear (2) speech should be done slowly, not quickly, and usually unable to hear high tones (3) CORRECT - also decrease background noise; speak at a slow pace, use nonverbal cues (4) nonverbal cues help, but need low tones.

The nurse cares for the child newly diagnosed with epilepsy. Which of the following items does the nurse have available at the bedside? 1. Suction machine and oxygen setup. 2. Catheterization set. 3. Intermittent positive pressure breathing machine (IPPB). 4. Restraints

Question: What should you have at the bedside for a child with a history of seizures? Strategy: Remember your ABCs. Needed Info: Epilepsy: seizure disorder characterized by abnormal, recurring, excessive, and self-terminating electrical disturbances; Dx made after 2 or more seizures; strong genetic component. (1) CORRECT - remove secretions, provide patent airway, provide oxygenation (2) can be incontinent; not done (3) inflates lungs through positive pressure; not necessary (4) muscle contractions could cause fracture; not done.

The patient is admitted to the hospital for evaluation of a gangrenous right foot. A right below-the-knee amputation is scheduled. The patient asks, "Why can't they just amputate my foot instead of my leg?" Which of the following statements, if made by the nurse, is MOST accurate? 1. "It is necessary to have good circulation in your leg for healing to occur." 2. "It will be easier to fit you with a prosthesis." 3. "This is the best method to control the infection." 4. "This will prevent further circulatory problems in your leg."

Question: What should you say to the patient? Strategy: "MOST accurate" indicates that there may be more than one correct response. Needed Info: Most amputations of lower extremities are a result of peripheral vascular disease resulting from diabetes or cardiac disease. (1) CORRECT - amputation done at most distal point that will heal; the most critical factor is circulation in remainder of extremity (2) not accurate (3) not accurate (4) underlying disease will continue.

The nurse cares for the patient receiving morphine sulfate by use of a patient-controlled analgesia (PCA) pump. When making evening rounds, the nurse finds the patient sleeping and the spouse at the bedside. The nurse observes that each time the patient grimaces, the spouse presses the button on the PCA machine. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Encourage the spouse to continue this practice. 2. Explain to the spouse that this should be done only once every hour while the patient is sleeping. 3. Explain the purpose of the patient-controlled analgesia to the spouse. 4. Instruct spouse to awaken the patient when patient grimaces and ask if patient is having pain.

Question: What should you say to the spouse? Strategy: "Most appropriate" indicates that there may be more than one correct response. Think about why the nurse would make each statement. Needed Info: PCA allows patients to control own administration of IV analgesics. (1) patient should push button (2) inappropriate; patient should push button (3) CORRECT - include family in teaching; spouse's behavior could result in morphine overdose (4) inappropriate.

The patient is being treated for heart failure (HF) and is placed on a 2 gram sodium diet. The nurse performs dietary teaching. Which of the following statements, if made by the patient, indicates that further teaching is necessary? 1. "Some medications and seasonings such as MSG contain sodium." 2. "Milk, fish, and celery are foods naturally high in sodium." 3. "I need to avoid soups and seasoned rice when eating at a restaurant." 4. "I can eat any food I like as long as I don't add additional salt to my food."

Question: What statement is WRONG about a low-salt diet? Strategy: Be careful! This is a negative question. Three statements are correct, one is wrong. Needed Info: Foods to avoid on a low-sodium diet: cured or smoked meat or fish, Kosher meats, peanut butter, processed cheese, salted crackers, seasoning mixes, tomato juice, canned foods. (1) true statement; read labels (2) true statement; intake restricted (3) true statement; plain foods better; soups and seasoned rice may contain significant amount of sodium (4) CORRECT - incorrect info; sodium can be found in many foods; it is not just in table salt itself; 2 g mild sodium restriction

The patient suffers a cerebrovascular accident (stroke) in the left temporal lobe and is admitted to the hospital. When performing an assessment of the patient, the nurse expects some patient impairment in which of the following? 1. Control of the left arm. 2. Glucose metabolism. 3. Corneal reflex in both eyes. 4. Speech.

Question: What symptom would you expect in patient with a CVA? What does the temporal lobe control? Strategy: Think about what functions the temporal lobe controls. Needed Info: CVA or stroke: disruption in blood supply to brain. Causes: thrombus, embolus, or hemorrhage. Risk factors: hypertension, diabetes, heart disease, smoking, substance abuse, obesity, stress, lack of exercise, high cholesterol levels. Usually seen after age 65. S/S: aphasia (impairment in ability to communicate through speech), alexia (difficulty reading), agraphia (impairment in ability to write), HA, syncope, motor or sensory disturbances (paresthesia, paralysis). (1) unaffected; nerve fibers cross in spinal canal, result in disabilities on opposite (contralateral) side (2) symptom of diabetes (3) function of fifth cranial nerve (trigeminal); caused by brain stem disorders (4) CORRECT - left hemisphere controls speech, math skills, analytical thinking

The nurse plans discharge teaching for the client with coronary artery disease (CAD). The client will continue taking warfarin sodium at home. Which of the following instructions does the nurse include in the teaching? 1. Have complete blood count every 1 - 4 weeks. 2. Test stools daily for blood. 3. Wear a MedicAlert bracelet. 4. Stop taking the warfarin sodium before going to the dentist.

Question: What teaching should be done with a patient who is going to be discharged on warfarin? Strategy: Think about the outcome of each answer choice. Needed Info: Coronary artery disease (CAD): narrowing of coronary arteries due to atherosclerosis. Risk factors: hereditary, smoking, age, gender (men higher risk), race (white higher risk), hypertension, elevated serum cholesterol, diabetes mellitus. warfarin sodium (Coumadin): smoking increases required dose; flu vaccine enhances effect for 1 month; fever, prolonged hot weather enhances effect; high-fat diet decreases effect of medication. (1) should have PT check, not complete blood count, every 1 - 4 weeks; (2) no need to check this often; should observe for blood (3) CORRECT - provides for safety; also teach to use soft toothbrush, electric razor (4) should continue to take, but tell dentist.

The nurse cares for the patient admitted to the hospital reporting severe abdominal cramping and diarrhea. The nurse evaluates the effectiveness of the patient's intravenous therapy. The nurse recalls that which of the following laboratory tests BEST reflects hydration status? 1. Erythrocyte sedimentation rate (ESR). 2. White blood cell count (WBC). 3. Hematocrit (HCT). 4. Serum glucose.

Question: What test gives you the BEST indication of hydration status? Strategy: Think about what each value measures. How does it relate to hydration? (1) ESR: rate at which RBCs settle out of unclotted blood in 1 hour; indicates inflammation/necrosis; normal: men 0 - 15 mm/h, women 0 - 20 mm/h (2) WBC: indicates infection (normal 4,500 - 11,000/mm3); reduced: leukopenia, elevated: leukocytosis (3) CORRECT - percentage of red blood cells (RBCs) in the plasma; increased with dehydration, reduced with fluid volume excess; normal: men 40 - 54%, women 36 - 46%; other tests that indicate hydration: BP, urine specific gravity (normal: 1.005 - 1.030) (4) indicates insulin production (normal 60 - 110 mg/dL).

The nurse manager is evaluating care given by the staff of a medical/surgical unit. The nurse manager should intervene if which of the following is observed? 1. A nursing assistant disposes of a patient's used tissue in the bedside container before opening the roommate's milk carton. 2. A student nurse washes hands for 15 seconds after removing gloves following inserting an indwelling urinary catheter. 3. A nurse puts on a gown, gloves, mask, and goggles prior to inserting a nasogastric tube. 4. An LPN/LVN visits with a client diagnosed with methicillin-resistant staphylococcus aureus (MRSA) wound infection while the client eats lunch.

Question: What will cause the spread of infection? Strategy: "Should intervene" indicates an incorrect action. Needed Info: Standard precautions are used to prevent nosocomial infections; wash hands as soon as gloves are removed, between patient contacts, between procedures or tasks with same patient, when touching blood, body fluids, or contaminated surfaces; masks, goggles, and gown if in danger of splashes. (1) CORRECT - contaminated hands cause cross-infections; instruct family about when hand washing is necessary and the correct procedure (2) wash hands for at least 10 seconds after removing gloves after a procedure (3) appropriate technique; splashes may occur (4) requires contact precautions; client in isolation may develop sense of loneliness; visiting with client during meals increases sensory stimulation

The nurse cares for the patient who is receiving warfarin sodium. It is MOST important for the nurse to have which of the following medications available? 1. Ferrous sulfate. 2. Protamine sulfate. 3. Vitamin E. 4. Vitamin K.

Question: What will counteract the actions of warfarin sodium? Strategy: Think about the action of each drug. Needed Info: Should check for hematuria (blood in urine), tarry stools, ecchymosis, petechiae, epistaxis (nosebleed). (1) used for iron deficiency; side effects: nausea, constipation; dilute liquid preparations in water or juice, not milk or antacids; absorption impaired by yogurt, cheese, milk, cereals, coffee, tea, whole grain breads (2) heparin antagonist; 1 mg neutralizes 90 - 115 units; give slowly IV over 1 - 3 min (3) fat-soluble vitamin; used in premature infants and patients with impaired fat absorption (4) CORRECT - Phytonadione (vitamin K) (Mephyton): promotes hepatic formation of prothrombin; controls abnormal bleeding; antidote for warfarin sodium (Coumadin) overdosage; side effects: transient hypotension, bronchospasm, anaphylaxis; used in newborns to prevent and treat hemorrhagic disease of newborns

The nurse does preoperative teaching with the client scheduled to have a transurethral prostatectomy (TURP) under spinal anesthesia. Which of the following statements about the result of the spinal anesthesia does the nurse include in the teaching? 1. "You will be unable to move your arms or legs immediately after surgery." 2. "You will require analgesics to relieve pain in your back." 3. "You will be unable to move your legs immediately after surgery." 4. "You will require a special machine to help you breathe immediately after surgery."

Question: What will result from the spinal anesthesia? Strategy: Think about each answer. Is it expected with spinal anesthesia? Needed Info: Spinal anesthesia: injection into the subarachnoid space. Complications: N + V, HA, resp paralysis, muscular weakness in legs. TURP: removal of enlarged portion of the prostate by the use of a resectoscope inserted through the urethra. (1) arms not affected below T-4 (2) not common problem (3) CORRECT - impulses temporarily blocked; will return (4) awake during procedure; no airway problem.

The nurse cares for the patient postoperatively after a transurethral prostatectomy (TURP) for treatment of benign prostatic hypertrophy (BPH). The patient has a continuous bladder irrigation (CBI) through a three-way urinary catheter with a 30 mL balloon tip. When changing the patient's bed, the nurse notices that the sheets are wet. Which of the following BEST explains this finding? 1. The patient is experiencing acute urinary retention. 2. The patient is experiencing autonomic dysreflexia. 3. The patient has a urinary tract infection. 4. The patient is having bladder spasms.

Question: What would cause leaking of the catheter for this patient? Strategy: Think about how each answer relates to a catheter. Needed Info: BPH: enlargement of the prostate gland that obstructs the urethra. TURP: removal of enlarged portion of the prostate by the use of a resectoscope inserted through the urethra. No incision is made. During the first 24 - 48 hours post-op, a continuous bladder irrigation (CBI) using isotonic fluids (normal saline) is used to keep catheter patent and remove clots and sediment. It should be regulated to provide for clear or pink urine. Traction may be applied to the catheter (by the physician) and the cath tubing taped to the thigh or abdomen. This prevents hemorrhage by applying pressure to the blood vessels. The Foley is usually removed after 2 - 3 days. Teaching: may initially have burning on urination, frequency, dribbling. Force fluids to 3,000 mL/day. Avoid alcohol, spicy foods, strenuous activities for 2 - 3 weeks. (1) urine would not be passed (2) seen after spinal cord injury; caused by distended bladder or colon; causes SNS discharge; results in hypertension, bradycardia, HA (3) would have foul smell, increased temp (4) CORRECT - passing urine around cath; normal to feel urge to void

The nurse is working with the family of the client with Parkinson's disease. The nurse knows that the client has autonomic system dysfunction. Which of the following signs and symptoms are cause by that problem? 1. Diarrhea. 2. Postural hypotension. 3. Depression. 4. Rigidity.

Question: When the client's autonomic system does not work right, what is the effect in the client's body? Strategy: Think about each answer choice. Needed Info: Parkinson's disease (PD) is a progressive, degenerative neurological disorder characterized by tremor, muscle rigidity, bradykinesia, and postural instability. Three kinds of dysfunctions: motor, autonomic system, and cognitive/psychologic. (1) autonomic system problems cause constipation, not diarrhea (2) CORRECT - autonomic system problems cause postural hypotension (3) psychologic system problems cause depression (4) motor problems cause rigidity.

The patient is admitted to the hospital with a fractured right femur. The patient is placed in balanced suspension traction with a Thomas splint and Pearson attachment. The patient's nurse is teaching a student nurse about traction. The student nurse asks, "Where is the pulling force of the traction applied?" Which of the following responses by the nurse is MOST accurate? 1. "It is applied to the quadriceps muscle." 2. "It is applied to the bone distal to the fracture site." 3. "It is applied to the bone proximal to the fracture site." 4. "It is applied to the knee."

Question: Where is the force of the pull for a patient in balanced suspension traction for a fractured femur? Strategy: Review the concepts of traction and picture the traction equipment. Needed Info: Traction: pulling force on part of the body. Used to reduce, align, and immobilize fractures, and to relieve muscle spasms. Balanced suspension traction: exerts pull on affected part and supports extremity in hammock or splint; the splint is held in place by balanced weights attached to overhead bar. Traction provided by system of ropes, pulleys, and weights. Countertraction provided by patient's body weight. Pull of traction on extremity remains constant, despite changes in position. (1) applied to the bone, never muscle in skeletal traction (2) CORRECT - ensures proper alignment of bone fragments (3) inaccurate; would not provide proper alignment (4) inaccurate.

*The picture wouldn't upload to this side of the card, so it's on the answer side :( * The nurse performs a physical assessment on the adult with a history of a mitral murmur. Identify the area where the nurse places the stethoscope to auscultate the mitral murmur. 1. A 2. B 3. C 4. D

Question: Where should the nurse assess for a mitral valve murmur? Strategy: Examine the diagram carefully. Select the area to assess for a mitral valve murmur. Needed Info: The following anatomical landmarks are used to evaluate heart sounds. The Angle of Louis is located at the manubrial sternal junction at the second rib. The aortic and pulmonic areas are found at the second intercostal space. Erb's point is found at the third intercostal space. The mitral area is found at the fifth intercostal space at the left midclavicular line. The point of maximal impulse (PMI), or the impulse of the left ventricle, is felt most strongly on an adult at the left fifth intercostal space in the midclavicular line. (1) INCORRECT (2) INCORRECT (3) mitral valve murmur is assessed at the PMI (4) INCORRECT

The parents of the 6-month-old bring the infant to the pediatrician's office for a routine immunization. The nurse is to administer the immunization by intramuscular (IM) injection. The nurse recognizes that which of the following is the preferred site for an IM injection in an infant? 1. Deltoid. 2. Vastus lateralis. 3. Dorsogluteal. 4. Ventrogluteal.

Question: Where should you give an IM injection to a 6-month-old child? Strategy: Think about each site. What is the size of the muscle? Are there nerves and blood vessels in the area? Needed Info: To determine where to give injection, consider: amount and type of med, size and condition of muscle, and the ability to access site. Inject up to 0.5 mL in infant and 1 mL in child. (1) small muscle mass; radial nerve near (2) CORRECT - no blood vessels or nerves; easily accessible (3) not used until walking (about 1 year) (4) not used until walking (about 1 year).

The nurse cares for the unresponsive patient admitted to the intensive care unit with a suspected brain injury from a motorcycle accident. It is MOST important for the nurse to intervene if a staff member performs which of the following assessments of pupillary activity? 1. Doll's eye oculocephalic reflex. 2. Direct light response. 3. Conjugate gaze. 4. Corneal reflex.

Question: Which assessment is contraindicated for this client? Strategy: "Nurse to intervene" indicates an incorrect action. Needed Info: Brain injuries include concussion, contusion, laceration, and hematoma; evaluate level of consciousness, perform neurological assessment, elevate head of bed 30 degrees to decrease intracranial pressure, careful intake and output. (1) CORRECT - observe patient's eye movement as head is turned quickly from side-to-side; if eyes move in opposite direction from side to which head is turned, reflex is intact; contraindicated because it requires head to be turned from side-to-side; patient with suspected brain injury may also have a cervical spine injury (2) darken room; eyelid is held open with other eye covered; penlight is swung from patient's ear toward midline of face and shown directly into eye; pupil should constrict immediately; no reason to intervene (3) nurse holds one finger up and asks patent to follow it with eyes alone; nurse moves finger up, down, lateral, and oblique to evaluate if the patient's eyes track together to follow the finger; unable to perform assessment if client unconscious (4) cotton ball touched to cornea; an immediate blink reflex is normal: no contraindication.

The nurse is presented with a group of patients in the emergency department (ED). Which of the following clients does the nurse see FIRST? 1. The client who reports being raped 30 minutes ago and is exhibiting self-blame, anxiety and feelings of worthlessness. 2. The client who reports a miscarriage last evening and has spotting of blood on her underwear. 3. The client who told the family of intent to commit suicide and has easy access to a gun. 4. The client who witnessed a child stabbed to death and is experiencing anxiety and difficulty coping.

Question: Which client should the nurse see first? Strategy: Remember Maslow. Determine most unstable client. Needed Info: Clients with physical needs take priority over clients with psychosocial needs. (1) follow emergency room protocol, may include clothing, hair samples, NPO; focus on here and now; be alert for potential internal injuries, e.g., hemorrhage (2) after spontaneous abortion, scant, dark discharge may persist for 1 - 2 weeks; instruct client to report any heavy, profuse, or bright red bleeding (3) CORRECT - client has expressed intent, and the risk of danger is great due to the lethal weapon; nurse should see this patient first (4) client experiencing a situational crisis; important to focus on the here and now; help client to become aware of feelings and validate them.

The client with a history of cholelithiasis and recurrent urinary tract infections is admitted to the medical unit with reports of fatigue. A small lump is discovered in the client's neck and the physician orders diagnostic testing. The nurse recognizes that which of the following tests should be performed FIRST? 1. Cholecystogram. 2. Intravenous pyelogram (IVP). 3. Myelogram. 4. Thyroid scan.

Question: Which diagnostic test should be performed first? Strategy: Think about how each test is performed. Needed Info: Cholelithiasis is presence of stones in the gallbladder; symptoms include intolerance to fatty foods, indigestion, nausea, vomiting, flatulence, eructation, and severe pain in the upper right quadrant of the abdomen. (1) iodide-containing contrast medium used to visualize the gallbladder (2) radiopaque iodine contrast medium used to visualize kidneys, ureters, and bladder (3) contrast dye is introduced into spinal subarachnoid space, so spinal cord and nerve roots are outlined and dura mater distortions are also visible (4) CORRECT - must be performed before radiographic exams, which use contrast substances; these would interfere with the interpretation of the thyroid scan which measures uptake of radioactive iodine by the thyroid

The adolescent is brought to the emergency room with a compound fracture of the left femur. Vital signs are BP 80/60, pulse 120, respirations 26, temperature 99.0°F (37.2°C). The nurse expects the physician to initially order which of the following fluids? 1. D10 in water. 2. D5 in 0.45% NaCl. 3. Lactated Ringer's solution. 4. 0.45% NaCl.

Question: Which fluids are best? Strategy: Think about the action of each fluid. Needed Info: Hypovolemic shock occurs because bone is vascular; can rapidly develop; nursing considerations: immobilize joint below and above fracture; assess for S/S shock--tachycardia, hypotension, cool, clammy skin, cyanosis, restlessness, decreased alertness; administer large amounts of isotonic fluids. (1) need isotonic fluid, not hypertonic fluid (2) hypertonic fluid; need isotonic fluid (3) CORRECT - need isotonic fluid to restore circulating blood volume; may also use 0.9% NaCl (normal saline solution) (4) hypotonic solution; isotonic fluid is needed at this time.

The nurse changes the dressing of the woman who had a mastectomy two days ago. After the nurse removes the old dressing, the woman turns her head away. Which of the following nursing diagnoses is MOST appropriate? 1. Powerlessness. 2. Knowledge deficit. 3. Dysfunctional grieving. 4. Body image disturbance.

Question: Which nursing diagnosis is most appropriate? Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. Needed Info: Stages of body image readjustment include psychological shock (denial and anger), withdrawal (passive and dependent), acknowledgment (beginning of grief process), and integration (integrate body changes into new image). (1) may feel powerless, but client is most likely reacting to change in body (2) no indication of knowledge deficit (3) no indication of dysfunctional grieving. (4) CORRECT - mastectomy may cause client to question her femininity, attractiveness, and self-esteem; encourage client to verbalize; encourage client to participate in planning of care

The nurse knows that it is important to identify patients at significant risk of developing a deep vein thrombosis (DVT). Which patient would the nurse assess as having the lowest risk profile? 1. A 67-year-old carpenter undergoing a left total knee replacement. 2. A 22-year-old woman who weighs 230 lbs and is 2 months pregnant with her second child. 3. A 44-year-old woman with ovarian cancer experiencing vomiting from chemotherapy. 4. A 50-year-old executive following removal of cataracts.

Question: Which patient is least likely to develop a deep vein thrombosis? Strategy: Think about risk factors. Needed Info: Deep vein thrombosis can cause pulmonary embolism; occurs in patients undergoing joint replacement, pregnancy, ulcerative colitis, heart failure, the immobilized patient, and patients with severe infections. To prevent, early ambulation, antithrombosis stockings, and anticoagulants are used. (1) age, surgery (up to 70% experience DVT as a complication), and immobility puts him at significant risk (2) obesity and pregnancy puts her at significant risk (3) cancer and dehydration put her at significant risk. (4) CORRECT - the patient with cataracts is not immobile after surgery, usually done in an outpatient setting

The nurse cares for patients on the surgical unit. When planning care, the nurse anticipates that which patient will have the MOST difficulty adjusting psychologically? 1. The 13-year-old girl who has a wart removed from her nose. 2. The 26-year-old man who has palliative surgery for stage 4 cancer of the pancreas. 3. The 42-year-old woman who has an elective hysterectomy. 4. The 60-year-old man who has a colostomy for severe diverticular disease.

Question: Which patient will feel most threatened by surgery? Strategy: "MOST difficulty" indicates that discrimination is required to answer the question. Needed Info: Stages of body image readjustment include psychological shock, withdrawal, acknowledgment, and integration. (1) adolescents fear being different from their peers; body image is a concern, which the surgery enhanced (2) CORRECT - average survival rate after diagnosis of cancer of the pancreas is 4.1 months; of all the patients, he is the only one facing a near-term death; the other patients derive some long-term benefit from their operations (3) loss of uterus will affect body image, but the client with the terminal illness has greater challenges (4) body image disturbance is common after colostomy, but the client will not have the debilitating and painful symptoms of his disease.

The nurse approaches the paranoid schizophrenic client on the psychiatric unit to perform an ordered venipuncture to obtain a blood specimen. The client becomes agitated and says to the nurse, "You pretend to take blood, but I know you really want to inject me with a poison that will kill me." Which of the following responses by the nurse is BEST? 1. "No, I do not want to kill you. Why do you think that drawing blood is going to kill you?" 2. "Calm down. I drew your blood last week and nothing bad happened to you, did it?" 3. "You sound frightened. The physician wants to ensure that your medications are working properly." 4. "Look, the tube is empty. I can't inject you with anything if the tube is empty."

Question: Which response is most therapeutic? Strategy: "BEST" indicates discrimination is required to answer the question. Needed Info: Delusions are persistent false beliefs; allow client to verbalize delusion, do not argue or try to convince client that delusion is not real. Point out feeling tone of delusion and provide activities to divert attention from delusion. (1) encourages discussion of delusion; directly counters client's perception; does not acknowledge underlying feelings (2) confrontational and challenging (3) CORRECT - acknowledges client's feelings; gives a clear matter-of-fact response directly related to the reason for the blood draw (4) responds to content of the delusion; assumes that client can engage in logical thinking.

The client scheduled for a cardiac catheterization says to the nurse, "I know you were in here when the doctor had me sign the consent form for the test. I thought I understood everything, but now I'm not so sure." Which of the following responses by the nurse is BEST? 1. "Why didn't you listen more closely?" 2. "You sound as if you would like to ask more questions." 3. "I'll get you a pamphlet about cardiac catheterization." 4. "That often happens when this procedure is explained to clients."

Question: Which response is most therapeutic? Strategy: "BEST" indicates that discrimination is required to answer the question. Needed Info: Informed consent is obtained by the individual who will perform the test; explanation of the test and expected results, anticipated risks, discomforts, potential benefits, and possible alternatives are discussed; consent can be withdrawn at any time. (1) "why" questions are nontherapeutic; does not respond to client's feelings or concerns; judgmental (2) CORRECT - directly responds to client's statement by paraphrasing; implies encouragement of expression of client's concern (3) may be helpful, but first the nurse needs to clarify the client's concerns by discussion (4) does convey acceptance and lets the client know that client's response is not abnormal, but response is closed and does not allow client to express feelings or concerns.

The nurse cares for the client diagnosed with genital herpes. After the client is informed of the diagnosis, the client begins crying. Which of the following responses by the nurse is BEST? 1. "We have support groups that may help you talk about some of your feelings." 2. "I see that you are upset. Share with me your thoughts." 3. "While herpes is a difficult disease, at least you don't have AIDS." 4. "I think the physician should explain more to you about genital herpes."

Question: Which response is most therapeutic? Strategy: "BEST" indicates that discrimination is required. Needed Info: Genital herpes: caused by herpes simplex virus; symptoms: painful, vesicular genital lesions and difficulty voiding; nursing care: offer emotional support, sitz baths, monitor Pap smears on a regular basis; treatment: Acyclovir. (1) passing the buck; nurse should acknowledge the client's feelings and allow the client to verbalize; support group may be suggested later (2) CORRECT - reflects the client's feelings and allows the client to verbalize concerns (3) minimizes the client's diagnosis and feelings (4) passing the buck; the nurse should explain the disease.

At the advice of the physician, the client with hypertension attends classes to help quit smoking. One month later when the client visits the clinic, the nurse notes a package of cigarettes in the client's pocket. Which of the following statements, if made by the nurse, is MOST appropriate? 1. "I see that you have cigarettes in your pocket." 2. "Please give me the cigarettes." 3. "I will have to report this to the physician." 4. "You will have to enroll in another class."

Question: Which response is most therapeutic? Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. Needed Info: Therapeutic communication is listening to and understanding the client while promoting clarification and insight; important for nurse to understand the client's verbal and nonverbal messages, listen for client's perception of the problem, and facilitate verbalization. (1) CORRECT - encourages client to verbalize issues and concerns; nonjudgmental (2) authoritarian (3) no need to involve physician at this point (4) need more information before determining a course of action.

The nurse cares for the client receiving vincristine sulfate. The nurse recognizes it is MOST important to assess for which of the following? 1. Fatigue and nausea. 2. Polyphagia and polydipsia. 3. Paresthesia and difficulty with gait. 4. Diarrhea and alopecia.

Question: Which side effect poses a safety issue with the client? Strategy: "MOST important" indicates a priority question. Needed Info: Vincristine sulfate (Oncovin) is an antineoplastic agent; side effects include peripheral neuritis, loss of reflexes, bone marrow depression, alopecia, and GI symptoms; avoid IV infiltration and extravasation; check reflexes, motor and sensory function; allopurinol (Zyloprim) given to increase excretion and decrease buildup of uric acid. (1) does not cause fatigue; does cause nausea and vomiting; not the priority (2) symptoms of diabetes; not caused by vincristine (3) CORRECT - indicate a peripheral neuropathy; to ensure client safety, support client when ambulating (4) diarrhea can be symptomatically treated; alopecia does occur; reassure client that it is usually reversible.

The nurse teaches the parent of the young child who has recently been diagnosed as having epilepsy about the condition. Which of the following statements, if made by the parent, indicates that further teaching is necessary? 1. "Epilepsy does not affect my child's mental capacities." 2. "Grand mal seizures do not cause brain damage." 3. "Epilepsy is a form of mental illness." 4. "Epilepsy can be controlled with medication."

Question: Which statement is NOT TRUE about epilepsy? Strategy: Be careful! This is a NEGATIVE question. Needed Info: Epilepsy: seizure disorder, characterized by abnormal, recurring, excessive and self-terminating electrical disturbances; Dx made after 2 or more seizures; strong genetic component (1) true statement (2) true statement (3) CORRECT - electrical disturbance in brain; can be controlled by medication; not a form of mental illness (4) true statement.

The patient is admitted to the hospital with a diagnosis of carcinoma of the colon and undergoes a colon resection. Two days postoperatively, the patient becomes confused and agitated. It is determined that the patient is delirious. The nurse recalls that delirium is BEST described by which of the following statements? 1. Delirium is characterized by acute onset with symptoms lasting for hours or weeks. 2. Delirium is characterized by gradual onset with symptoms lasting for months or years. 3. Delirium is characterized by either acute or gradual onset with symptoms lasting from several months to several years. 4. Delirium is characterized by either acute or gradual onset with symptoms lasting for several days.

Question: Which statement is TRUE for delirium? Strategy: Think about each answer choice. Needed Info: Delirium: onset rapid, often at night; manifestations fluctuate over 24-hour period: awareness, orientation, recent memory, sleep/wake cycle disturbed; associated with illness or meds. Dementia: onset insidious, develops over years, not associated with physical illness. Alertness not impaired. Nursing responsibilities: ensure safety, meet patient's physical needs. (1) CORRECT; delirium has acute onset with symptoms lasting for hours or weeks (2) inaccurate; delirium has rapid onset (3) inaccurate; delirium has rapid onset and shorter duration of symptoms (4) inaccurate; delirium has rapid onset.

The client comes to the emergency department reporting chest pain that occurs nightly while the client is at rest. The client is diagnosed with resting angina. The nurse instructs the client about how to decrease the anginal attacks. Which of the following statements, if made by the client to the nurse, indicates that teaching is successful? 1. "I am going to sign up for meditation classes at the community center." 2. "I am going to take a brisk walk after dinner every night." 3. "I am going to take a part-time job at a day care center." 4. "I am going to take over-the-counter diet pills to lose weight."

Question: Which statement is correct? Strategy: Think about what the client's words mean. Needed Info: Angina is chest pain due to ischemia that does not cause permanent damage; symptoms include pain that may radiate down left arm; arm pain associated with stress, exertions, or anxiety; administer antianginal exercise program to reduce blood pressure and pulse rate; percutaneous transluminal coronary angioplasty (PCTA), coronary artery bypass graft surgery (CABG) may be performed. (1) CORRECT - will decrease and manage stress; focus on breathing will have calming effect on client as well as assist with oxygenation; will not produce chest pain, shortness of breath, or undue fatigue (2) should not engage in physical exercise for 2 hours after meals (3) may involve too much physical activity and stress (4) obesity is a risk factor of angina, but over-the-counter diet pills contain sympathomimetic substances that can increase heart rate.

The nurse reviews the charts of four antepartal women. The nurse recognizes that which woman is at MOST risk for having a child with a cleft lip and palate? 1. A 22-year-old Asian woman who is having a girl. 2. A 35-year-old African American woman who is having a boy. 3. A 25-year-old Native American woman who is having a boy. 4. A 40-year-old Caucasian who is having a girl.

Question: Which woman is at greatest risk for having a child with a cleft lip and cleft palate? Strategy: Think about each answer. Needed Info: Cleft lip: small or large fissure in facial process of upper lip or up to nasal septum, including anterior maxilla; cleft palate: midline, bilateral, or unilateral fissures in hard and soft palate. (1) individuals of Asian background are more likely than African Americans or Caucasians to have a child with cleft lip and palate; less likely to be found in a girl (2) African Americans are least likely to have a child with cleft lip and palate (3) CORRECT - Native Americans have the highest incidence of cleft lip and palate; males are more likely than females to have both (4) Caucasians are less likely to have a child with cleft lip and cleft palate; more common in males.

The woman delivers a 6 lb 10 oz infant. The mother observes the nurse in the delivery room place drops in the infant's eyes. The mother asks the nurse why this was done. Which of the following responses by the nurse is BEST? 1. "The drops will constrict your infant's pupils to prevent injury." 2. "The drops will remove mucus from your infant's eyes." 3. "The drops will prevent infections that might cause blindness." 4. "The drops will prevent neonatal conjunctivitis."

Question: Why are eye drops placed in a newborn's eyes? Strategy: "BEST" indicates that discrimination may be required to answer the question. Needed Info: Prophylactic care of newborn includes administration of antibiotic eye drops containing erythromycin and tetracycline. Eye irritation may occur, but it is not common and is self-limiting. (1) erythromycin or tetracycline do not cause miosis (2) does not remove mucus from baby's eyes (3) CORRECT - precaution against ophthalmia neonatorum (inflammation of the eyes due to gonorrheal or chlamydia infection) (4) conjunctivitis is inflammation of the conjunctiva.

The nurse at the community mental health center cares for the new client with a diagnosis of depression. The physician prescribes amitriptyline. One week after starting amitriptyline, the client reports to the nurse that there has been no improvement. Which explanation, if made by the nurse, is MOST accurate? 1. "It takes two to four weeks for the medication to work." 2. "You may need more medication." 3. "Your depression is probably deepening." 4. "This medication probably is not the right one for you."

Question: Why are the patient's symptoms not relieved? Strategy: "MOST accurate" indicates that there may be more than one correct response. Think about each statement. Is it true about amitriptyline? Needed Info: Amitriptyline (Elavil): tricyclic antidepressant; take full dose at bedtime; delay of 2 - 4 weeks before effects seen; side effects: drowsiness, dizziness, orthostatic hypotension, blurred vision, dry mouth, urinary retention, constipation, sweating; nursing responsibilities: monitor for risk of suicide. (1) CORRECT - broken down by liver; drowsiness precedes antidepressant effect by several weeks, so med may improve sleep patterns before other symptoms (2) too early to know (3) inaccurate (4) not nursing decision.

The patient is postoperative orthopedic surgery. The physician orders morphine sulfate to be administered using a patient-controlled analgesia (PCA) pump. The nurse checks the PCA pump to determine how many times the patient has triggered the system. Which of the following explanations BEST explains why the patent triggered the system 11 times but received only 6 injections? 1. The patient is developing an addiction to morphine. 2. The patient does not understand how to use the pump. 3. The patent is developing a tolerance to morphine. 4. The amount of narcotic prescribed is not controlling the patient's pain.

Question: Why did the patient receive only 6 injections of medication? Strategy: "Best" indicates that there may be more than one correct response. Think about the outcome of each answer choice. Needed Info: PCA allows patients to control administration of IV analgesics. Preloaded pump system administers preset amount of medication when button is pushed by patient. Predetermined lock-out time interval. Amount of medication is displayed on front of machine. Reduces pulmonary complications, and patient is more alert. (1) develops over long period (2) more likely is pressing button to get pain relief (3) develops over long period. (4) CORRECT - patient is pressing button before lock-out time has expired because is in pain; system keeps track of number of requests for medication

The patient receiving paroxetine for obsessive-compulsive disorder tells the nurse that there is dizziness when standing up from a sitting or lying position. The nurse should recognize that this problem is PRIMARILY due to which of the following? 1. Paroxetine can cause hypoglycemia. 2. Paroxetine can affect the cerebellum. 3. Paroxetine can affect the vestibular branch of the auditory nerve. 4. Paroxetine can cause orthostatic hypotension.

Question: Why does paroxetine cause dizziness? Strategy: Think about each answer choice and its relationship to dizziness. Needed Info: Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) type of antidepressant. Effects felt in 1 - 4 weeks. Not addictive. Sudden discontinuation could lead to withdrawal symptoms. (1) inaccurate; does not change glucose metabolism (2) inaccurate (3) inaccurate (4) CORRECT - sudden drop in BP with change in position from sitting or lying to standing

The patient with a fractured right femur has traction applied through the use of a Steinmann pin through the femur. Balanced suspension traction is used with a Thomas splint and a Pearson attachment. The nurse explains to the patient that the purpose of the pin is which of the following? 1. To maintain alignment of the fracture. 2. To hold the Thomas splint in place. 3. To hold the Pearson attachment in place. 4. To immobilize the femur.

Question: Why is a pin used for a fractured femur? Strategy: Visualize the type of traction described. Needed Info: Pin: inserted directly through skin into the bone. Nursing responsibilities: check skin for redness, odor, and drainage. Change dressing and clean with hydrogen peroxide and/or saline if ordered. (1) CORRECT - provides pull directly to bone; results in realignment of bone (2) splint elevated at 45 degree angle to bed; supports thigh (3) fastened to Thomas splint at knee joint; knee is flexed 45 degrees; lower leg lies in Pearson attachment parallel to bed (4) purpose of traction itself.

The nurse plans teaching for the client scheduled for an amniocentesis. It is MOST important for the nurse to include which of the following statements? 1. "The test assesses gestational age using the biparietal circumference." 2. "The test determines the gender of the baby." 3. "The test is used to detect possible birth defects." 4. "The test should not be completed if you have a history of previous miscarriages."

Question: Why is an amniocentesis done? Strategy: Think about each answer. Needed Info: Amniotic fluid is aspirated by needle inserted through the abdominal and uterine walls and is done after 14 weeks gestation to diagnose genetic disorders or neural tube defects; instruct client to empty bladder. (1) age determined by ordering a sonogram, not an amniocentesis; after 30 weeks, can assess the lecithin/sphingomyelin ratio to determine fetal lung maturity (2) can be done but that is not the primary reason (3) CORRECT - completed to determine genetic disorders or neural tube defects; takes 2 - 4 weeks to obtain results; complications include premature labor, infection, Rh isoimmunization (4) not a contraindication.

The nurse plans to administer furosemide 20 mg IV to the patient diagnosed with chronic renal failure. The nurse recalls that the PRIMARY purpose of this medication is which of the following? 1. To increase the blood flow to the renal cortex. 2. To decrease the circulatory blood volume. 3. To increase excretion of sodium and water. 4. To decrease the workload on the heart.

Question: Why is furosemide given to a patient diagnosed with chronic renal disease? Strategy: Think about the action of furosemide. Needed Info: Chronic renal failure is progressive, irreversible kidney injury caused by hypertension, diabetes mellitus, lupus erythematosus, and chronic glomerulonephritis; symptoms include anemia, acidosis, azotemia, fluid retention, and urinary output alterations; nursing care includes monitoring potassium levels, daily weight, intake and output, and diet teaching about regulating protein intake, fluid intake to balance fluid losses, and some restrictions of sodium and potassium. Furosemide (Lasix) is a potassium-wasting diuretic, which increases renal potassium excretion. Monitor blood pressure, serum electrolytes, weight, I + O. Do not give at bedtime. (1) Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle (2) Furosemide used to treat fluid overload due to chronic renal failure (3) CORRECT - Furosemide is administered in order to augment the kidney's excretory functioning (4) correcting the fluid overload will decrease the workload on the heart, but the primary reason Furosemide is given to patient diagnosed with chronic renal failure is to augment the kidneys' excretory functioning.

The 65-year-old patient is recovering from a right below-the-knee amputation. The patient observes the "figure eight" bandage on the residual limb. The patient asks the nurse why the bandage is applied in this manner. Which of the following explanations, if made by the nurse, is the MOST important reason? 1. "It decreases the possibility of infection." 2. "It helps to minimize postoperative pain." 3. "It reduces the possibility of clot formation." 4. "It reduces postoperative swelling."

Question: Why is the bandage after a BKA applied in a figure eight? Strategy: Picture a BKA with the bandage. Needed Info: Pressure to an operative site reduces postoperative swelling. To promote a return to better circulation, the pressure bandage is changed at regular intervals. As secondary effects, this activity reduces pain caused by swelling and the possibility of clot formation in the residual limb. (1) antibiotics first 48 - 72 hours do this (2) not primary purpose; pain medications play this role (3) reducing the possibility of clot formation happens secondary to the primary purpose of reducing postoperative swelling. (4) CORRECT - hastens venous return, controls edema; must be worn at all times except bathing; must be removed and reapplied several times a day

One afternoon in the hospital day room, the nurse overhears the newly admitted patient with chronic schizophrenia say to another patient, "I hate you. Get away from me or I'll kill you." Which of the following interpretations of this behavior, by the nurse, is MOST justifiable? 1. The patient does not like the other patient. 2. The patient is angry. 3. The patient feels threatened. 4. The patient feels powerful.

Question: Why is the patient acting like this? Strategy: "MOST justifiable" indicates that there may be more than one correct response. Think about each answer choice and how it relates to schizophrenia. Needed Info: Chronic schizophrenia distorts the way a patient thinks, acts, expresses emotions, perceives reality, and relates to others. The patient can misinterpret what the other patient's behavior meant. (1) assumption; not most justifiable (2) assumption; not most justifiable (3) CORRECT - patient not in usual environment; patients with schizophrenia hear voices and have trouble interpreting reality (4) assumption and unlikely.

The client is admitted to the hospital reporting persistent lower back pain. The nurse puts the client in bed in semi-Fowler's position with the hips and knees moderately flexed. The nurse recognizes the PRIMARY rationale for this position is to accomplish which of the following? 1. Relieve tension at the lumbo-sacral region. 2. Maintain proper alignment of the vertebral joints. 3. Improve breathing for better oxygen supply to the sacral musculature. 4. Increase blood flow to the spinal cord.

Question: Why is this position used for this patient? Strategy: Picture the patient as described. Determine the outcome of each answer choice. Needed Info: Causes of low back pain: herniated nucleus pulposus, muscle sprain. S/S: knifelike pain, sensory changes. Diagnosis: CT scan or MRI. Treatment: muscle relaxants, NSAIDS, analgesics, heat, traction (separates vertebrae to relieve pressure on nerve), transcutaneous electrical nerve simulation (TENS), surgery. (1) CORRECT - knees flexed relieves pressure on sciatic nerve or disk (2) done in any position; does not relieve pain (3) done to increase comfort (4) no change.