NCLEX Study questions comprehensive

A male client who sustained a head injury following an automobile collision is admitted to the hospital. the nurse includes the client's risk for developing Increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? A. increase glasgow coma scale score B. nuchal rigidity and dystonia C. confusions and papilledema D. periorbital ecchymosis

C. confusions and papilledema Papilledema is always an indicator of increase ICP, and confusion is usually the first sign of increased ICP. a indicates and improvement in neurologic status. b and d may be responses to injury, but do not necessarily reflect increased ICP

The nurse instructs a client newly diagnosed with diverticular disease. Which statement indicates to the nurse that additional teaching is required? (Select all that apply.) 1. "I should eat food high in fiber." 2. "I should drink plenty of fluids every day." 3. "I should eat red meat several times a week." 4. "I should eat a diet high in fat and carbohydrates." 5. "I should limit alcohol intake to several times a week."

CORRECT 3 4 5 1) Fiber reduces the risk of outpouching in the colon. 2) Eight, or more, 8-ounce glasses of water a day reduces the risk of constipation. 3) CORRECT — It is recommended to limit the intake of red meat to reduce the risk of constipation. 4) CORRECT — A low-fat diet reduces risk of symptoms and constipation. A balanced diet of carbohydrates, proteins, fats, and fiber is recommended for most clients. 5) CORRECT — A client should avoid alcohol as it can irritate the lining of the gastrointestinal tract and exacerbate symptoms of diverticular disease.

The nurse provides care for a client who reports mid-back discomfort. Which technique does the nurse use to determine if the pain is coming from the kidneys? 1. Auscultation. 2. Light palpation. 3. Blunt percussion. 4. Hooking technique.

I GOT THIS ONE WRONG 3) CORRECT — Blunt percussion is used over the costovertebral angle to assess for kidney tenderness. 1) Auscultation is not a technique to assess pain but to hear sounds. 2) It is not possible to identify the kidneys using light palpation. 4) The hooking technique is used to palpate the edges of the liver.

The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp, face, and trunk. Which transmission-based precaution does the nurse implement for this child? 1. Contact precautions. 2. Airborne and contact precautions. 3. Airborne and droplet precautions. 4. Droplet precautions.

*REMEMBER PEDS SIM!* 2) CORRECT — The client demonstrates signs of a varicella infection. Airborne and contact precautions are needed and should be maintained for at least 5 days after the onset of the rash and until the vesicular lesions are gone.

The nurse provides care for an alcohol-dependent client diagnosed with pancreatitis. Which sign leads the nurse to determine that the client is experiencing alcohol withdrawal? (Select all that apply.) 1. Hallucinations. 2. Apathy. 3. Depression. 4. Seizures. 5. Gross tremors.

1) CORRECT — Visual and auditory hallucinations are a major characteristic of alcohol withdrawal. 4) CORRECT — Seizures are a major characteristic of alcohol withdrawal. 5) CORRECT — Tremors are a major characteristic of alcohol withdrawal. 2) Apathy is characteristic of withdrawal from stimulants, not from alcohol. 3) Depression is characteristic of withdrawal from stimulants, not from alcohol.

The nurse teaches a community education class about preventing lead poisoning for parents of young children. At which age will the nurse instruct that screening for lead poisoning begins? 1. 12 months. 2. 18 months. 3. 24 months. 4. 36 months.

1) CORRECT— The nurse will start screening a child for lead poisoning at age 12 months for low-risk clients and perform a repeat screening at 24 months of age. High —risk infant clients should have initial lead poisoning screening at 6 months of age.

The nurse is teaching the client about the warning signs and symptoms of lung cancer. Which statement is appropriate for the nurse to include in the teaching? 1. "There are hardly any signs and symptoms with lung cancer." 2. "Early symptoms of lung cancer include constant cough and bloody sputum." 3. "Symptoms of lung cancer are vague and often present late in the disease." 4. "Wheezing on exhalation is usually considered a positive sign of lung cancer."

1) There are symptoms associated with lung cancer that are often vague and nonspecific. 2) Constant coughing and bloody sputum are late, not warning, symptoms of lung cancer. 3) CORRECT — Lung cancer is often diagnosed in late stages because the symptoms are vague and often attributed to other causes. 4) Wheezing can be due to a number of conditions and is not a positive sign for lung cancer.

The nurse works in a health care organization that has earned the American Nurses Credentialing Center Magnet Recognition status for excellence in nursing. Which component is an indicator of this status? (Select all that apply.) 1. Transformational leadership. 2. Structural empowerment. 3. Exemplary professional practice. 4. Willingness to recommend the agency. 5. Innovation.

1, 2, 3, 5. 1) CORRECT — Transformational leadership is one of the Magnet indicators. 2) CORRECT — Structural empowerment is one of the Magnet indicators. 3) CORRECT — Exemplary professional practice is one of the Magnet indicators. 4) Willingness to recommend the hospital/agency is a component of the Hospital Consumer of Assessment of Healthcare Providers and Systems survey. 5) CORRECT — Innovation is one of the Magnet indicators.

The nurse provides care for a client experiencing supraventricular tachycardia (SVT). Which action by the nurse is appropriate when giving adenosine? 1. Inject over 1 minute, followed by a normal saline flush (NS). 2. Inject over 1 to 3 seconds, followed by a normal saline flush. 3. Inject over 2 minutes using an intravenous (IV) pump. 4. Inject over 10 seconds while doing cardiac compressions.

2) CORRECT — To maximize efficacy, inject over 1 to 3 seconds, followed with a 20 mL NS flush. 1) Giving adenosine over 1 minute is ineffective. 3) Use of an IV pump is not appropriate. 4) Cardiac compressions are not indicated because the client is in SVT, an organized rhythm.

The nurse provides care to a client who reports "ringing in the ears" and dizziness. Which medication in the client's history will the nurse suspect as causing this client's symptoms? 1. Valsartan. 2. Amikacin. 3. Spironolactone. 4. Cinacalcet hydrochloride.

2) CORRECT - Amikacin is an aminoglycoside that can cause ototoxicity. Manifestations of ototoxicity include tinnitus and vertigo.

The nurse reviews the daily lab results of four clients. Which client does the nurse delegate to the LPN/LVN to provide care? 1. Client with a brain natriuretic peptide (BNP) level of 300 pg/mL. 2. Client with an erythrocyte sedimentation rate of 10 mm/h. 3. Client with a C-reactive protein (CRP) level of 4 mg/L. 4. Client with an international normalized ratio (INR) level of 8.0.

2) CORRECT - An elevated sedimentation rate indicates an inflammatory process. The normal value for males under 50 years is less than 15 mm/h. For males over 50 years, it is less than 20 mm/h. For females under 50 years, it is less than 25 mm/h. For females over 50 years, it is less than 30 mm/h. This client can be delegated to the LPN/LVN. 1) An elevated BNP level indicates congestive heart failure and requires observation by the nurse. The normal value is less than 100 pg/mL. This client requires frequent assessment of breathing and circulation. 3) An elevated CRP indicates inflammation, tissue injury, infection, or atherosclerosis and follow up by the nurse. The normal CRP level is less than 1 mg/L. 4) The INR level monitors the effectiveness of warfarin. The therapeutic range is 2 to 3.5, based on the diagnosis and the reasons for taking warfarin. An elevated INR indicates that the warfarin dose is not therapeutic. The client is at high risk for bleeding and should be monitored by the nurse.

The nurse provides care for a client diagnosed with type 2 diabetes mellitus. The nurse anticipates that the client will be prescribed a second-generation sulfonylurea. Which medication in the hospital formulary belongs to this class of drugs? 1. Metformin. 2. Glipizide. 3. Repaglinide. 4. Miglitol.

2) CORRECT - Glipizide, a second-generation sulfonylurea, controls blood glucose levels in type 2 diabetes by stimulating pancreatic beta cells to secrete insulin.

A client receiving 50 mL/hr of continuous bladder irrigation fluid has a total output of 500 mL over 8 hours. Which action does the nurse take? 1. Assess the catheter for kinks. 2. Notify the health care provider. 3. Manually irrigate the catheter for clots. 4. Reduce the rate of the bladder irrigation fluid.

2) CORRECT- The client received 400 mL of bladder irrigation fluid over 8 hours with an output of 500 mL. The urine output for this time frame is 100 mL (12.5 mL/hr). Normal urine output is at least 30 mL/hr; therefore, the nurse notifies the health care provider.

The nurse encourages clients in a community population to attend a diabetes screening event scheduled at a local community center. Which level of intervention is the nurse advocating? 1. Primary prevention. 2. Secondary prevention. 3. Tertiary prevention. 4. Health risk assessment.

2) CORRECT— Secondary prevention focuses on screening to ensure early disease detection and prompt intervention. 1) Primary prevention focuses on health promotion and prevention of illness or disease, not disease screening. 3) Tertiary prevention focuses on preventing deterioration associated with disease and improving the client's quality of life, not disease screening. 4) Health risk assessment plays an important role in primary prevention, not disease screening.

The nurse observes a student nurse provide a client with a subcutaneous injection of heparin. For which student action will the nurse intervene? (Select all that apply.) 1. Pinches the skin and inserts the needle 90 degrees. 2. Places the needle in the sharps container. 3. Administers the injection 1/2 inch from the umbilicus. 4. Aspirates after inserting the needle. 5. Massages the site.

3 4 5 3) CORRECT — The injection should be at least 2 inches away from umbilicus. 4) CORRECT — Heparin injections are not aspirated. 5) CORRECT— Massaging is not indicated after a subcutaneous injection. 1) The skin should be pinched and needle inserted at a 90 degree angle when giving a subcutaneous injection. 2) Used needles should be placed in a sharps container for safety.

The nurse provides care for a client who reports difficulty breathing. Which assessment finding requires immediate action by the nurse? (Select all that apply.) 1. Non-productive cough. 2. Flushed skin appearance. 3. Use of accessory muscles. 4. Oxygen saturation of 78%. 5. A heart rate of 145/minute.

3 4 5 1) A non-productive cough is a benign finding and does not require immediate attention. 2) Flushed skin is not an emergency and could be due to a non-emergency reasons. 3) CORRECT - Use of accessory muscles for breathing signifies air hunger and immediate attention. 4) CORRECT- Severe hypoxia requires emergent action. 5) CORRECT - Tachycardia indicates hypoxia and respiratory distress status, and must be addressed immediately.

The nurse prepares to administer fondaparinux to a client. Which laboratory test result will the nurse monitor in the client receiving this medication? 1. International normalized ratio. 2. Prothrombin time. 3. Creatinine level. 4. Partial thromboplastin time.

3) CORRECT - Fondaparinux (Arixtra) is excreted by the kidneys; creatinine level should be monitored periodically, and the drug stopped in clients who develop unstable kidney function or severe renal impairment. Fondaparinux, an anticoagulant that inhibits factor Xa, has no effect on routine coagulation tests, such as prothrombin time.

A client receiving a blood transfusion experiences a febrile reaction. Once the transfusion is discontinued, which action will the nurse take next? 1. Flush the blood tubing with normal saline. 2. Place tubing and bag in a red biohazard bag and discard. 3. Keep the blood bag and tubing hung in case the health care provider wants to restart the transfusion. 4. Place the bag and tubing in a biohazard container to send back to the blood bank.

4 1) Flushing the tubing will cause the blood that is in the tubing to be infused into the client, making the reaction worse. 2) The tubing and blood is not to be discarded. It is sent back to the blood bank. 3) It is unlikely that this transfusion will be restarted. 4) CORRECT - The tubing and blood bag should be sent to the blood bank for analysis.

The nurse delivers a kosher lunch to a client who is Jewish. Which nursing action is most appropriate when assisting the client? 1. Moving the food from paper plates to glass plates. 2. Unwrapping the eating utensils for the client. 3. Replacing the plastic utensils with metal utensils. 4. Asking the client to unwrap the eating utensils and to prepare the meal for eating.

4 Asking the client to unwrap the utensils and allowing the client to prepare the meal for eating Rationale: Kosher meals arrive on paper plates and with plastic utensils sealed. Health care providers should not unwrap the utensils or transfer the food to another serving dish.

The nurse assesses a client with obsessive compulsive personality disorder. Which finding will the nurse expect to observe? (Select all that apply.) 1. Requires excessive support from others when making decisions. 2. Believes is able to know what others are thinking. 3. Possesses exaggerated feelings of helplessness when alone. 4. Demonstrates unwillingness to delegate tasks unless others follow strict rules. 5. Imposes perfectionism in own completion of tasks.

4 & 5 4) CORRECT - A client with obsessive compulsive personality disorder is preoccupied in maintaining control in all aspects of life. In order to do so, the client is unwilling to let anyone assist in any tasks unless done exactly in the manner dictated. 5) CORRECT - A client with obsessive compulsive personality disorder attempts to maintain control by imposing standards of perfectionism in all aspects of life. This interferes with the ability to complete tasks and maintain close relationships. 1) A client with dependent personality disorder has an excessive need for others to take care of them. This leads to clinging behavior and fears of separation. The client must have a great deal of support from others when making important life decisions. 2) A client with schizotypal personality disorder has difficulty establishing close relationships. The client demonstrates perceptual distortions and eccentric behavior, such as believing the ability to know what others are thinking. 3) A client with dependent personality has exaggerated feelings of helplessness when alone because of the fear of not being able to care for self.

A client with a newly casted lower leg reports to the nurse that the foot feels numb. Which action will the nurse take first? 1. Assess for pain. 2. Monitor the cast for dampness. 3. Measure the client's blood pressure. 4. Notify the health care provider.

4) CORRECT — Compartment syndrome begins with edema and increased pain. It progresses with decreased perfusion, causing a change in skin color and weak pulses. Numbness is a later sign that could indicate tissue necrosis. This is an emergency that should be reported to the health care provider.

The nurse provides care for a client recovering from a hysterectomy. The nurse asks the nursing assistive personnel (NAP) to help the client ambulate in the hallway within the next hour. Three hours later the client reports still not being assisted to ambulate. The nurse finds the NAP in the break room shopping on the Internet. Which action will the nurse take next? 1. Tell the NAP to ambulate the client in the hallway now. 2. Complete an incident report. 3. Tell the NAP to clock out and go home. 4. Report the NAP to the nursing supervisor.

4) CORRECT — This action appropriately utilizes the nursing chain of command. 1) If the NAP did not perform the task when asked the first time, there is reasonable doubt it may be performed when the NAP is asked by the nurse again. 2) There is no valid reason to complete an incident report. 3) The nurse does not have the authority to do this and it does not address the issue.

A client reports having chest irradiation as a child for non-Hodgkin lymphoma (NHL). On which potential adulthood complication will the nurse focus when assessing this client? 1. Chronic infertility. 2. Asthmatic bronchitis. 3. Hodgkin lymphoma. 4. Lung cancer.

4) CORRECT— The development of secondary cancers in adults is a long-term complication of childhood cancer treatment. These cancers can be site specific, such as lung cancer or leukemia. 1) Radiation to the pituitary gland, ovaries, and testes, and alkylating agents may cause infertility. 2) Asthmatic bronchitis is not associated with radiation. Pneumonitis and pulmonary fibrosis can occur from radiation and alkylating agents. 3) Hodgkin disease may morph into NHL; however, does not occur in reverse.

The nurse provides care for a client experiencing the final stage of chronic kidney disease. Which lab value does the nurse anticipate for this client when providing care? 1. Serum calcium of 9.5 mg/dL (3 mmol/L). 2. Hemoglobin of 15 mg/dL (150 g/L). 3. Serum creatinine of 0.6 mg/dL (53 µmol/L). 4. Phosphate of 5 mg/dL (2 mmol/L).

4) CORRECT— The nurse anticipates hyperphosphatemia for this client, caused by a decreased excretion of phosphate and increased stimulation of parathyroid glands. This causes a release of phosphate from bones. The normal serum phosphate range is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). 1) The final stage of chronic kidney disease is associated with hypocalcemia, not hypercalcemia. The normal serum calcium range is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). 2) The final stage of chronic kidney disease is associated with anemia. The normal range 12 to 18 mg/dL (140-175 g/L); therefore, this is not anticipated when providing client care. 3) The final stage of chronic kidney disease is associated with elevated creatinine. The normal creatinine range is 0.5 to 1.2 mg/dL (44 to 106 µmol/L); therefore, this is not anticipated when providing client care.

The nurse provides dietary teaching to a client with an acute kidney injury. Which menu selection made by the client indicates to the nurse that teaching is effective? 1. Potatoes. 2. Raisins 3. Pasta. 4. Bananas.

ANYTIME ITS KIDNEYS WATCH K+!! 1) A client with an acute kidney injury is at risk for hyperkalemia. Potatoes are high in potassium and should be avoided. 2) A client with an acute kidney injury is at risk for hyperkalemia. Raisins are high in potassium and should be avoided. 3) CORRECT - A client with an acute kidney injury is at risk for hyperkalemia. Pasta is not a good source of potassium and should be selected. Pasta is also good to meet caloric requirements and spare using protein for energy. 4) A client with an acute kidney injury is at risk for hyperkalemia. Bananas are high in potassium and should be avoided.

A mother brings her 1-week-old newborn to the clinic for a wellness checkup. She verbalizes frustration with breastfeeding because of nipple soreness. Which recommendation by the nurse may help alleviate nipple soreness? 1. Ensure that the neonate grasps half of the areola. 2. Do not allow breast milk to dry on the nipples. 3. Use plastic-backed nursing pads and change them frequently. 4. Apply ice to the nipples after feeding.

REMEMBER "BEST ANSWER" OWWW 4) CORRECT - Applying ice to the nipples after breastfeeding may decrease discomfort due its numbing affect. 1) The client must ensure that the entire areola is grasped by newborn. An inappropriate latch increases nipple soreness. 2) The client can allow breast milk to dry on the nipples as this helps relieve nipple soreness. 3) The client is to avoid plastic-backed nursing pads, which trap moisture and can add to the discomfort.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD) exacerbation. Which finding would require immediate attention from the nurse? (Select all that apply.) 1. Decreased expiratory peak flow meter readings. 2. Evidence of finger clubbing. 3. Increased anterior-posterior chest diameter. 4. Change in sputum color and amount. 5. Presence of fever and tachycardia.

THIS QUESTION WAS TRICKY BECAUSE IT WAS REALLY ASKING YOU ABOUT ACUTE COPD EVEN THOUGH ? SAYS ADMITTED WITH CHRONIC COPD. KEY WORDS= IMMEDIATE INTERVENTION! The correct answer is 1, 4, 5 1) CORRECT - Decreased expiratory peak flow meter readings indicate bronchoconstriction. 4) CORRECT - Changes to sputum color and amount may indicate an infection or worsening of exacerbation. 5) CORRECT - Fever and tachycardia indicate a possible infection or sepsis. 2) Clubbed fingers are associated with longstanding COPD and not with acute changes. 3) Increased anterior-posterior diameter is associated with longstanding COPD, not with acute changes.

The nurse completes a minimum data set on each assigned client as a standardized, primary screening and assessment tool of health status. In which clinical area does the nurse work? 1. Skilled nursing facility. 2. Adult day-care center. 3. Psychiatric facility. 4. Acute rehabilitation facility.

The correct answer is 1 1) CORRECT — Nurses who work in a in a Medicare-certified or Medicaid-certified long-term care facility, nursing home, or skilled nursing facility are required to complete a minimum data set for each resident

The graduate nurse attends an orientation to the oncology unit. Which statement indicates that the graduate nurse understands the teaching? 1. "Angiogenesis is only accomplished by malignant cells." 2. "Everyone diagnosed with cancer will die from it." 3. "Cancers metastasize through lymphatic spread to organs." 4. "Cell mutations cannot be managed by the body's immune system."

The correct answer is 3 . 1) Angiogenesis is the creation of a blood supply. The human body does this for many reasons; it is not unique to tumors. 2) Cancer is not always lethal. Most cancers, when detected early, are treatable for cure or remission. 3) CORRECT - Cancers metastasize primarily by spreading cancerous cells through the lymph system. 4) Normally, the body can manage and destroy cell mutations.

The client says to the nurse, "I'm so upset! I've tried my hardest to give my children everything, but they still hate me." Which response by the nurse is appropriate? 1. "I'm sure they don't hate you." 2. "Children say things they don't mean." 3. "What would make them feel that way?" 4. "You think your children hate you?"

"If you are in nursing school, you are right-- they probably hate you." just kidding yall 4) CORRECT - Restating the client's statement is a therapeutic communication technique. This question repeats the main idea expressed by the client and gives the client an idea of what has been communicated. If the message has been misunderstood, the client can clarify it. 1) This statement offers false reassurance and is non-therapeutic. 2) This statement dismisses the client's expressed concerns and is non-therapeutic. 3) Asking a "what" question is another variation of asking why (i.e. "Why would your children feel this way?"). This question is a non-therapeutic communication response.

The nurse provides care to a client with a total serum calcium level of 7.0 mg/dL (1.75 mmol/L). Which action will the nurse take first? 1. Withhold antacids containing phosphorus. 2. Educate about calcium-rich foods. 3. Instruct to avoid drinking alcohol. 4. Initiate seizure precautions.

*CALCIUM REMEMBER 9-11* 4) CORRECT— The client is at risk for seizures because hypocalcemia increases irritability of the central nervous system and peripheral nerves. 1) Withholding antacids containing phosphorus is important because they decrease calcium absorption, but the immediate priority is safety. 2) Educating about calcium-rich foods is important, but the immediate priority is safety. 3) Instructing to avoid drinking alcohol is important, but the immediate priority is safety.

The nurse provides care for a client with chronic obstructive pulmonary disease (COPD). The nurse determines that formoterol is effective if which finding is noted on assessment? (Select all that apply.) 1. The client's PaO2 of 88 mm Hg. 2. The client is alert and oriented X 4. 3. The client experiences a baseline weight loss of 12%. 4. The client's arterial PaCO2 of 52 mm Hg. 5. The client's pH is 7.33.

*EVEN IF YOU DO NOT KNOW WHAT THE MEDICATION IS FOR (I HONESTLY FORGOT) PICK THE LABS THAT ARE NOT NORMAL* The correct answer is 1, 2 1) CORRECT - A PaO2 of 88 mm Hg is within normal range of 85 to 95 mm Hg and indicates improved oxygenation. Formoterol is a long-acting bronchodilator. 2) CORRECT—Improvement in cognitive status (alert and oriented to person, place, time, and situation) indicates improved oxygenation. 3) Weight loss is caused by COPD. It is not an effect of formoterol. 4) A diagnosis of COPD results in the high PaCO2 level of 52 mm Hg, which is significantly elevated above normal range of 35 to 45 mm Hg. This is not a therapeutic effect of formoterol. 5) A diagnosis of COPD results in decreased pH below normal range of 7.35 to 7.45, which is indicative of respiratory acidosis due to air-trapping. This is not a therapeutic effect of formoterol.

A client with a chronic kidney injury takes sevelamer as prescribed. Which finding indicates to the nurse that the medication is effective? 1. Serum calcium of 7.8 mg/dL (95 mmol/L). 2. Serum creatinine of 5 mg/dL (133 micromol/L). 3. Serum potassium of 5 mEq/L (5.5 mmol/L). 4. Serum .phosphate of 4 mg/dL (1.42 mmol/L).

*I DIDN'T KNOW THIS ANSWER OR MEDICATION BUT BY KNOWING LAB VALUES I WAS ABLE TO ANSWER CORRECTLY* 4) CORRECT - Sevelamer is used to manage hyperphosphatemia in clients with chronic kidney injury. It binds phosphate in the bowels to facilitate excretion in the stool. Effective treatment with sevelamer results in a serum phosphate value within the normal range of 2.4 to 4.4 mg/dL (0.78 to 1.42 mmol/L). *The normal range for phosphorous is 2.5-4.5 mg/dL* 1) A serum calcium of 7.8 mg/dL (1.95 mmol/L) is below the normal range of 9 to 10.5 mg/dL (1.9 to 2.6 mmol/L). Effective treatment with sevelamer results in a normal calcium level. 2) Sevelamer does not affect creatinine levels. 3) Sevelamer does not affect potassium levels.

The nurse educator teaches a group of staff nurses about measures to prevent the transmission of healthcare-associated infections when providing care for clients. Which intervention does the nurse educator include in the teaching? (Select all that apply.) 1. Clean stethoscopes between clients. 2. Empty bedpans as soon as possible. 3. Limit fresh flowers in client rooms. 4. Use personal protective equipment (PPE) 5. Perform handwashing and alcohol-based sanitizing.

1 4 5 1) CORRECT - Cleaning stethoscopes between clients is a practical method for preventing infections. 4) CORRECT - Using personal protective equipment (PPE) is part of standard precautions, when warranted, and helps prevent infections. 5) CORRECT - Performing handwashing and alcohol-based sanitizing is a major method for preventing infections. 2) Although this is a good practice, emptying bedpans as soon as possible does not prevent healthcare-associated infections. 3) Although this is a good practice, limiting fresh flowers in client rooms does not prevent healthcare-associated infections.

The nurse provides care for a client diagnosed with new onset atrial fibrillation. The client's health care provider prescribes a transesophageal echocardiogram (TEE). What reason will the nurse give to the client as the primary reason for performing a TEE? 1. To measure the cardiac index. 2. To rule out thrombus in the heart. 3. To estimate the ejection fraction. 4. To observe ventricular wall motion.

1) A TEE is not used to measure cardiac index. *2) CORRECT* In clients with atrial fibrillation, a TEE is done to rule out blood clots in the heart chambers, especially if the client is being considered for cardioversion. 3) A TEE might be able to estimate the ejection fraction; however, this is not the main reason for doing a TEE for clients with atrial fibrillation. 4) Wall motion can be observed in TEE; however, it is not the main reason for doing a TEE for clients with atrial fibrillation.

The nurse evaluates laboratory values for a client experiencing diaphoresis and weight loss. Which value will the nurse immediately report to the health care professional? 1. Calcium 9.0 mg/dL (2.25 mmol/L). 2. Hemoglobin A1C 8% (0.08). 3. Magnesium 2.2 mg/dL (1.10 mmol/L). 4. Blood glucose 118 mg/dL (6.55 mmol/L).

1) A calcium level of 9.0 mg/dL (2.25 mmol/L) is within normal limits. This value would not cause diaphoresis and weight loss. 2) CORRECT — A hemoglobin A1C value of 8% (0.08) indicates hyperglycemia. This blood level evaluates the levels of blood glucose over the previous months. Diaphoresis and weight loss are manifestations of an elevated blood glucose level. 3) A magnesium level of 2.2 mg/dL (1.10 mmol/L) is within normal limits. This value would not cause diaphoresis and weight loss. 4) A blood glucose level of 118 mg/dL (6.55 mmol/L) is considered high-normal, although within normal limits. This isolated value would not cause diaphoresis and weight loss.

A nurse who is in Generation X, works the night shift and requests more time off than other staff nurses. Which statement best explains a characteristic of this generation? 1. Believes that there are enough other nurses to fill the staffing needs. 2. Prefers to work the day shift, but hesitates to ask for the schedule change. 3. Wants to increase leisure time to balance work time. 4. Wants to be rewarded for the time spent at work.

1) Believing that there are enough nurses to fill staffing needs is not a characteristic of this generation. 2) Individuals in this generation would likely request the schedule change. 3) CORRECT - Individuals in this generation have a tendency to want work-life balance. 4) Wanting to be rewarded for time spent at work is a characteristic of a person in Generation Y.

The nurse reviews care needs for assigned clients. Which client will the nurse assess first? 1. Client who had a vaginal hysterectomy 2 days ago and is reporting that the right calf is warm to touch. 2. Client who received a dose of prescribed warfarin while receiving a heparin infusion. 3. Client with chronic obstructive pulmonary disease who is using pursed-lip breathing. 4. Client who had an abdominal aortic aneurysm repaired 10 hours ago and has bronchial breath sounds over the trachea.

1) CORRECT - A warm calf might indicate a deep vein thrombosis. Having a hysterectomy is a risk factor for this health problem, which is a priority since it can be life-threatening if it becomes an embolus. 2) Oral warfarin is appropriate to provide to a client whose heparin infusion is being discontinued in a few days. There is no reason to assess this client first. 3) Pursed lip breathing prolongs exhalation and increases airway pressure. It is an appropriate breathing technique for a client with chronic obstructive pulmonary disease. There is no reason to assess this client first. 4) Bronchial breath sounds are considered normal over the trachea. There is no reason to assess this client first.

The nurse provides care to clients on a progressive care unit. Which client does the nurse see first? 1. The client recovering from a transjugular intrahepatic portosystemic shunt (TIPS) procedure. 2. The client who received subcutaneous insulin to treat a blood glucose of 317 mg/dL. 3. The client newly diagnosed with systemic lupus erythematosus (SLE). 4. The client receiving continuous octreotide infusion to treat portal hypertension.

1) CORRECT - After a TIPS procedure the client is at risk for bleeding. This client's clotting factors are likely to be altered due to liver dysfunction. The procedure shunts blood away from esophageal varices and requires an assessment by the nurse. 2) The client who received an insulin injection for an elevated blood glucose level is in no acute distress. 3) The client with SLE is in no acute distress. 4) The client receiving octreotide for portal hypertension is in no acute distress.

The nurse educator plans an educational program to review transmission-based precautions with unit staff. Which substance is included on the list of potential sources of infection as outlined by the Centers for Disease Control and Prevention (CDCP)? (Select all that apply.) 1. Blood. 2. Vaginal secretions. 3. Sputum. 4. Non-intact skin. 5. Sweat.

1) CORRECT - Blood is considered potentially infectious as outlined by the CDCP. 2) CORRECT- Vaginal secretions are considered potentially infectious as outlined by the CDCP. 3) CORRECT- Sputum is considered potentially infectious as outlined by the CDCP. 4) CORRECT - Non-intact skin, whether or not blood is visible, is considered potentially infectious as outlined by the CDCP. 5) Sweat is the only bodily secretion that is not considered infectious as outlined by the CDCP.

While preparing medications, the nurse documents that a client is allergic to penicillin. Which medication will the nurse question before administering to this client? 1. Cefazolin. 2. Doxycycline. 3. Ciprofloxacin. 4. Clarithromycin.

1) CORRECT - Cefazolin is a cephalosporin that is contraindicated in clients who have an allergic reaction to penicillin. 2) Doxycycline is a tetracycline antibiotic and is safe to give to a client with an allergy to penicillin. 3) Ciprofloxacin is a quinolone antibiotic and is safe to give to a client with an allergy to penicillin. 4) Clarithromycin is a macrolide antibiotic and is safe to give to a client with an allergy to penicillin.

The nurse provides care to a client in hypovolemic shock. Which intravenous solution will the nurse recognize as being an isotonic crystalloid solution? (Select all that apply.) 1. Normal saline. 2. Lactated ringer. 3. 0.5% normal saline. 4. 10% dextrose. 5. 0.45% dextrose in normal saline.

1) CORRECT - Normal saline is an isotonic crystalloid solution commonly used for resuscitation in hypovolemic shock. This solution has the same concentration of electrolytes as the extracellular fluid so it does not alter the concentrations of electrolytes in the vascular system. 2) CORRECT - Lactated ringer is an isotonic crystalloid solution commonly used for resuscitation in hypovolemic shock. This solution has the same concentration of electrolytes as the extracellular fluid so it does not alter the concentrations of electrolytes in the vascular system. 3) 0.5% normal saline is a hypotonic solution. 4) 10% dextrose is a hypertonic solution. 5) 0.45% dextrose in normal saline is a hypertonic solution.

The nurse assesses a client's sleep patterns. The client tells the nurse, "I am so tired in the morning. How do I know if I have sleep apnea?" Which clinical manifestation does the nurse explain to the client as indicative of sleep apnea? (Select all that apply.) 1. Awakening at night. 2. Snoring. 3. Irritability. 4. Vivid dreams. 5. Hyperactivity.

1) CORRECT - Snoring and changes in blood gasses stimulate the client to wake up suddenly, and are signs of sleep apnea. 2) CORRECT - When the client goes to sleep, the muscles relax and the upper airway can obstruct, causing snoring. This can be a sign of sleep apnea. 3) CORRECT - Personality changes and irritability are often seen due to sleep deprivation from sleep apnea. 4) Vivid dreams are not reported with sleep apnea. 5) Waking up tired and daytime sleepiness are common reports with sleep apnea, not hyperactivity.

The nurse provides care to a client with pneumonia, anorexia, and chronic pain. Which laboratory result does the nurse report to the health care provider immediately? 1. PaCO2 of 50 mm Hg. 2. pH of 7.33. 3. PaO2 of 86 mm Hg. 4. HCO3 of 23 mEq/L.

1) CORRECT - The PaC02 is significantly higher than the normal range of 35 to 45 mm Hg. This finding suggests compromised alveolar exchange with a potential for respiratory acidosis. 2) This pH is slightly below the normal range of 7.35 to 7.45. 3) The PaO2 is within the normal range of 85 to 95 mm Hg. 4) The HCO3 is within the normal range of 22 to 26 mEq/L.

The nurse learns that a client was not prescribed a treatment for a disease process because of age. For which principle violation will the nurse bring this issue to the organization's ethics committee? 1. Justice. 2. Veracity. 3. Beneficence. 4. Nonmaleficence

1) CORRECT - The ethical principle of justice means that clients are treated fairly and receive fair treatment. Because the treatment was not prescribed due to the client's age, the ethical principle of justice is in question. 2) The ethical principle of veracity means telling the truth. 3) The ethical principle of beneficence means that the goal of actions are to "do good." 4) The ethical principle of nonmaleficence means to do no harm.

The nurse provides care for a newborn who is recovering from necrotizing enterocolitis (NEC). Which intervention does the nurse include in the newborn's plan of care? 1. Feed the newborn fresh breast milk. 2. Use droplet transmission precautions. 3. Assess rectal temperature frequently. 4. Place the newborn in a prone position.

1) CORRECT - The use of fresh breast milk is the preference for the newborn who is recovering from NEC. It is the preferred enteral nutrient because it confers some passive immunity (IgA), macrophages, and lysozymes. Also, breast milk is more easily digested than formula.

The nurse provides care to a client receiving lactulose as treatment for hepatic encephalopathy. For which reason will the nurse withhold the next scheduled dose of the medication? 1. Experienced five watery stools today. 2. Increased confusion. 3. Serum potassium level 4.0 mEq/L (4.0 mmol/L). 4. Reported intestinal cramping.

1) CORRECT - Two to three soft bowel movements is desireable when taking lactulose. Watery stools indicate lactulose overdose. 2) Lactulose is used to improve mental status. 3) The serum potassium level is within the normal range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). 4) Intestinal cramping is a side effect, but not an adverse effect.

The nurse provides discharge instructions for an older adult client with osteoporosis. Which point about exercise is most important for the nurse to include in the teaching? 1. Exercise must include weight bearing activities. 2. Avoid exercises that increase the risk of fracture. 3. Yoga is useful for flexibility and muscle strength. 4. Perform aerobic activities for weight reduction.

1) CORRECT - Weight bearing exercises are beneficial in the treatment of osteoporosis because the bone adapts by building and becoming stronger. 2) The nurse may counsel the client to avoid activities that include jumping, but must be specific about exercises to avoid or the client may avoid all activity. 3) Yoga is useful as part of the overall exercise regimen, but this does not address improving bone strength. 4) Aerobics are good for stamina, overall health, and weight reduction, but this exercise does not resolve osteoporosis. Often, clients with osteoporosis already have a low body mass index.

The nurse observes a wrench taped to the head of the bed of a client who is currently in surgery. Which device does the nurse expect this client to have when returning to the care area? 1. Halo vest. 2. Buck traction. 3. External fixation device. 4. Passive range of motion device.

1) CORRECT — A wrench is needed to open the halo vest in the event the client needs cardiopulmonary resuscitation.

After receiving a unit of red blood cells, a child reports tingling in the ears, nose, fingers, and toes. Which electrolyte imbalance does the nurse suspect the client is experiencing? 1. Hypocalcemia. 2. Hypercalcemia. 3. Hyponatremia. 4. Hypernatremia.

1) CORRECT — Hypocalcemia results from blood transfusions containing citrate. Citrate causes increased cell membrane permeability, leading to increased neuromuscular excitability, which may result in numbness or tingling of the ears, nose, fingers, and toes. If severe, laryngospasm, seizures, and cardiac arrest may occur.

The nurse provides care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which finding indicates to the nurse that the client is experiencing cor pulmonale? 1. Jugular vein distension. 2. Whitish frothy sputum. 3. Finger clubbing. 4. Chest tightness.

1) CORRECT — Jugular vein distention indicates cor pulmonale (right-sided heart failure). 2) A whitish frothy sputum may indicate left-sided, not right-sided, heart failure. 3) Finger clubbing is not a specific sign of cor pulmonale. This finding may be seen in COPD, indicating chronic hypoxemia. 4) Chest tightness is not a specific sign of cor pulmonale.

A client with a history of intravenous drug abuse experiences a low-grade fever, cough, night sweats, fatigue, weight loss, and a productive cough with mucopurulent sputum. Which transmission-based precaution will the nurse use for this client? 1. Airborne. 2. Contact. 3. Droplet. 4. Standard.

1) CORRECT — The client's history and signs suggest pulmonary tuberculosis, which is spread by airborne pathogens (M. tuberculosis). Airborne transmission-based precautions should be initiated immediately. 2) Contact transmission-based precautions are instituted for clients with infections spread through direct contact with skin or bodily secretions or with items in the client's environment. 3) Droplet transmission-based precautions are initiated for a client with a known or suspected infection spread by droplets. 4) Standard precautions should be followed when providing care for any client.

The nurse teaches a client about prescribed vaginal suppositories for use at home. Which client statement indicates a need for *further instructions?* 1. "I should insert the suppository about a half inch into my vagina." 2. "I should plan to lie on my back with my hips elevated for 5 to 10 minutes after inserting the suppository." 3. "I should wear a perineal pad if I have some of the melted medication come out." 4. "If I reuse an applicator, I should wash it with soap and water before I use it again."

1) CORRECT — The suppository should be inserted a minimum of 2 inches for the medication to be effective. 2) The client should recline for 5 to 10 minutes with the hips elevated after inserting the suppository. 3) The client should wear a perineal pad to protect the clothing from drainage or staining. 4) The applicator for the suppository should be cleansed with soap and water prior to reuse.

The nurse assists with a cardiac arrest for a client in ventricular fibrillation. Cardiopulmonary resuscitation is in progress and 1 mg of epinephrine was just given. The nurse is likely to give which medication next? 1. Magnesium. 2. Amiodarone. 3. Vasopressin. 4. Atropine.

2) CORRECT - Give amiodarone, an antiarrhythmic, after epinephrine in v-fib and v-tach. 1) Magnesium IV is given in torsades de pointes, not in v-fib. 3) Vasopressin is no longer indicated in cardiac arrest. 4) Atropine is no longer indicated in cardiac arrest, only in symptomatic bradycardia.

The nurse provides care for a newborn in the delivery room. Which nursing intervention will the nurse use to prevent the newborn from experiencing conductive heat loss? 1. Drying the newborn's skin immediately after birth. 2. Putting the unclothed newborn against the mother's skin. 3. Keeping the incubator away from windows and outside walls. 4. Placing the newborn under a radiant warmer.

2) CORRECT - Placing the unclothed newborn against the mother's helps prevent conductive heat loss. 1) Drying the newborn's skin immediately after birth helps prevent convective heat loss. 3) Keeping the incubator away from windows helps prevent radiant heat loss. 4) Placing the newborn under a radiant warmer can increase heat loss from evaporation.

The nurse provides care for a client with an oral temperature of 90 °F (32 °C). Which nursing diagnosis will the nurse use first to guide this client's care? 1. Risk for impaired cognition. 2. Risk for cardiac dysrhythmia. 3. Risk for acid-base imbalance. 4. Risk for shivering and spasm.

2) CORRECT - Severe hypothermia can lead to cardiac arrest. 1) A low body temperature will probably impair cognition; however, this is not a priority. 3) Acid-base imbalance will most likely occur; however, this is not a priority. 4) The client will most likely shiver and experience spasms; however, this is not a priority.

The nurse delegates care of a client diagnosed with osteoporosis to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include? 1. "Monitor the urinary output." 2. "Clean up clutter in the room." 3. "Encourage the client to bathe independently." 4. "Perform passive range-of-motion exercises."

2) CORRECT — Safety is a priority in clients with osteoporosis. Falls can lead to fractures. 1) Monitoring output is part of routine nursing care and not unique to clients with osteoporosis. 3) Promoting independence is important, but it is not the priority in this situation. 4) Passive range-of-motion exercises are not the priority. Weight-bearing exercises prevent osteoporosis.

The nurse auscultates the heart of a client experiencing increasing shortness of breath. Which finding causes the nurse the most concern? 1. S1 heart sound. 2. S2 heart sound. 3. S3 heart sound. 4. S4 heart sound.

3) CORRECT - An S3 heart sound, a significant finding in older adult clients, suggests heart failure. It is heard in early diastole during the period of rapid ventricular filling as blood flows from the atrium into a noncompliant ventricle. 1) An S1 heart sound, a normal finding, occurs when the mitral and tricuspid valves of the heart close. It corresponds with the onset of ventricular contraction. 2) An S2 heart sound, a normal finding, occurs when the aortic and pulmonic valves close. It occurs at the end of ventricular contraction and the onset of ventricular diastole. 4) An S4 heart sound occurs immediately before the S1 heart sound. It is considered a normal finding in older adult clients.

The nurse follows up with a client diagnosed with insomnia. The nurse seeks to determine if treatment was successful. Which response by the client best indicates treatment was successful? 1. "I am sleeping 4 hours a night." 2. "I fall asleep within 1 to 2 hours at night now." 3. "I am not napping in the day anymore." 4. "I am waking up twice a night."

3) CORRECT - Insomniacs typically nap in the daytime. Not napping indicates the client is getting through the day now. This is a positive response to treatment. 1) 4 hours may be an improvement, but is not an adequate amount of sleep. 2) 1 to 2 hours to fall asleep may be an improvement, but is not the most successful response to treatment. 4) Continual interruption of sleep during the client's sleep time is not the most successful response.

The nurse provides care for several assigned clients. Which situation requires an immediate follow-up by the nurse? 1. A client on mechanical ventilation has moisture in the ventilator tubing. 2. A client's blood glucose monitor shows a message noting there is insufficient amount of blood to complete the glucose level. 3. A client receiving a liter of intravenous fluid at 120 mL/hr has 460 mL remaining after 2 hours. 4. A client with a chest tube attached to suction has bubbling in the control chamber of the closed-drainage system

3) CORRECT — A complication of intravenous therapy is fluid overload from a too-rapid infusion. This is the priority as heart failure can result from fluid overload.

The nurse is assessing a neonate born at 44 weeks' gestation. Which finding does the nurse document as consistent with the newborn's gestational age? 1. Slow recoil of the pinna. 2. Absence of plantar creases. 3. Cracked, peeling skin. 4. Abundant vernix.

3) CORRECT — A post-term neonate has dry, cracked (desquamating) skin at birth. 1) In preterm neonates of less than 34 weeks gestation, the ear has little cartilage to keep it stiff. It will remain folded over or return slowly when folded longitudinally and horizontally. In a full- or post-term neonate, the ear springs back to the original position immediately. 2) Full- and post-term neonates have deep plantar creases. A preterm newborn has few creases on the foot. 4) There is little vernix on the body of a full-term neonate except small amounts in the skin creases. No vernix is on the body of a post-term newborn. A preterm neonate has a thick covering of vernix.

The nurse provides care for a client diagnosed with intractable pain. The client is prescribed magnesium sulfate 2 mg intravenous push (IVP) now and every 4 to 6 hours, PRN for pain. Which action should the nurse take first? 1. Administer the medication. 2. Insert an intravenous access device. 3. Question the prescribed medication. 4. Assess pain level using a numeric rating scale.

3) CORRECT- Magnesium sulfate is used as an electrolyte replacement or anticonvulsant. It is not used for pain management. The nurse will question this prescription. 1) Magnesium sulfate is not a pain medication. Administering this medication would cause a medication error. 2) An intravenous access device will need to be inserted to administer intravenous medications; however, that is not the priority action. 4) Assessing current pain level is appropriate before administering pain medication; however, this medication is not an analgesic.

The nurse receives a prescription to start an IV dopamine infusion for a client with hypotension. Which action does the nurse take next? 1. Verify that the client has a "full code" status documented. 2. Ensure the client has a gauge 18 peripheral IV line. 3. Check to see if the client received volume replacement. 4. Attach the client to an oxygen saturation monitor.

3) CORRECT— Adequate fluid volume must be achieved before vasopressors are given because this vasoconstrictor results in further reduction in tissue perfusion without volume.

The nurse provides care to a client at risk for hypercalcemia. Which action is most appropriate for the nurse to take? 1. Encourage strict bed rest. 2. Limit dietary fiber. 3. Encourage oral fluids. 4. Hold prescribed zoledronate.

3) CORRECT— Dehydration contributes to and exacerbates hypercalcemia. Fluids containing sodium should be administered, unless contraindicated, because sodium assists with calcium excretion. About 3L of fluids per day or more are encouraged. 1) Immobility contributes to and exacerbates hypercalcemia. 2) Fiber helps prevent constipation associated with hypercalcemia. 4) Zoledronate, a bisphosphonate drug, inhibits the action of osteoclasts and therefore reduces serum calcium levels. The medication should not be held.

A client receives an antibiotic every 8 hours. The antibiotic has an onset of action of 2 hours and a duration of action of 8 hours. The client is prescribed a peak blood level. If the medication is provided at 1000, at which time will the nurse schedule the peak level to be drawn? 1. 1100. 2. 1200. 3. 1400. 4. 1800.

3) CORRECT— Peak concentration occurs after the onset but before the end of the duration.

The nurse provides care for a client with a brain natriuretic peptide (BNP) level of 899 pg/mL. Which priority nursing diagnosis does this finding substantiate? 1. Activity intolerance. 2. Electrolyte imbalance. 3. Risk for injury. 4. Excess fluid volume.

4) CORRECT - A BNP level of 899 pg/mL indicates acute congestive heart failure. There is excess fluid volume related to increased venous pressure and decreased renal perfusion secondary to acute congestive heart failure. This is the priority nursing diagnosis. 1) A BNP level of 899 pg/mL is significantly above normal finding of <100 pg/mL. The finding indicates acute congestive heart failure, which is a potential nursing diagnosis, but not a priority. 2) Electrolyte imbalance is not a priority nursing diagnosis in acute congestive heart failure. 3) Risk for injury is not a priority nursing diagnosis in acute congestive heart failure.

The nurse provides care for a client diagnosed with trigeminal neuralgia. The client reports severe burning and shooting pain. Which understanding does the nurse have about managing this type of pain? 1. It is usually well controlled with salicylates or nonsteroidal anti-inflammatory drugs (NSAIDs). 2. It is acute and will require short-term treatment. 3. Treatment will include low or moderate regular doses of oral opioids. 4. Treatment will include the use of adjuvant analgesics.

4) CORRECT - Neuropathic pain is not well controlled by opioid analgesics alone and often requires the addition of tricyclic antidepressants or anti-seizure drugs to help prevent pain transmission.

The nurse prepares for the admission of a child diagnosed with rubeola. Which isolation precaution does the nurse plan for the child? 1. Enteric. 2. Contact. 3. Protective. 4. Respiratory.

4) CORRECT - Rubeola is transmitted by airborne particles or direct contact with infectious droplets, so respiratory isolation is required. 1) Enteric isolation is not indicated based on the method of transmission of the rubeola infection. 2) Contact isolation is not indicated based on the method of transmission of the rubeola infection. 3) Protective isolation is not appropriate for this disease process. This is appropriate for a client with neutropenia.

The nurse provides care for a client who is confused and reports a headache. The client's vital signs are as follows: temperature 101.0°F (38.3°C), BP 150/64 mm Hg, pulse 58 beats/min, and irregular respirations of 12 breaths/min. Which action does the nurse take next? 1. Lower the head of the bed to a flat position. 2. Prepare for a lumbar puncture (LP). 3. Administer morphine 4 mg intravenously. 4. Prepare for a head computerized tomography (CT) scan.

4) CORRECT - The client is demonstrating signs of increased intracranial pressure (ICP) and Cushing triad. A head CT scan is indicated. 1) The head of the bed should be maintained at a 15 to 30 degree angle to promote jugular venous drainage. 2) An LP will confirm meningitis; however, it is contraindicated if increased intracranial pressure (ICP) is present. 3) Morphine alleviates pain but may mask neurological symptoms.

The nurse teaches a group of nursing students about managed care. Which information will the nurse include in the teaching session? 1. Provides full coverage of health care costs. 2. Allows providers to focus on illness care. 3. Assumes the financial risk involved. 4. Encourages providers to focus on prevention.

4) CORRECT - The focus of health care shifts from illness to health and wellness. 1) The health care provider or the health care system receives a predetermined capitated (fixed amount) payment for each patient enrolled in the program. 2) The focus of care shifts from individual illness care to prevention, early intervention, and outpatient care 3) The managed care organization (provider) assumes financial risk, in addition to providing patient care.

The nurse conducts a staff development workshop about organ donations. Which statement by a staff member indicates a correct understanding of the Uniform Anatomical Gift Act? 1. "A client needs to complete an advance directive and identify a health care proxy to become an organ donor." 2. "The health care provider is the person who requests organ donation from a client's family members." 3. "The health care provider who signs the client's death certificate must supervise the removal of the client's donated organs." 4. "Family members can consent to organ donation after the client's death, even if the client had not expressed a desire to have organs donated."

4) CORRECT — Family members can consent to organ donation after the client's death, even if the clients had not expressed a desire to have organs donated.

The nurse develops a teaching plan for a client diagnosed with heart failure. Which information does the nurse include? 1. Tell the client to notify the health care provider of a weight gain of 1 pound a week. 2. Teach the client to monitor urine output for changes in color. 3. Encourage the client to check blood pressure every 4 hours. 4. Advise the client to have flu and pneumococcal immunizations.

4) CORRECT — Flu and pneumonia create a greater hemodynamic burden and lead to higher mortality. The Centers for Disease Control and Prevention (CDC) recommends flu and pneumonia immunizations for clients with heart failure and all chronic diseases. 1) A weight gain of a pound a week is not clinically significant. A weight gain of 2 or more pounds per day is reportable. 2) Changes in urine color are not a reliable indicator of relevant clinical changes. 3) Self-monitoring of blood pressure every 4 hours is not evidence-based practice.

The nurse assesses a client recovering from an acute myocardial infarction (MI). Which assessment finding indicates to the nurse that the client is developing cardiogenic shock? 1. Temperature 97.4ºF (36.3ºC). 2. Heart rate 58 beats/min. 3. Respiratory rate 10 breaths/min. 4. Blood pressure 100/88 mm Hg.

4) CORRECT — Hypotension with a narrow pulse pressure is a clinical manifestation associated with cardiogenic shock.

The nurse provides care for a client who had epidural morphine following a cesarean birth. Which intervention does the nurse include in the client's plan of care for the first 24 hours after the delivery? 1. Keep the client flat in bed. 2. Monitor the client for tachycardia. 3. Determine patellar reflexes. 4. Encourage increased fluid intake.

4) CORRECT — The client can prevent constipation by increasing fluid intake, and fiber intake also should be increased when possible. 1) Keeping the client flat is not related to morphine. 2) Monitoring for tachycardia is not related to morphine. 3) Patellar reflexes are not related to morphine.

The husband of an older woman diagnosed with pernicious anemia calls the clinic to report that his wife still has memory loss and some confusion since she received the first does of nasal cyanocobalamin two days ago. he tells the nurse that he is worried that she may be getting alzheimer's disease. What action should the nurse take? A. explain that memory loss and confusion are common with vitamin B12 deficiency. b. ask if the client is experiencing any change in bowel habits c. determine if the client is taking iron and folic acid supplements. D. encourage the husband to bring the client to the clinic for a complete blood count.

A. explain that memory loss and confusion are common with vitamin B12 deficiency. pernicious anemia is related to the absence of the intrinsic factor in gastric secretions, leading to malabsorption of vitamin B12, and commonly causes memory loss, confusion, cognitive problems, and GI manifestations, The nurse should reassure the husband that the cleint's signs are consistent with the primary disease. Although b, c, and d provide additional information about the client's compliance and response to therapy, a quick and dramatic response can occur after 72 hours of b12 injections.

The nurse observes that a client's peripheral intravenous (IV) dressing has loosened. Which action does the nurse take next? 1. Immediately change the IV dressing. 2. Tape the IV dressing to secure it in place. 3. Replace the IV catheter at another site. 4. Apply a skin adhesive where the IV dressing loosened.

The correct answer is 1 . 1) CORRECT - The nurse should immediately change the dressing if it becomes loosened, dampened, or soiled to reduce the risk for an intravascular catheter-associated bloodstream infection. 2) Taping the dressing in place increases the risk for intravascular catheter-associated bloodstream infection. Instead, the nurse should immediately change the dressing. 3) It is not necessary to replace the catheter; instead, the nurse should change the dressing. 4) Applying a skin adhesive without first replacing the dressing increases the risk for intravascular-associated infection.

While administering an intravenous push medication to a client, the nurse notes that the color of the medication changed in the tubing. Which type of response will the nurse identify occurred with this medication? 1. Incompatibility. 2. Additive effect. 3. Synergistic effect. 4. Allergic reaction.

The correct answer is 1 . 1) CORRECT - The change in color when the medication is administered indicates incompatibility. This is chemical response that occurs when medications or solutions that should not be mixed are given together. 2) Additive effect occurs when two medications with similar actions are given together. 3) A synergistic effect is when the combination of two medications causes a response that is greater than when the medications are given separately. 4) Hypersensitivity to a medication causes an allergic reaction.

The nurse provides care for a client who is newly diagnosed with active tuberculosis and has just been isolated in a negative airflow pressure room. The client is coughing up a large amount of thick, rust-colored sputum and is short of breath. The client states, "I have been exhausted for weeks! I don't understand why I am not getting better. All these medicines are not working." Which nursing diagnoses are appropriate for the nurse to include in the plan of care? (Select all that apply.) 1. Ineffective health management. 2. Risk for infection (spread/reactivation). 3. Impaired gas exchange. 4. Ineffective airway clearance. 5. Imbalanced nutrition: more than body requirements.

The correct answer is 1, 2, 3, 4 . 1) CORRECT- The active tuberculosis is newly diagnosed. This nursing diagnosis is related to insufficient knowledge about the disease process and the therapeutic regimen. 2) CORRECT- This nursing diagnosis is related to inadequate primary defenses and an immunocompromised state, as evidenced by active tuberculosis. 3) CORRECT- This nursing diagnosis is related to a ventilation-perfusion imbalance, as evidenced by shortness of breath and fatigue. 4) CORRECT- This nursing diagnosis is related to a productive cough and excess, thick mucous. 5) Imbalanced nutrition is appropriate, but it would be 'less than body requirements,' as clients are exhausted and very ill during the active phase of tuberculosis.

The nurse notes that a client has 3+ pitting edema of both feet and ankles. Which additional assessment does the nurse make before contacting the health care provider (HCP)? (Select all that apply.) 1. Pulse. 2. Weight. 3. Lung sounds. 4. Temperature. 5. Blood pressure.

The correct answer is 1, 2, 3, 5 . 1) CORRECT - Pitting edema indicates fluid overload. An increase in body fluid can cause a full, rapid, and bounding pulse. 2) CORRECT - Body weight is the most reliable indicator of fluid balance. Since pitting edema is present, body weight should be measured and compared with previous weights. 3) CORRECT - Excess body fluid can back up in the peripheral vasculature and cause fluid to pool in the lungs. Lung sounds should be assessed. 4) Body temperature is not affected by fluid volume. 5) CORRECT - Excess body fluid affects heart function, causing an increase in blood pressure. The blood pressure should be assessed.

The nurse prepares a handout for clients about primary prevention strategies to reduce the incidence of urinary tract infections. Which information does the nurse include? (Select all that apply.) 1. Empty the bladder completely. 2. Void at least every 2 to 3 hours during the day. 3. Unless contraindicated, drink 6 to 8 liters of fluid per day. 4. Shower rather than bathe in the tub. 5. After voiding or having a bowel movement, the client should wipe from front to back.

The correct answer is 1, 2, 4, 5 . 1) CORRECT — Residual urine left in the bladder increases the potential for bacterial growth. 2) CORRECT — Frequent emptying of the bladder decreases the potential for bacterial growth. 3) An intake of 2 to 3 liters per day is adequate. 4) CORRECT - Bacteria in the bath water can enter the urethra during the bath. 5) CORRECT — Cleansing front to back decreases the bacteria near the urethra and does not drag bacteria from the rectum forward.

The nurse develops a brochure on informed consent. Which information is appropriate for the nurse to include in the brochure? (Select all that apply.) 1. An informed consent should not be obtained until the client has discussed the exact details of the surgery or procedure. 2. Witnessing an informed consent means that the nurse verifies that the client is mentally competent. 3. The nurse needs to explain the benefits and risks of the procedures that require an informed consent. 4. Even if a client has signed a general admission consent, an informed consent is required for the client to have a chest X-ray. 5. Acting as a client advocate, the nurse is responsible for ensuring that the client has received adequate information regarding the proposed procedure.

The correct answer is 1, 2, 5 . 1) CORRECT — Informed consent is permission granted by a client after discussing the exact details of the treatment with the health care provider who will perform the surgery or procedure. 2) CORRECT — By witnessing a client's signing of an informed consent, the nurse verifies that the client is mentally competent and that the signature is that of the client. 5) CORRECT — The nurse, as a client advocate, is responsible for ensuring that the client has received adequate information regarding the proposed procedure. 3) It is not the nurse's responsibility to explain the benefits and risk of the procedures that require an informed consent. The health care provider needs to do that. 4) General consent forms giving permission for treatment in a hospital are signed by a client before being admitted. An informed consent would not be required for a chest X-ray.

Which statement is appropriate for the professional development educator to include in a discussion of medical asepsis with a group of new clinical employees? (Select all that apply.) 1. "It is necessary to keep the door closed when caring for a client on airborne precautions." 2. "I need to wear gloves when taking the blood pressure of a client on contact precautions." 3. "I should put on a mask when taking the temperature of a client on contact precautions." 4. "It is necessary to use disposable dishes and utensils for a client on droplet precautions." 5. "A surgical mask is required when working within 3 feet of client on droplet precautions."

The correct answer is 1, 2, 5 . 1) CORRECT — This is an appropriate statement for the professional development educator to include when teaching new clinical staff in regard to medical asepsis. It is necessary to keep the door closed when caring for a client on airborne precautions. 2) CORRECT — This is an appropriate statement for the professional development educator to include when teaching new clinical staff in regard to medical asepsis. Gloves are required when taking the blood pressure of a client on contact precautions. 3) A mask is not needed when taking the temperature of a client on contact precautions. 4) Disposable dishes and utensils are not needed for a client on droplet precautions. 5) CORRECT — This is an appropriate statement for the professional development educator to include when teaching new clinical staff in regard to medical asepsis. A surgical mask is required when working within 3 feet of client on droplet precautions.

The nurse prepares to teach a group of student nurses about protecting client health information. Which measure does the nurse include in the teaching plan? (Select all that apply.) 1. Position computer screens away from public view. 2. Conversations regarding clients are permitted on the unit. 3. The client's name cannot be visible to the public. 4. Facsimile machines are not used to transmit client data. 5. Whiteboards cannot be used on the nursing unit.

The correct answer is 1, 3 . 1) CORRECT — Computer screens must be positioned away from public view to prevent the public from viewing protected health information. 2) Conversations regarding client information must take place in private places where they cannot be overheard. 3) CORRECT — The names of clients on medical records, clipboards, and other devices cannot be visible to the public. 4) Facsimile machines can be used to transmit client information; however, a cover sheet and statement indicating that the faxed data contains confidential information must accompany the transmitted information. 5) Whiteboards can be used but they must be free of information that links a client with a diagnosis, procedure, or treatment.

The health care provider prescribes a unit of packed red blood cells for a client admitted with lower gastrointestinal bleeding. Which step will the nurse take when administering the blood product? (Select all that apply.) 1. Ensure adequate infusion access is present before obtaining the blood from the blood bank. 2. Initiate the transfusion within 1 hour of removing the blood from the blood bank refrigerator. 3. Use a two-person verification process to match the unit of blood to the prescription and the client to the unit of blood. 4. Monitor the client closely during the first 15 to 30 minutes of administration. 5. Ensure the administration time does not exceed 6 hours.

The correct answer is 1, 3, 4 . 1) CORRECT - An adequate intravenous catheter should be inserted prior to obtaining the blood from the blood bank. 2) The infusion should be started within 30 minutes of removing the blood from the blood bank refrigerator. 3) CORRECT - Two-person verification in the presence of the client is done to make sure that the blood product matches the health care provider 's prescription and the blood product is properly identified to the client to prevent a blood incompatibility error. 4) CORRECT - The client should be closely monitored for the first 15 to 30 minutes of the transfusion. Most transfusion reactions occur within this time. 5) The blood administration time should not exceed 3 to 4 hours to reduce the risk for bacterial growth.

The nurse plans to teach a local community group about chronic obstructive pulmonary disease (COPD). Which information does the nurse include? (Select all that apply.) 1. Uncontrolled COPD can lead to cardiac disease. 2. Asthma in childhood leads to COPD later in life. 3. Cigarette smoking is the leading COPD risk factor. 4. More females are affected by COPD than males. 5. Co-existing illness may cause COPD exacerbation.

The correct answer is 1, 3, 5 . 1) CORRECT — Right-sided heart failure results from uncontrolled COPD. 2) There is no evidence that childhood asthma leads to COPD in adults. 3) CORRECT — Cigarette smoking is a major risk factor for COPD. 4) More males than females are affected by COPD. 5) CORRECT — Heart failure, gastroesophageal reflux disease (GERD), and pneumonia may lead to COPD exacerbation.

The health care provider prescribes erythromycin eye ointment for a full-term newborn. Which nursing action is appropriate when administering this medication? (Select all that apply.) 1. Wear disposable gloves while administering the medication. 2. Hold the ointment tube in a vertical position to prevent injury. 3. Apply ointment from the outer canthus to the inner canthus. 4. Apply ointment to the lower conjunctival sac of each eye. 5. Rinse each eye with sterile saline after administering the ointment.

The correct answer is 1, 4 . 1) CORRECT - Gloves should be worn when providing newborn care. 4) CORRECT - The ointment should be applied to the lower conjunctival sac. 2) The ointment tube should be held horizontally to prevent eye injury. 3) The ointment should be applied from the inner canthus to the outer canthus. 5) Rinsing the eyes would remove the medication.

A wound located on the foot of a client with type 2 diabetes mellitus (DM) is healing. The nurse teaches the client about the prevention of future foot wounds. Which client statement indicates the teaching is effective? (Select all that apply.) 1. "I should not cross my legs." 2. "I should wear shoes only when I go outside." 3. "I should apply lotion between my toes after a shower." 4. "I should inspect the inside of my shoes before I put them on." 5. "I should use a mirror to examine the bottom of my feet every day."

The correct answer is 1, 4, 5 1) CORRECT- Any activity, such as crossing, the legs reduces blood flow to feet and should be avoided. 2) The client is to wear shoes or slippers at all times when walking indoors or outside to protect the feet from injury by objects on the floor or ground. 3) The client must dry thoroughly between toes after shower, and lotion may retain moisture. 4) CORRECT- The client may have peripheral neuropathy and not be able to feel pebbles or other item inside shoes. 5) CORRECT- The client may lack flexibility to examine the bottom of feet, and using a mirror can visualize the soles of the feet.

The nurse prepares teaching for a client prescribed alendronate sodium. Which information will the nurse include in this teaching? (Select all that apply.) 1. "Take this medication with at least 8 ounces of water." 2. "Take this medication while ingesting the first bite of food in the morning." 3. "Wait 30 minutes after eating before taking this medication." 4. "Sit upright for at least 30 minutes after taking the medication." 5. "Take this medication 30 minutes before food or other medications."

The correct answer is 1, 4, 5 . 1) CORRECT - Bisphosphonate alendronate sodium is given as treatment for osteoporosis. The medication should be taken with at least 8 ounces of water. 2) Alendronate sodium is to be taken on an empty stomach. 3) Alendronate sodium is to be taken before any food is eaten. The best time to take this medication is upon awaking in the morning and 30 minutes before eating breakfast. 4) CORRECT - Alendronate sodium can cause esophageal irritation and erosion. Because of this, the client should be instructed to sit upright for at least 30 minutes after taking. 5) CORRECT - Alendronate sodium is to be taken on an empty stomach. Once taken, the client should wait 30 minutes before eating so as not to interrupt the absorption of the medication from the gastrointestinal tract

The nurse provides care for a client diagnosed with a duodenal ulcer. The client asks how a stomach infection can cause a duodenal ulcer. Which response by the nurse is best? 1. "Bacteria in the duodenum deteriorate the area, causing an ulceration." 2. "The bacteria enters the lining of the intestines and changes the protective layer." 3. "There is no explanation for how this occurs in a vast majority of people." 4. "Medication for the stomach infection causes the duodenal lining to break down."

The correct answer is 2 . 2) CORRECT- With Helicobacter pylori (H. pylori), the bacteria penetrate the intestinal mucosa, altering the function and consistency leading to ulcerations. 1) A duodenal ulcer is not caused by bacteria that is found in the duodenum. It is caused by gastric bacteria. 3) An H. pylori infection causes different manifestations, such as chronic atrophic gastritis, stomach cancer, acute gastritis, or duodenal ulcers. 4) Antibiotic therapy to treat H. pylori does not cause duodenal ulcer development.

The nurse provides care for a post-operative client. Which conditions does early ambulation after surgery help prevent? (Select all that apply.) 1. Dehiscence. 2. Thromboembolism. 3. Atelectasis. 4. Paralytic ileus. 5. Pressure decubiti.

The correct answer is 2, 3, 4, 5 1) There is no evidence that ambulation reduces the risk of wound separation. 2) CORRECT - Ambulation reduces the risk of thromboembolism by increasing venous blood flow. 3) CORRECT - Ambulation reduces the risk of atelectasis by increasing the mobilization and expectoration of mucus. 4) CORRECT - Ambulation reduces the risk of paralytic ileus and promotes peristalsis. 5) CORRECT - Ambulation reduces the risk of pressure decubiti by reducing the time in bed and relieving pressure on bony prominences.

The nurse finds a client lying on the floor. The client is unresponsive with agonal, gasping respirations and no palpable pulse. Which action is appropriate for the nurse to take? (Select all that apply.) 1. Administer synchronized cardioversion. 2. Begin cycles of 30 chest compressions and two breaths. 3. Call for nearby help. 4. Check the client's heart rhythm. 5. Activate the emergency response system using a mobile device.

The correct answer is 2, 3, 4, 5 . According to the American Heart Association guidelines, the nurse should call for nearby help, activate the emergency response system using a mobile device, send someone for a defibrillator or automated external defibrillator, and begin cycles of 30 chest compressions and two breaths. 1) Synchronized cardioversion is indicated for *ventricular tachycardia with a pulse.* The client does not have a pulse. Therefore, defibrillation is indicated if the client has a shockable rhythm.

The nurse provides care for a client with a morphine addiction. Which symptom of withdrawal does the nurse expect to assess in the client? (Select all that apply.) 1. Constipation. 2. Diarrhea. 3. Hypertension. 4. Hypotension. 5. Emesis.

The correct answer is 2, 3, 5 . 2) CORRECT - Diarrhea is due to a rebound excitability of the bowels that have been depressed during morphine use. 3) CORRECT - Hypertension is a rebound effect of the hypotension that occurred while using morphine. 5) CORRECT - Vomiting, or emesis, occurs due to the rebound effects on the gastrointestinal tract that include changes in stomach tone and increased peristalsis. 1) Constipation occurs during morphine use because opioids decrease intestinal peristalsis and increase the tone of the anal sphincter. 4) Hypotension is a side effect of morphine use because opioids cause peripheral blood vessel dilation.

The nurse prepares to document care given to clients. Which areas will the nurse include in complete and accurate documentation? (Select all that apply.) 1. Subjective nursing observations. 2. Client symptoms and response to treatments. 3. Nursing care given. 4. Explanation of a medication error. 5. Medications and treatments.

The correct answer is 2, 3, 5 . 1) Only objective nursing observations belong in documentation. 2) CORRECT — Objective assessment of client's symptoms and response to treatment should be documented. 3) CORRECT — An objective description of nursing care and a client's response are appropriate to document. 4) An explanation of any incident does not belong in a client record, but in an incident report. 5) CORRECT — The nurse would document medications and treatments given following appropriate and clear medical orders.

The nurse teaches a group of clients about skin cancer prevention. Which statement does the nurse include in the teaching? (Select all that apply.) 1. Avoid sun exposure between 1600 and 1800. 2. Wear opaque clothing and a hat when outside. 3. Have genetic testing to assess skin cancer risk. 4. Keep a "body map" of skin spots for a baseline. 5. Restrict shaving of arms and lower extremities.

The correct answer is 2, 4 . 2) CORRECT - Opaque clothing protects the skin from direct sun exposure. 4) CORRECT - Being aware of skin markings and spots allows the client to note changes. 1) Sun exposure should be avoided between 1100 and 1500. 3) There is no genetic testing available for skin cancer. 5) Not shaving the arms and legs has no skin cancer protective effect.

The nurse performs cardiac compressions on a pulseless client. Which action by the nurse maintains high-quality cardiopulmonary resuscitation? (Select all that apply.) 1. Give compressions at a rate of 80 per minute. 2. Push compressions to 2 inches of depth. 3. Rotate the rescuers every 5 minutes. 4. Maintain a ventilation-compression ratio of 15:2. 5. Allow for complete chest recoil between compressions.

The correct answer is 2, 5 . 1) Compressions are performed at a rate of at least 100 per minute. 2) CORRECT — A depth of at least 2 inches per compression is necessary to compress the heart within the chest cavity. 3) Rescuers change roles every 2 minutes. 4) The proper ventilation-compression ratio is 30:2. 5) CORRECT — Complete chest recoil is essential at the end of each compression to allow the heart to refill.

The nurse provides care for a client recovering from an above the knee amputation. Which is the best intervention for the nurse to include in this client's plan of care? 1. Remind the client to rest the residual limb on a soft surface. 2. Elevate the residual limb on a pillow 2 hours every day. 3. Assist the client into the prone position for 30 minutes, three or four times a day. 4. Encourage the client to sit out of bed in a chair for 2 hours several times a day.

The correct answer is 3 . 1) The residual limb should be on a soft surface at first, but surfaces should gradually become more firm to prepare the limb for a prosthesis. 2) Elevating the limb on a pillow for 2 hours encourages the development of hip contractures. 3) CORRECT — Lying prone for 30 minutes, three or four times a day, prevents the development of hip contractures. 4) Sitting in a chair for greater than an hour encourages the development of hip contractures.

The nurse observes the umbilical cord protruding from the vagina of a client in labor. Which action does the nurse take next? 1. Place client in high Fowler's position. 2. Attempt to reinsert cord into cervix. 3. Contact the health care provider. 4. Administer oxygen via nasal cannula.

The correct answer is 3 . 1) The client should be placed in extreme Trendelenburg, modified Sims' position, or a knee-chest position. The goal is to shift the fetal presenting part toward the mother's diaphragm. 2) The nurse should not attempt to replace the cord into the cervix. Doing so could traumatize and further reduce blood flow through the cord. The nurse should wrap the cord loosely in a sterile towel saturated with warm sterile normal saline solution to prevent drying of the cord. 3) CORRECT - This situation is a medical emergency. The nurse needs to contact the health care provider and prepare for immediate vaginal birth if the cervix is fully dilated or cesarean birth if it is not. 4) The nurse should administer oxygen via nonrebreather mask at 8 to 10 L/min to increase oxygen availability to the fetus. Priority is to prepare for immediate delivery of the fetus.

The nurse provides care to a client whose insurance coverage is Medicare. Which understanding will the nurse have about Medicare before planning care for this client? 1. The hospital will be paid for the full cost of the client's hospitalization. 2. Medicare will pay the hospital the national average cost for the client's condition. 3. Diagnosis-related groups provide a fixed reimbursement of cost. 4. Capitation provides the hospital with a means of recovering variable charges.

The correct answer is 3 . 3) CORRECT - Medicare uses a fixed reimbursement amount based on assigned diagnosis-related group, regardless of a patient's length of stay or use of services. Diagnosis-related group reimbursement is based on case severity, rural/ urban/ regional costs, and teaching costs, not national averages. 1) The hospital is paid based on a diagnosis-related group system, so a specific amount is paid based on the case severity and the rural/urban/regional standard rates. 2) The reimbursement is based on case severity, rural/urban/regional costs, and teaching costs, not national averages. 4) Capitation means that providers receive a fixed amount per patient or enrollee in a health care plan.

The nurse provides care for an older adult client in the clinic. The client reports perineal irritation due to frequent incontinence. Which strategy is most appropriate for the nurse to recommend to the client? (Select all that apply.) 1. Wear extra-large incontinence underwear to allow air movement. 2. Expose the perineum to air for several minutes of each day. 3. Apply a barrier cream three or four times per day. 4. Apply bacitracin cream to the perineum. 5. Gently clean the perineum two or three times per day and pat dry.

The correct answer is 3, 5 3) CORRECT — Keeping the skin clean and protected is most important. 5) CORRECT — Keeping the skin clean and protected is most important. 1) These may not fit and can cause further irritation or rubbing. 2) This does not keep the skin clean or protected. 4) There is no infection that warrants this. A barrier cream is more appropriate.

The nurse provides care for a client experiencing a sickle cell crisis. Which nursing diagnosis is the priority for the nurse to include in the plan of care? 1. Risk for infection. 2. Risk for ineffective cerebral tissue perfusion. 3. Activity intolerance. 4. Ineffective peripheral tissue perfusion.

The correct answer is 4 . 1) A client is at risk for infection but it is not highest priority. 2) Risk for ineffective cerebral tissue perfusion is a concern but not the highest priority. 3) Activity intolerance related to fatigue is a problem but not as high of a priority as ineffective peripheral tissue perfusion. 4) CORRECT - Due to infarction, ineffective peripheral tissue perfusion is the highest priority for a client with a sickle cell crisis.