NUR280
The nurse is caring for a client who has bumetanide (Bumex) prescribed. The nurse should suggest that the client include which of the following foods in the diet? (a) Apricots (b) Organ meats (c) Sardines (d) Fish
A. Bumex is a potassium depleting diuretic. Apricots are a source of potassium; organ meats, sardines and are not a source of potassium; apples contain a low quantity of potassium. Physiological Integrity; Pharmacological and Parenteral Therapies
The nurse is reviewing medical prescriptions for newly admitted clients. It would be a priority for the nurse to follow up with the physician if a client with (a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene) prescribed (b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions (c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen) (d) sensitivity to Penicillin is prescribed Zithromax (azithromycin)
1. A. The normal potassium level is 3.5 - 5.0 mEq/L. Giving Kayexalate in this situation may cause the client to lose potassium, causing hypokalemia, therefore the drug is not indicated; the therapeutic level for Dilantin is 10 - 20 mcg/ml, a level of 8 is sub therapeutic thereby increasing the risk of seizure activity. Acetaminophen can be safely prescribed to clients with ASA sensitivity. Azithromycin (Zithromax) can be safely prescribed for clients with sensitivity to Penicillin.
The nurse from the pediatric unit has been temporarily assigned to the Emergency Department. It would be most appropriate to assign that nurse to the client who (a) reports epigastric pain that "feels like indigestion" (b) has back pain and a pulsating abdominal mass (c) is HIV+ reporting vomiting and diarrhea (d) presents with lower abdominal pain and is six weeks pregnant
11. C. Vomiting and diarrhea can be managed on a non-emergent basis; clients reporting "indigestion" may be experiencing a cardiac event; clinical manifestations suggestive of abdominal aortic aneurysm include abdominal mass and abdominal throbbing; the client who is 6 weeks pregnant experiencing abdominal pain must be evaluated to rule out ectopic pregnancy which could be life threatening. Safe Effective Care environment; Management of Care
The nurse should intervene if the nurse notes a staff member (a) obtaining a clients consent prior to their operative procedure after receiving Ativan (lorazepam) (b) placing a client on the affected side following surgical repair of a retinal detachment (c) handling a wet cast with the palms of the hands (d) using a broad base of support while transferring a client
2. A. Informed consent, explanation and decision making must occur before sedation is given; therapeutic interventions for retinal detachment include bedrest with the area of detachment in a dependent position to promote healing; the cast should be handled with the palms of the hands while wet to prevent denting; a broad base of support is used during transfers to prevent muscle injury.
The nurse is caring for a client who has been prescribed 1,000 ml of Ringer's Lactate to infuse over 8 hours. The available intravenous set delivers 10 drops per milliliter. How many drops per minute should the nurse set the intravenous controller to administer?
21 ml. Volume (1000ml) X Drip factor (10gtts/ml) Time in minutes (8hours x 60 minutes) Physiological Integrity; Pharmacological and Parenteral Therapies
The community health nurse is caring for the following clients. It would be a priority for the nurse to initiate a multidisciplinary conference for the client who is (a) 12 years old with Autism who is starting a new school and recently had a URI (upper respiratory tract infection) (b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent Hemoglobin A1c of 13% (c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and employed as a mail carrier (d) 70 years old, has schizophrenia, lives alone and reports hearing non threatening voices.
3. B. An adolescent with uncontrolled Diabetes Mellitus would require the greatest number of disciplines (multidisciplinary) to manage their care i.e. Medicine, Nursing, Social Work, Nutritionist; the other choices do not require as many providers of care to meet their needs.
The primary health care provider has prescribed an oral solution of Potassium Chloride (KCL) 20 mEq, PO, QD. The drug available is Potassium Chloride 10 mEq/15ml. How many ml should the nurse administer?
30 ml. Desired amount (20mEq) X Quantity (15ml) Amount on hand (10 mEq) Physiological Integrity; Pharmacological and Parenteral Therapies
The nurse from the postpartum unit has been temporarily assigned to the medical surgical unit. It would be most appropriate to assign this nurse to the client who (a) has returned from right total hip replacement surgery four hours ago (b) is being observed for increased intracranial pressure (c) had surgery two hours ago to remove the appendix (d) is two weeks post partum being maintained on a mechanical ventilator for respiratory failure
4. C. The management of a client following abdominal surgery is standard. The postpartum nurse routinely cares for mothers following caesarean section; therefore it is appropriate to assign this client; The other choices are not appropriate to assign to this nurse.
The nurse in a well baby clinic has assessed several children today. It would be a priority for the nurse to suggest follow up for the child who is (a) 2 months old with a positive babinski reflex (b) 5 months old and does not hold their own bottle (c) 10 months old who cries around strangers (d) 18 months old who needs support while ambulating
5. D. A child experiencing normal growth and development should be ambulating independently by 12 months; the Babinski reflex disappears after 2 years of age; an infant typically holds their own bottle by 6 months; stranger anxiety usually develops at approximately 7 months
The nurse is caring for a mechanically ventilated client who was declared brain dead. An Advance Directive is not documented on the medical record. It would be most appropriate to obtain consent for organ donation from the (a) client's primary care provider (b) client's nurse manager (c) closest living family member (d) hospital's ethics committee
6. C. Consent for organ donation is given by a client's next of kin in the absence of an Advance Directive
The nurse has received report on four clients. The nurse should first assess the client who has: (a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90% (b) Parkinson's Disease and is demanding to leave the hospital against medical advice (AMA) (c) been admitted with suspected Guillian Barre Syndrome and has begun plasmapheresis therapy (d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+)
7. C. The client admitted with Guillain-Barre' Syndrome should be assessed first because of the possibility of rapid progression of this illness and neuromuscular respiratory failure; clients with COPD are likely to have pulse oximetry readings of 90% related to chronic hypoxia; this client along with the other two choices are important, but not the priority.
The nurse should intervene if a staff member is observed: (a) discussing a client's diagnosis with visiting family members (b) collaborating with another nurse to review a prescription for blood transfusion (c) interrupting other staff members discussing a client in the cafeteria (d) reviewing a clients lab values with the nutritionist
9. A. To maintain confidentiality the nurse should not discuss the client's diagnosis with family members; it is advisable that two nurses review the prescription for blood transfusion to identify the client, blood type, Rh factor, expiration date and the blood numbers; interrupting staff members discussing a client in a public place should be done to maintain client confidentiality; collaborating with the nutritionist is an appropriate nursing intervention. Safe Effective Care Environment; Management of Care
The nurse is caring for a client who is ventilator dependent. The nurse is aware that the high pressure alarm can be sounded for various reasons. Select all reasons that could apply. (a) _____increased bronchial secretions (b) _____the presence of an air leak (c) _____the presence of a kink in the tubing (d) _____the client stops breathing spontaneously (e) _____acute bronchospasm (f) _____the client is biting the tube (g) _____the ventilator tubing is disconnected
A, C, E, F. The high pressure alarm on the ventilator is triggered with increased pressure in the system (obstruction) as in kink in the tubing, increased bronchial secretions, during acute bronchospasm and biting of the tube by the client; the other choices would cause the low pressure alarm to sound. Physiological Integrity; Reduction of Risk Potential
The primary health care provider has prescribed amitriptyline (Elavil) 150 mg P.O. daily for a client diagnosed with major depression. Choose all of the correct answers for nursing considerations for the administration of Elavil. (a) ______ administer this medication with meals (b)_______ teach the client that the appetite will be diminished (c)_______ administer this medication in the morning (d)_______ monitor the client for hypertension (e)_______ Instruct the client that this medication may cause the development of a dry mouth (f)________ inform the client that this medication may cause photosensitivity
A, E, and F. A- Elavil is given with or immediately after meals to minimize gastric upset; E- Dry mouth is a possible adverse effect when using this drug. Instruct client to increase fluid intake if not contraindicated, or use sugarless gum or candy to diminish dry mouth; F-Photosensitivity is a possible adverse effect. Caution the client to use sunscreen and protective clothing; B, C and D are not correct; Clients taking this drug are likely to experience an increased appetite. Teach to monitor food intake to prevent undesired weight gain; the medication should not be administered in the morning because of the side effects; hypotension is associated with this drug, not hypertension. Physiological Integrity; Reduction of Risk Potential
The primary health care provider has prescribed Heparin 5000 units SC. The drug available is heparin sodium 7500units/ml. Choose all of the correct answers for nursing considerations for the administration of heparin sodium. a)______ administer the heparin in the abdomen b)______ administer 0.5ml of heparin sodium c)______ aspirate after inserting the needle d)______ use a 1 inch 21 gauge needle e)______ refrain from massaging the site after administer heparin (f)______ remember that protamine sulfate is the antidote for heparin
A, E, and F. Heparin is best absorbed from the abdomen; aspiration and massaging the site after injection is contraindicated, a 26 - 27 gauge 5/8 inch to ½ inch needle is used; the antidote for heparin is Protamine Sulfate. The correct dosage to be administered is 0.66ml. Desired amount 5,000 units X Quantity (1ml) Amount on hand 7,500 units Physiological Integrity; Pharmacological and Parenteral Therapies
The nurse is developing a nursing care plan for a client who is the manic phase of bipolar disorder. Which intervention should the nurse include in the plan of care? (a) Provide the client with finger foods (b) Engage the client in competitive games (c) Encourage the client to avoid foods that contain tyramine (d) Place the client on direct suicide observation
A. A client in the manic phase of bipolar disorder may have difficulty meeting nutritional needs because of their inability to sit still; competitive games are avoided because the client is hyperactive, impulsive and distractible. Structured activity is more appropriate; foods containing tyramine are avoided in clients prescribed MAO inhibitors; placing the client on suicide observation may be indicated during the depressed phase. Physiological Integrity; Physiological Adaptation
The nurse is assessing a 5-month-old infant. The nurse should expect the infant to (a) Roll from abdomen to back (b) Sit without support (c) Say 'mama' and 'dada' (d) Prefer use of one hand over the other
A. At 5 months old the typically developing infant should be able to roll from abdomen to back; sitting without support as well as hand dominance is expected at 7-9 months; imitative speech should develop between 10-12 months of age. Health Promotion and Maintenance
The nurse has provided health promotion teaching for a group of clients who were recently diagnosed with the Human immunodeficiency virus (HIV). Which statement, if made by one of the clients, would require further teaching? (a) "I am glad that I can still clean my parakeet's cage" (b) "I will not go to the parade this weekend" (c) "I will increase protein in my diet" (d) "I will miss not being able to work in my garden"
A. Client teaching of HIV infected individuals should include avoidance of bird droppings and soil to prevent the opportunistic infections toxoplasmosis and cryptococcosis; avoiding crowds and increasing protein in the diet are important for the maintenance of health; these clients do not need further teaching. Safe Effective Care Environment; Safety and Infection Control
The nurse is developing a teaching plan for a client with pulmonary tuberculosis who has been prescribed rifampin (Rifadin), isoniazid (INH), pyrazinamide (Tebrazid) and ethambutol (Myambutol). The nurse should include in the teaching plan that (a) the combination of drugs prescribed is necessary to decrease the risk of drug resistance (b) the medications should be taken on an empty stomach (c) the medications can be discontinued in one month (d) the client will require hepatic function tests every month
A. Drugs are prescribed in combinations of two or three anti-tuberculin agents to decrease the risk of drug resistance. Isoniazid (INH) is usually the primary drug; these medications may be given with food to minimize G.I. upset; they are taken for 9-12 months to ensure eradication of the organism; the client should be taught to have blood drawn to monitor hepatic function every 2-4 weeks during therapy due to the risk of hepatotoxicity while taking these drugs. Physiological Integrity; Pharmacological and Parenteral Therapies
The nurse is caring for a 49 year old female client who reports having frequent vaginal yeast infections. The client is 35% over her ideal body weight. The client has had several diagnostic blood tests prescribed. It would be a priority for the nurse to review the results for an elevated (a) fasting blood glucose (b) white blood count (c) hemoglobin (d) blood urea nitrogen
A. Female clients with new onset diabetes mellitus may report recent major or minor infections particularly vaginal yeast infections; elevations in white blood cell count, hemoglobin and blood urea nitrogen are not the priority in this situation. Physiological Integrity; Reduction of Risk Potential
The nurse is caring for a client who has oxalate kidney stones. The nurse should teach the client to avoid (a) Spinach and rhubarb (b) Mushrooms and rice (c) Shell fish and aged cheese (d) Organ meats and wine
A. Foods containing oxalate should be restricted to prevent recurrent renal stones. Examples of these foods are spinach, rhubarb, strawberries, tea, peanuts and wheat bran. Physiological Integrity; Basic Care and Comfort
The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse would be correct to include which of the following examples? (a) Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is false imprisonment (b) Telling a client that you will put in a feeding tube if the client does not eat is an example of battery (c) Telling a client with bipolar disorder who is suicidal that they have a right to refuse to take their medications is an example of malpractice (d) Placing hands on a client who says "do not touch me" is an example of assault
A. Putting a client in a geriatric chair with the lap tray in front of them restricts movement which constitutes false imprisonment; choice B is an example of assault not battery; C is an example of negligence not malpractice and D is an example of battery not assault. Safe Effective Care Environment; Management of Care
The nurse is developing a plan of care for a client diagnosed with fibromyalgia. Which nursing diagnosis should the nurse include? (a) Sleep pattern disturbance (b) Risk for infection (c) Deficient volume deficit (d) Urge urinary incontinence
A. Sleep disturbances is characteristic of fibromyalgia related to severe exhaustion. Other manifestations are pain, muscle stiffness and spasms with sensory changes; risk of infection, fluid volume deficit and urge incontinence is not associated with fibromyalgia. Physiological Integrity; Physiological Adaptation
A nurse is caring for a two-month-old infant being evaluated for congenital hypothyroidism. The nurse should recognize which of the following findings as being consistent with congenital hypothyroidism? (a) The infant sleeps for 6 hours at a time (b) The infant has a high-pitched cry (c) The infant has been having frequent loose stools (d) The infant has 3 + reflexes
A. Statements made by the mother of the infant sleeping for prolonged periods support the diagnosis. Follow up is needed for diagnostic workup to confirm this disorder. Signs of congenital hypothyroidism include lethargy, poor feeding, constipation and bradycardia; high pitched cry is not suggestive of hypothyroidism; frequent loose stools and brisk reflexes may be indicators of hyperthyroidism. Physiological Integrity; Physiological Adaptation
The nurse at a health clinic is screening male clients for testicular cancer. It would be a priority for the nurse to teach testicular self examination to (a) a 17-year-old college football player (b) a 39-year-old who smokes a pack of cigarettes day (c) a 55-year-old with benign prostatic hypertrophy (d) a 69-year-old with a family history of testicular cancer
A. Testicular cancer is most common in males 15-35 years of age. Health Promotion and Maintenence
The infection control nurse is making rounds on a Medical Surgical unit. The infection control nurse should immediately intervene if a nurse is observed (a) wearing a disposable surgical face mask when entering the room of a client with active pulmonary tuberculosis (b) keeping the door to the room closed of a client with disseminate varicella zoster (c) leaving a dedicated stethoscope in the room of a client with respiratory syncytial virus (d) wearing a gown, gloves, and mask while taking the blood pressure of a client with Ebola Virus
A. The N95 particulate respirator mask is required by the nurse entering the room of the client being treated for TB. A surgical mask does not protect against transmission, however during transport out of the room the surgical mask should be placed on the client; varicella zoster requires droplet precautions which include closing the door; RSV (respiratory synctival virus) is spread by direct contact with a contaminated client or contaminated object. Supplies are left in the client's room for their use only; Ebola virus is present in all body fluids, wearing a gown, mask and gloves are necessary to prevent exposure and spread. Safe Effective Care Environment; Safety and Infection Control
The nurse on a pediatric unit has been informed that the following clients are being admitted. The nurse should first plan to assess the client who is (a) 2 years old, has a temperature of 100.8 F and a blood pressure of 68/44 (b) 4 years old with a history of asthma and has a peak expiratory flow rate (PERF) of 81% (c) 5 years old, has a fracture of the tibia and is reporting pain rated 7 on a pain scale of 0 (no pain) to 10 (severe pain) (d) 7 years old with ulcerative colitis and has had 15 bloody tinged stools today
A. The child experiencing fever and hypotension should be seen first, they are at the highest risk in this situation for decompensation; the average blood pressure for a toddler is 92/56; the child with asthma is not acutely ill at this time; pain is expected with a bone fracture, management of pain is important but does not take priority; ulcerative colitis is expected to produce 10 - 20 bloody stools per day, this is not the priority in this situation. Safe Effective Care environment; Management of Care
The nurse at a health promotion fair has taught a group of parents about car seat and seat belt safety. Which of the following statements, if made by the parent, would indicate a correct understanding of the information given? (a) "I will place my newborn infant in a rear facing car seat in the middle of the rear seat." (b) "I will wear a lap seat belt high on my belly since I am 8 months pregnant." (c) "I can use a front-facing car seat once my baby weighs 15 pounds." (d) " I can allow my six-year-old to use a seat belt in the front passenger seat"
A. The newborn should be placed in a rear facing car seat with appropriate restraints until about one year of age and at least 20 pounds; the lap portion of the shoulder belt should be positioned snug around the hips, never the abdomen; all children under the age of 12 should be placed in the rear seat of the vehicle. Safe Effective Care Environment; Safety and Infection Control
The nurse is precepting a newly-hired nurse who is caring for a client receiving a prescribed continuous nasogastric feeding. The nurse should intervene immediately if the newly-hired nurse a. Instills 30cc of saline into the feeding tube while auscultating over the stomach for bowel sounds b. Checks the pH of the 60ml gastric aspirate removed from the feeding tube c. maintains the client with the head of the bed elevated at 45 degrees d. hangs four hours worth of prescribed feeding formula in an open delivery system
A. The nurse verifies nasogastric tube placement by instilling 30cc of air into the feeding tube while auscultating over the stomach for bowel sounds; fluids are not introduced because of the risk of aspiration if the tube is malpositioned. Safe Effective Care Environment; Safety and Infection Control
The nurse is caring for a client being treated for Vancomycin Resistant Enterococcus (VRE). The nurse should place the client on (a) contact precautions (b) droplet precautions (c) protective precautions (d) airborne precautions
A. Vancomycin resistant enterococcus (VRE) is spread by direct contact; disease that are transmitted by droplets (sneezing, coughing) include influenza, pneumonia, streptococcal pharyngitis; protective isolation precautions are used for persons with suppression of the immune system; airborne precautions are instituted for diseases transmitted via the air such as measles (rubeola), tuberculosis (TB), and varicella (chickenpox). Safe Effective Care Environment; Safety and Infection Control
The nurse observes an adult collapse on the street. Indicate the correct sequence for the nurse to follow. (a) phone emergency medical system at 911 (b) verify unresponsiveness (c) check for breathing (d) establish an airway using a head-tilt/chin-lift
B, A, D, C. The American Heart Association recommends this sequence of CPR to provide rescue support and maintain some oxygen and blood flow to the heart and brain. Physiological Integrity; Physiological Adaptation
The nurse is caring for a child with an acyanotic heart defect. Which of the following would be an expected finding. Select all that apply. (a) poor suck reflex (b)tachycardia (c) increased respiratory rate (d) bradycardia (e) fainting spells (f) delayed growth and development
B, C, and F. Children experiencing acyanotic defects may experience tachycardia, tachypnea and delay in growth and development; poor suck reflex, bradycardia, and fainting spells are indicative of cyanotic defects. Physiological Integrity; Physiological Adaptation
The nurse is providing teaching for a client with ulcerative colitis. Select all of the following that the nurse should include in the teaching (a)_____steatorrhea commonly occurs or excessive secretion of fecal lipids is common (b)____ ulcerative colitis occurs most frequently in Jewish males 30-50 years of age (c)_____ a diet in high in residue and low in complex carbohydrates is helpful in controlling symptoms (d)_____ Corticosteroids may be prescribed during an exacerbation (e) _____metronidazole (Flagyl) and ciprofloxacin (Cipro) are antibiotics commonly used during acute exacerbations (f) _____eating small frequent meals and lay down after eating promotes absorption of nutrients
B, D, and E. is true of ulcerative colitis; steatorrhea is common in cystic fibrosis clients; A diet low in residue (not high) is recommended to minimize symptoms; eating small frequent meals and lying down after eating are interventions used to prevent dumping syndrome. Physiological Integrity; Physiological Adaptation
A student nurse is administering magnesium hydroxide/aluminum hydrate (Maalox) prescribed as an antacid to a client. The nursing instructor should intervene if the student plans to administer the antacid (a) two hours after the client has eaten a meal (b) at the same time as a prescribed iron preparation (c) after briskly shaking the bottle of Maalox (d) when assessing the client for the presence of gastric pain
B. Antacids should not be administered at the same time with iron preparations because absorption is inhibited; to enhance the antacid effect Maalox (aluminum hydroxide/magnesium hydroxide) is administered 1-3 hours after meals and at bedtime; shaking the medication and assessing for the presence of gastric pain is applicable. Physiological Integrity; Pharmacological and Parenteral Therapies
The primary health care provider has prescribed ampicillin (Omnipen) 0.5 GM PO Q6H to a 15 month old toddler who weighs 22 pounds. The drug available is ampicillin suspension 250 mg/5 ml. The recommended dosage is 50 mg/kg/day every 6 to 8 hours. The nurse should (a) call the primary health care provider to report that the prescription exceeds the recommended dosage (b) determine if the toddler has previously had a penicillin or a cephalosporin prescribed (c) give the toddler the ampicillin mixed with applesauce (d) wait until the result of the throat culture obtained one hour ago is reported
B. Assessing whether or not the child took these medications in the past will help to determine if an allergic reaction occurred; the recommended pediatric dose for ampicillin (Omnipen) is 50mg/kg/day; mixing the medication with apple sauce will help to make it palatable to the child; it is not necessary to wait for throat culture result, however the nurse should obtain the culture before giving the first dose of antibiotic. Physiological Integrity; Pharmacological and Parenteral Therapies
The nurse in a health clinic is reviewing prescribed medications with several clients. It would be a priority for the nurse to follow up with the client who states (a) "I am taking losartan (Cozaar) to lower my blood pressure." (b) "I crush my verapamil (Calan SR) to make it easier to swallow." (c) "I try to avoid sudden position changes since I am taking hydralazine (Apresoline)." (d)) "I will not use any salt substitutes since I am taking captopril (Capoten."
B. Calan SR is a sustained release medication, it should never be crushed, chewed or broken; Cozaar (Losartan) is prescribed to control hypertension. Clients taking antihypertensives should avoid sudden position changes to prevent orthostatic hypotension; clients taking Captopril (Capoten) need to avoid the use of salt substitutes secondary to the risk of hyperkalemia. Physiological Integrity; Pharmacological and Parenteral Therapies
A nurse is observing a newly-hired nurse provide care for assigned clients. The nurse should follow up if the newly-hired nurse is observed (a) wearing gloves when taking the blood pressure of a client with disseminated varicella zoster (b) cleansing the wound from the outer surface to the inner surface for a client whose wound is infected with a multi-drug resistant organism (c) washing the hands with the fingertips pointed downward before providing care for a client on protective precautions (d) removing the gloves before removing the gown when leaving a room of a client who is on contact precautions
B. Cleansing of the wound from the outer surface to the inner surface is incorrect technique. Wounds should be cleansed in an outward direction to avoid transferring organisms from the surrounding skin into the wound. Choices A, C, and D follow the principles of infection control, follow up is not required. Safe Effective Care Environment; Safety and Infection Control
The nurse has become aware of the following client situations. It would be a priority for the nurse to follow-up if a client who (a)had a total knee replacement 24 hours ago is using continuous passive motion (CPM) exerciser while in a supine position (b) is scheduled for a myelogram in 4 hours and states "I can not drink any liquids until after the procedure is finished." (c) had a total knee replacement 24 hours ago and is sitting in a fowlers position to eat a meal (d) had a pin inserted 4 hours ago for a fractured femur has a small amount of bright red bleeding at the pin site
B. Clients undergoing myelogram should be hydrated for at least 12 hours before the test. This client needs follow up for further teaching. Safe Effective Care Environment ; Management of Care
The nurse in the emergency department is admitting a client who is hallucinating and reports insects crawling on the skin. The client's pulse rate is 124 and the respiratory rate is 10. The nurse notes muscle twitching of the lower extremities. It would be a priority for the nurse to determine if the client has (a) a history of attention deficit disorder (b) recently ingested cocaine (c) taken disulfiram (Antabuse) within the past 24 hours (d) an allergy to anticholinergics
B. Cocaine use is often associated with the presence of hallucinations, tachycardia and respiratory depression. Untreated, this client is likely to die, they are the priority in this situation; attention deficit disorder, use of Antabuse (disulfiram) or anticholinergic drugs do not produce hallucinations. Safe Effective Care Environment; Safety and Infection Control
The nurse is caring for a 72-year-old client who was recently diagnosed with metastatic breast cancer. The client is expressing feelings of depression and is asking the nurse, "Why me"? According to Erikson, which developmental stage is the client experiencing? (a) Industry vs. inferiority (b) Ego integrity vs. despair (c) Generativity vs. stagnation (d) Intimacy vs. isolation
B. Erikson states that the adult over the age of 65 goes through the developmental stage of ego integrity vs. despair. This client is experiencing despair secondary to the diagnosis of breast cancer; the school age child experiences industry vs. inferiority; generativity vs. stagnation is present in the middle aged adult; intimacy vs. isolation is associated with the young adult. Health Promotion and Maintenence
The home health care nurse is assigned to see four clients who all live within three miles of each other. The nurse should first see the client who has (a) gastroesophageal reflux disease (GERD) and is reporting a burning abdominal pain that is relieved by walking (b) cancer of the esophagus who has given away a favorite shirt since the last visit (c) regional enteritis (Crohn's disease) who has an elevated temperature and is vomiting (d) a gastrostomy tube who will begin self-feeding for the first time
B. Giving away one's belongings could be an indication that this client is suicidal and has made a plan to end their life; this client is the priority to ensure safety. One to One observation may be needed. Safe Effective Care environment; Management of Care
The nurse is preparing a class for parents of children diagnosed with sickle cell anemia. The nurse should instruct the parents to have their children avoid (a) exposure to hot water (b) other children with infections* (c) medications containing aspirin (d) contact sports
B. It is important that the child with sickle cell anemia avoid other children with infections because infection could precipitate a sickle cell crisis; fluid intake is increased not limited. Physiological Integrity; Reduction of Risk Potential
The nurse is admitting a 20-year-old client with anorexia nervosa. The nurse should assess the client for (a) Stained enamel of the teeth (b) Lanugo-type hair on body (c) persistent ringing in the ears (d) white patches on the tongue
B. Lanugo type hair on the body is a characteristic of anorexia nervosa; stained enamel of the teeth is associated with bulimia nervosa related to the frequent vomiting; persistent ringing in the ears and white patches on the tongue are not associated with anorexia nervosa. Psychosocial Integrity
The nurse in a community health clinic is talking with the parent of a child with Celiac Disease. Which of the following statements would require follow-up by the nurse for additional teaching? (a) "This weekend we are going to a seafood restaurant" (b) "I can feed my child oatmeal and eggs for breakfast" (c) "My child loves to eat rice and chicken for dinner" (d) "Last night we ate fish with corn for dinner"
B. Oatmeal is contraindicated for children with Celiac disease. These clients should be on a gluten free diet. Foods to be avoided include barley, rye, oats and wheat; the other choices are permissible as a part of the dietary plan. Safe Effective Care Environment; Management of Care
The nurse is admitting a client to the emergency department who is reporting progressive visual impairment and loss of peripheral vision. The nurse should recognize that these symptoms are consistent with the medical diagnosis of (a) macular degeneration (b) closed angle glaucoma (c) senile cataract (d) retinal detachment
B. Reports of loss of peripheral vision, rapid decrease in the visual fields, acute eye pain and halos around the lights are symptoms associated with closed angle glaucoma; clients with macular degeneration experience loss of central vision; senile cataracts is manifested by blurred vision and decreased color perception; pain or redness is not associated with age related cataract formation; retinal detachment produces sudden flashes of light (photopsia) or floating dark spots in the affected eye. Physiological Integrity;Physiological Adaptation
It would be appropriate to assign which of these tasks to the CNA? (a) Feeding a client who is experiencing dysphagia (b) One-on-one client observation for safety (c) Removal of an indwelling catheter (d) Performing a simple dressing change
B. The Certified Nursing Assistant may be assigned to a client that requires one- to-one observation for safety; the other choices require skilled nursing intervention by a LPN (Licensed Practical Nurse) or RN (Registered Nurse).
The nurse working in the labor and delivery room has become aware of the following client situations. The nurse should first assess the client who is (a) in the first phase of labor and the fetal heart rate ranges from 128 to 140 between contractions (b) in the first phase of labor and the fetal heart rate is consistently beating at 132 beats per minute (c) in the third phase of labor and the fetal heart rate has decelerated to its lowest point at the acme of the contraction (d) in the third phase of labor and the contractions are lasting 60-70 seconds
B. The normal fetal heart rate (FHR) is 120-160 beats per minute, however the client who has a consistent FHR of 132 beats per minute should be seen first to assess for fetal distress. There should be a fluctuation of the heart rate 6-25 beats per minute which indicates a well oxygenated and functioning central nervous system; the other choices are not the priority in this situation. Safe Effective Care Environment; Management of Care
The nurse is reviewing a client's arterial blood gas (ABG) results which reveal the following: pH: 7.35; PaO2: 75 mm Hg; PaCO2: 55 mm Hg; HCO3: 30 mEq/L. The nurse should recognize that this result is suggestive of which acid base imbalance? A) compensated metabolic acidosis B) compensated respiratory acidosis C) compensated metabolic alkalosis D) compensated respiratory alkalosis
B. The normal pH is 7.35-7.45; the normal pCO2 is 35-45 mmHg. The normal HCO3 is 22-26 mm Hg. With respiratory acidosis there is an increase of carbon dioxide. Generally the renal and pulmonary systems compensate for each other to return the pH to normal.In this situation, the kidney increased the retention of HCO3 to normalize the pH. When the PH is within normal range and the pCO2 and or HCO3 are not, consider compensation.
The nurse is providing discharge instructions to the parents of an infant who has a cleft lip. The nurse should instruct the parents to (a) place the infant in a prone position after each feeding (b) encourage the parents to provide the infant rest periods during feedings (c) regularly offer the infant a pacifier to enhance the sucking reflex (d) elevate the child's head forty five degrees during feeding
B. The parent should be taught the ESSR (Enlarged nipple, Stimulate Suck by rubbing the nipple on the lower lip, Rest after each swallow to allow infant to complete swallowing) method of feeding to decrease the risk of aspiration; the infant should be fed in an upright position; prone position and pacifiers should not be used. Physiological Integrity; Physiological Adaptation
The nurse has become aware of the following client situations. The nurse should first assess the client who (a) had received a unit of packed red blood cells four hours ago and is requesting a bedpan (b) had an abdominal hysterectomy yesterday and is reporting calf pain (c) has history of multiple sclerosis and is reporting diplopia (d) had a tonsillectomy three hours ago and is reporting a sore throat
B. The presence of calf pain postoperatively is suggestive of the development of DVT (deep vein thrombosis) which is a potentially life threatening post operative complication of clients undergoing gynecologic surgeries. This client should be seen first; the other situations are not the priority in this situation. Safe Effective Care environment; Management of Care
A client with left-sided weakness following a cerebral vascular accident (CVA) is learning to ambulate with a cane. The nurse should teach the client to (a) hold the cane on the left side and move the cane with the right leg (b) hold the cane on the right side and move the cane with the left leg (c) hold the cane on the left side and move the cane with the left leg (d) hold the cane on the right side and move the cane with the right leg
B. The proper technique to be used when teaching a client to ambulate with a cane is to hold the cane in the hand opposite the affected leg. Physiological Integrity; Basic Care and Comfort
The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client (a) scheduled for an EEG is washing the hair (b) is being transported to have a magnetic resonance image (MRI) test and is attached to a pulse oximeter (c) is being taught to hold the breath at intervals during a computerized tomography (CT Scan) (d)) on protective precautions is eating soup brought in by a visitor
B. The pulse oximeter and all other metals objects should be removed before the client enters the room where the MRI is to be performed. Metal containing objects are attracted to the magnetic field and may cause injury. Safe Effective Care Environment; Management of Care
The nurse is caring for a client who has been diagnosed with rheumatoid arthritis. The nurse should anticipate that the client will initially be prescribed (a) Disease-modifying rheumatic agents (DMARDs) (b) Nonselective anti-inflammatory drugs (NSAIDs) (c) Long-term corticosteroids (d) Biologic Response Modifiers
B. The treatment of rheumatoid arthritis is aimed at relieving pain. NSAID's (Non steroidal anti-inflammatory drugs) are customarily the first type of agent used; the other agent's listed are used later in the management process. Physiological Integrity; Pharmacological and Parenteral Therapies
The nurse in a community health setting is assessing the following clients. It would be a priority for the nurse to utilize a multidisciplinary approach for the client who is (a) 12 years old, with chicken pox and cannot attend school (b) 21 years old, pregnant, unemployed and has active pulmonary tuberculosis (c) 32 years old, a grade school teacher and is recovering from a sickle cell crisis (d) 74 years old, with mild Alzheimer's disease and is in an assisted living residence
B. This client's care requires involvement of various members of the health care team (multidisciplinary) i.e. nursing, medicine- OB/GYN, social worker, nutritionist; the other clients do not need as many health care workers for the provision of care. Safe Effective Care Environmen ; Management of Care
The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client (a) Who had a cervical radium implant inserted sixteen hours ago is placed on bed rest (b) who had transsphenoidal hypophysectomy twelve hours ago is drinking fluids through a straw (c) who has received prescribed lithium for the past three days is observed eating a pickle brought in by a family member (d) who had retinal detachment repaired using a gas bubble four hours ago is lying on the operative side postoperatively
B. Transphenoidal hypophysectomy is the surgical removal of the pituitary gland through the sphenoid sinus. Patient teaching includes avoidance of any activity that raises intracranial pressure; bedrest is indicated following radium implants; foods high in sodium are encouraged for clients on Lithium (Eskalith) therapy to prevent hyponatremia which predisposes the client to Lithium toxicity; postoperative positioning following a repaired retinal detachment is on the operative side. Safe Effective Care Environment; Safety and Infection Control
The nurse is teaching a client about crutch walking. Which of the following statements if made by the client indicates a need for further teaching? (a) "My elbows should be flexed 20-30 degrees, while walking." (b) "When I climb stairs I advance my affected leg first, with my crutches." (c) "I do not apply pressure under my arm when I use my crutches." (d) "When I am going to sit in a chair I put both crutches in the hand on my unaffected side."
B. When climbing the stairs the client is taught to step up with the unaffected leg while putting weight on the crutch handles. The elbows should be flexed at a 20-30 degree angle with avoidance of pressure under the arm to prevent damage to the axillae nerve; placing both crutches on the unaffected side is the correct technique when sitting down. Physiological Integrity; Basic Care and Comfort
The staff members of an out patient clinic have successfully assisted the clients to safety during a fire in the waiting area. Which action should the nurse perform next? (a) Close all open doors (b) Call for additional help (c) Attempt to extinguish the fire (d) Assess the clients' vital signs
B. When responding to a fire, there are four sequential priorities that must be followed: Rescue the clients, which was already done in this situation, Alarm (call for additional help), Confine the fire, Extinguish the fire. Safe Effective Care Environment; Safety and Infection Control
The nurse and the nursing assistant are caring for a group of clients. Which of the following client care activities should the nurse assign to the nursing assistant? Select all that apply. (a)_____ reinforcing the dressing of a client who has a decubitus ulcer (b) _____monitoring the vital signs of a client who had a myocardial infarction 12 hours ago and is being transferred from the coronary care unit (c)______administering a prescribed Fleet's enema to a client who will undergo a colonoscopy in two hours (d)______ placing a client who had an above the knee amputation 24 hours ago in a prone position (e)______ assisting a client who had a colon resection 36 hours ago to ambulate (f) ______showing a client who had a vaginal hysterectomy 36 hours ago how to perform perineal care
C, D, and E. All of these tasks are within the job description of a Certified Nursing Assistant and can be safely delegated; A, B, and F would require assessment, nursing intervention and patient education which is the role of the nurse. Safe Effective Care environment; Management of Care
The charge nurse is observing a Licensed Practical Nurse (LPN) performing care for assigned clients. Follow up will be required if the LPN: (a) assesses a client's apical pulse before administering Digoxin (lanoxin) (b) elevates the client's stump on a pillow eight hours after amputation (c) dons a clean glove on the dominant hand before tracheal suctioning (d) positions a client on the operative side following a pneumonectomy
C. A sterile glove, not clean, should be used on the dominant hand during tracheal suctioning to prevent infection; the apical pulse should be assessed for one full minute prior to the administration of Digoxin (Lanoxin); elevation of the stump following amputation is performed for the first 24 hours only to prevent hip or knee flexion contracture; clients should be positioned on the operative side to promote lung expansion of the unaffected lung. Safe Effective Care Environment; Management of Care
The nurse is assessing a 3-year-old during a well-child visit. During the visit the boy says to his mother, "Mommy, I love you. I'm going to marry you". The nurse should (a) suggest to the mother not to encourage these types of statements (b) explain to the child that he will not be able to marry his mother even though he loves her (c) tell the mother that this statement is appropriate for his stage of development (d) recommend that the mother provide more opportunities for her son to play with other 3-year-old boys
C. According to Sigmund Freud, the phallic stage occurs between 3 - 6 years of age. During this stage the child experiences unconscious sexual attraction to the parent of the opposite sex. This is called the Oedipal Complex. The statement is reflective of this stage of development. The other choices are not correct actions. Safe Effective Care environment; Management of Care
The nurse is assessing a 2-month-old-infant at a well baby clinic. The nurse should anticipate the infant should (a) roll from prone to back (b) have no head lag (c) smile socially (d) have no tonic neck reflex
C. An infant at 2 months of age should have developed a social smile; at 4 months head control is gained; the 5 month old loses the tonic neck reflex and is able to turn from prone to back. Health Promotion and Maintenance
The nurse is admitting a client with major depression. It would be a priority for the nurse to (a) determine if the client was voluntarily admitted (b) ask the client if suicide has been contemplated (c) have the client's possessions searched for sharps (d) administer to the client the prescribed antidepressant
C. Asking about suicidal thoughts or plans is a priority when caring for the depressed client. The person may not volunteer this information without being asked. If the client answers yes, further assessment is required and suicide precautions initiated. Psychosocial Integrity
The nurse has attended a staff development conference on on Meniere's Disease. Which of the following statements, if made by the nurse would require follow-up? a) "Meniere's Disease symptoms result from excess endolymphatic fluid in the inner ear." (b) "Clients with Meniere's Disease are encouraged to have a low salt diet." (c) "Assistive listening devices are required for clients with Meniere's Disease." (d) "Stress is suspected to have a role in Meniere's Disease."
C. Assistive listening devices are not routinely required for clients with Meniere's disease. Most clients respond well to treatment with a low sodium diet and medications like Meclizine (Antivert); the other options are true of this condition, follow up is not necessary. Physiological Integrity;Physiological Adaptation
The nurse is caring for a client with disseminated intravascular coagulation (DIC) who is receiving a unit of packed red cells. Thirty minutes after the start of the transfusion, the client reports chills and flank pain. The nurse should first (a) flush the intravenous tubing with normal saline (b) assess the client's vital signs (c) stop the transfusion* (d) Notify the primary health care provider
C. Chills and flank pain are symptoms of a blood transfusion reaction. The first action by the nurse is to stop the transfusion; assessment of vital signs is important but not done first. The intravenous tubing is not flushed with normal saline because the remaining blood in the line will be infused. Instead, the nurse would change the entire intravenous set up then infuse normal saline to maintain patency of the IV. Notification of the primary health care provider must also occur. Physiological Integrity; Physiological Adaptation
The nurse is caring for a client with Acquired immunodeficiency syndrome (AIDS) who was started on Zidovidine (AZT). It would be important for the nurse to assess (a) blood ammonia serum (b) serum potassium (c) complete blood count (CBC) (d) serum uric acid
C. Clients being treated with Zidovudine (AZT) should have routine monitoring of CBC (complete blood count), hepatic and renal function studies. Physiological Integrity; Physiological Adaptation
The nurse working on a maternity unit has become aware of the following client situations. It would be a priority for the nurse to intervene if a client states (a) "I will not take my terbutaline (Brethine) if my pulse is greater than 110 beats per minute." (b) "It is normal for my 10 hour old baby to have blue feet and hands." (c) "I cannot breast feed because my nipples are cracked and sore." (d) "I have changed my perineal pad every two hours since I delivered my baby 12 hours ago."
C. Cracked nipples are not a contraindication to breast feeding. The mother should be instructed to expose the nipples to air for 10-20 minutes after feeding, rotate the position of the baby for each feeding and ensure that the baby is latched on to the areola not just the nipple. Safe Effective Care Environment; Management of Care
The nurse is caring for several clients who have been prescribed diuretics. The nurse should teach about increasing the consumption of citrus fruits and bananas to the client who has been prescribed (a) amiloride (Midamor ) (b) spironolactone (Aldactone) (c) torsemide (Demadex) (d) triamterene (Dyrenium )
C. Demadex (torsemide) is a potassium depleting diuretic; client education should be done to include foods high in potassium to prevent hypokalemia; Midamor (amiloride), Aldactone (spironolactone) and Dyrenium (triamterene) are all potassium sparing diuretics; the nurse would limit foods containing potassium with use of these medications. Physiological Integrity; Pharmacological and Parenteral Therapies
A 45 year old client who was recently diagnosed with terminal cancer says to the nurse "If God could only let me live long enough to put my daughter through college, I wouldn't mind dealing with this illness." The nurse caring for this client recognizes this statement as reflective of which stage of grieving? (a) Denial (b) Acceptance (c) Bargaining (d) Anger
C. During the bargaining stage the client attempts to negotiate to prolong their life. Kübler-Ross identified the stages of death and dying as denial (disbelief), anger (hostility), bargaining, depression (sadness) and acceptance (coming to terms with death). Psychosocial Integrity
The nurse is caring for a client who has a new colostomy. The colostomy stoma is red, moist and slightly raised. The nurse should (a) determine if the client is allergic to the skin barrier (b) apply petroleum jelly gauze around the stoma (c ) document the condition of the stoma (d) assess the client's temperature
C. During the initial post operative period, the stoma is red moist and slightly swollen. These are normal findings that should be documented; petroleum jelly is not applied to the stoma. Physiological Integrity;Physiological Adaptation
The nurse on an orthopedic unit has become aware of the following client situations. It would be a priority for the nurse to follow-up if a client who (a) had a total hip replacement 8 hours ago has had 100 ml of bloody drainage in the closed would suction device (b) has an external fixation device after a repair of a fractured femur is requesting pain medication (c) had an open reduction and internal fixation (ORIF) of a fractured femur 12 hours ago has developed a small rash on the chest and neck (d) had a total hip replacement three hours ago has a temperature of 37.8° C (100.2° F)
C. Fat embolism, a serious complication of fractures of long bones is manifested by petechiae (a fine rash) over the chest, neck, upper arms or abdomen, tachycardia, tachypnea, fever and respiratory distress. This client should be evaluated first. Safe Effective Care Environment ; Management of Care
The nurse has attended a staff development conference on preparing clients for neurological diagnostic tests. Which of the following statements, if made by the nurse would require follow-up? (a) "The electromyogram (EMG) is performed by introducing small needle electrodes into muscles." (b) "After having a Positron Emission Tomography (PET) of the head the client can resume normal activities." (c) "The electroencephalogram (EEG) will require the client to be NPO for 12 hours before the test." (d) "After the lumbar puncture (LP) the client will need to lie flat for about 3 hours."
C. NPO is not required prior to an EEG. The client is allowed to have breakfast if prescribed. Caffeine and other stimulants should be avoided for 24 hours prior to the procedure; the other statements are true of those diagnostic tests, therefore follow up is not required. Physiological Integrity; Reduction of Risk Potential
The nurse is observing a staff member caring for clients. It would require immediate intervention if the nurse observes the staff member (a) placing a client who had an above-the-knee amputation (AKA) 24 hours ago in a prone position (b) keeping the head of the bed elevated for the client who had an supratentorial craniotomy 12 hours ago (c) giving orange juice to a client who has a clear liquid diet prescribed* (d) removing all liquids from the tray before giving the tray to a client who has dumping syndrome
C. Placing a client in prone position after above the knee amputation is done to prevent contractures; following supratentorial surgery the head of the bed is elevated 30degrees to promote venous outflow. Removing all liquids is not necessary for clients experiencing Dumping Syndrome. The client should be taught to avoid drinking with meals. Safe Effective Care Environment; Safety and Infection Control
While performing an assessment of a 3-year-old client, the nurse notices bruises in various stages of healing on the concealed surfaces of the body. Which action should the nurse take next? (a) document the locations of the bruises in the medical record (b) notify the primary health care provider (c) contact the local reporting agency for suspected child abuse (d) ask the parent to explain the injuries
C. Reporting of suspected child abuse and maltreatment is mandated by most states. The goal is to protect the child from further abuse. Documentation should be clear and objective—the record may be subpoenaed in court. Safe Effective Care Environment; Safety and Infection Control
The nurse is caring for postpartum clients who had vaginal deliveries within the last eight hours. The nurse should first assess the client who (a) has a pulse rate of 66 beats per minute (b) has saturated one perineal pad in two hours (c) reports swelling in her right calf (d) asks if her baby can sleep in the nursery tonight.
C. Reports of swelling in the calf 8 hours postpartum may be suggestive of the development of a deep vein thrombosis, a potentially life threatening condition. Immediate intervention is needed; other symptoms include pain, warmth, chills, diminished peripheral pulses, erythema, or shiny white skin on the extremity. Safe Effective Care Environment ; Management of Care
The nurse is teaching a new mother about immunizations. Which of the following should the nurse include in the teaching? (a) "Your baby should wait six months to receive any immunizations since the baby was born preterm." (b) "Your baby will receive the first hepatitis B vaccine after one year of age." (c) "Acellular Pertussis vaccine has less side effects than whole-cell pertussis vaccine." (d) The Haemophilus Influenza Type b (HIB) is given annually to protect against the flu."
C. Safety data from several studies show that acellular pertussis vaccine cause fewer adverse reactions than whole-cell vaccines. Pre term infants generally do not wait 6 months before beginning vaccinations; the first Hepatitis B vaccine is given at birth; the Haemophilus influenzae type b (HIB) is given at 2 months, 4 months, and 6 months and between 12 - 15 months. Health Promotion and Maintenance
The nurse is teaching a class on infant nutrition. The nurse should instruct parents to introduce (a) fruit juices at 3 months (b) honey sweetened water at 6 months (c) pureed chicken at 7 months (d) whole milk at 9 months
C. Solids may be introduced by approximately 6 months of age. Rice cereal is usually introduced first with the addition of fruits, vegetables then meats at a rate of one new food per week to monitor for allergic reactions. Solids should be puréed, strained or mashed; Honey is avoided in infancy due to the risk for infant botulism; whole milk is not introduced until after one year of age. Physiological Integrity; Basic Care and Comfort
The nurse in the emergency department is assessing a toddler who has swallowed some bleach. The toddler is crying. It would be a priority for the nurse to follow up if the parent says (a) "I brought the container of bleach with me." (b) "I could not get my toddler to vomit." (c) "I gave my toddler a tablespoonful of ipecac syrup (d) "I attempted to perform CPR to prevent my toddler from becoming unresponsive."
C. Syrup of Ipecac is not indicated in this situation as it will induce vomiting which could lead to further damage of the gastric mucosa by the bleach. Safe Effective Care Environment; Safety and Infection Control
The nurse is caring for a 7-year-old who has thrombocytopenia and is on protective precautions. Which of the following would be an appropriate toy for the nurse to provide to the client? (a) finger paints and paper (b) a rubber ball and bat (c) a board game (d) a stuffed toy
C. The child with thrombocytopenia needs to be protected from injury secondary to the risk of bleeding. Use of a board game, a quiet activity provides diversion and challenges that is developmentally appropriate while eliminating the risk of injury; finger paints is applicable to a preschool client; the ball and bat is avoided to prevent injury; the stuffed toy may be offered to the toddler. Health Promotion and Maintenance
The nurse is caring for a client with bipolar disorder who has lithium (Lithotabs) prescribed. The nurse should suggest that the client have which of the following snacks? (a) A fresh fruit cup (b) Coffee and oatmeal cookies (c) Tuna fish salad on saltine crackers (d) Raw vegetables
C. The client receiving Lithium (Eskalith) should be careful to include sodium in the diet to prevent hyponatremia which predisposes the client to Lithium toxicity; Caffeine should be avoided because of the diuretic effect which will further increase the risk of hyponatremia; There is no contraindication for fresh fruit or raw vegetables.
A nurse is admitting a client with suspected pulmonary tuberculosis (TB). Which of the following actions should the nurse take? (a) wear a gown when taking the client's health history (b) place the client on droplet precautions (c) keep the door to the client's room closed (d) use disposable gloves when taking the client's blood pressure
C. The client with Tuberculosis (TB) is placed no airborne precautions which include placement in a negative pressure room with the door closed and use of a particulate respirator mask; a gown and gloves are not needed when talking with the client or taking the blood pressure; droplet precautions are used for meningitis, HIB (haemophilus influenzae type b), mumps, rubella, pertussis and epiglottitis. Physiological Integrity; Physiological Adaptation
The nurse in a well child clinic is taking the vital signs of a 4 year old client. The nurse obtains the following readings: temperature 98.2°F pulse 110 respirations 22 blood pressure 86/60. The nurse should (a) ask the parent knows what the child's pulse rate is usually (b) encourage the child to rest for 10 minutes and reassess vital signs (c) document the findings in the client's medical record (d) notify the primary health care provider of the findings
C. These findings should be documented in the medical record as they are within the guidelines for the preschool child. A, B and D are not indicated since the vital signs are within normal range. Physiological Integrity; Physiological Adaptation
The nurse has provided discharge instructions for a client who has been prescribed digoxin (Lanoxin). It would require follow up by the nurse if the client says (a) "I will consult my primary health care provider before taking medications that contain aspirin." (b) "I will not take any antacids within two hours of taking the digoxin." (c) "I will avoid fruits such as avocados, grapefruit and cantaloupe." (d) "I will remember that any visual disturbance can be a sign of digitalis toxicity."
C. These fruits are rich in potassium. They should be included in the diet to prevent hypokalemia. Hypokalemia, hypercalcemia, and hypomagnesemia predispose the clientto Digoxin (Lanoxin) toxicity; the other statements are true of Digoxin therapy.
37. The nurse is performing an abdominal assessment. Indicate the correct sequence the nurse should use to perform this assessment. (a) percussion (b) palpation (c) auscultation (d) inspection
D, C, B, and A. Inspection is done first. Auscultation is performed before palpation to decrease the risk of stimulating the bowel which could result in false positive findings. Health Promotion and Maintenance
The nurse should initiate protective precautions for a client who has a (a) Red Blood Cell Count (RBC) of 3,900/mm3 (b) Platelet count of 400,000μ/L (c) Hemoglobin (Hgb) 9.0 g/dl (d) White Blood Cell Count (WBC) 2,500/mm3
D. A white blood cell count of 2,500/mm3 is low therefore the client is at risk for infection. Protective precautions should be implemented. The normal White blood cell count (WBC) is 5,000 - 10,000/mm3; The normal red blood cell count (RBC) is 4 - 5 millioion/mm3, a deficit of red blood cells is indicative of anemia. The normal platelet count is 150,000 - 400,000µ/Liter. A low platelet count predisposes the client to bleeding; the normal hemoglobin value is 13.5 - 18g/dl male and 12 -16g/dl female. A low hemoglobin is suggestive of anemia and possible active bleeding. Safe Effective Care Environment; Safety and Infection Control
The nurse in the emergency department is caring for clients admitted following a rescue from a burning bus. The nurse should first see the client who (a) has the tibia bone protruding through the skin and is in severe pain (b) has third degree burns of the left foot and is crying (c) is unconscious, pulseless, and has dilated pupils (d) has soot on the face and the nares and is coughing
D. After a disaster clients are seen in order of priority. Those with life threatening injuries who are likely to survive are seen first (Class 1; Priority 1). Those that require immediate care, who can be evaluated within 2 hours, are seen next (Class II; Priority 2). Next are clients who could wait hours to days before treatment (Class III; Priority 3). The client in choice C is the most seriously injured and not likely to survive, they would be seen last (Class IV; Priority 4). That person should be separated from others but not abandoned. Safe Effective Care Environment; Safety and Infection Control
The nurse is caring for a client with a soft tissue injury. The client reports using a herbal remedy for 3 weeks prior to seeking health care but can not remember what was taken. The nurse should recognize that which of the following herbal remedies can be utilized effectively for soft tissue injuries? (a) Saint John's Wort (b) Kava Kava (c) Dong-Quai (d) Aloe Vera
D. Aloe Vera is effective as an inflammatory agent for soft tissue injuries, burns, and abrasions; St. John's Wort is helpful with menstrual disorders, depression and as a diuretic; Kava Kava may be used to decrease anxiety and stress; Dong-Quai is a smooth muscle relaxant used to regulate menstrual periods, treat symptoms of premenstrual syndrome and cleanse the blood. Physiological Integrity; Pharmacological and Parenteral Therapies
The nurse is teaching a group of parents about the expected growth and development of three-year-old children. The nurse should include that a three-year- old should (a) discriminate between fantasy and reality (b) ride a tricycle independently (c) have a vocabulary of 7,000 words (d) play in a group of two or three with one being the leader
D. By the age of 3, a toddler should be able to ride a tricycle independently; the pre- school child is not able to discriminate between fantasy and reality. This is the developmental task of a school age child; at 3 years of age the vocabulary is at about 900 words; cooperative play with the incorporation of imaginary friends is common in this age group. Health Promotion and Maintenance
The nurse is made aware of the following situations. The nurse should first check the client who (a) had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours after the indwelling catheter is removed (b) has cervical traction and is moving the legs by flexing and extending the feet (c) has Alzheimer's disease (stage 1) and was returned to the room after being found wandering in the hallway (d) has a history of partial seizures and is sitting in the bed picking at the clothing and smacking the lips
D. Clients with a history of complex partial seizures may black out for one to three minutes. They experience automatisms (the client is not aware of the behavior) such as lip smacking, patting, and picking of the clothes. This client should be seen first; dribbling, urinary frequency and burning on urination may be expected after an indwelling catheter is removed; flexion and extension of the neck is contraindicated with cervical traction, not foot traction; returning the confused client with Alzheimer's disease is not a priority. Safe Effective Care Environment; Management of Care
The nurse is assessing a child with coarctation of the aorta. Which of the following would be an expected finding? (a) diminished blood pressure in the upper extremities (b) excessive weight gain (c) high pitched murmur (d) absence of femoral pulses
D. Coarctation of the aorta is characterized by narrowing of the aorta. As a result of this narrowing, absent femoral pulses, poor weight gain and increased blood pressure in the upper extremities are expected findings. A high pitched murmur is not present. Physiological Integrity; Physiological Adaptation
Four clients recently returned to the unit following invasive diagnostic testing. The nurse should immediately intervene if one of the clients: (a) reports blood tinged sputum following a bronchoscopy (b) has decreased abdominal girth following paracentesis (c) reports a headache following a lumbar puncture (d) is observed flexing and extending the legs two hours after cardiac catheterization
D. Following cardiac catheterization of the femoral artery, the client remains on bedrest for 2 to 6 hours with the affected leg straight and the head of the bed elevated to 30 degrees; blood tinged sputum is an expected finding after bronchoscopy; removal of fluid from the peritoneal cavity as in paracentesis will result in decreased abdominal girth; post lumbar puncture headache ranging from mild to severe may appear a few hours to days following the procedure. Safe Effective Care Environment; Management of Care
The nurse has attended a staff development conference on sexually transmitted diseases. Which of the following statements, if made by the nurse would require follow-up? (a) "During the primary stage of syphilis a lesion occurs at the site of infection called a chancre" (b) "A client with HIV who has a reading of 5 or more on the mantoux test is considered to have a positive finding for pulmonary tuberculosis" (c) "Gonorrhea is often asymptomatic in women but causes urinary frequency and dysuria in males" (d) "Chlamydial infections are strongly linked with cervical cancer in women."
D. HPV (human papilloma virus), not Chlamydia is the sexually transmitted infection linked with cervical cancer; the other statements are accurate, they do not need follow up. Physiological Integrity; Physiological Adaptation
A client with end stage renal disease (ESRD) is scheduled for hemodialysis in one hour. The nurse should notify the primary health care provider that the client has a (a) BUN of 60 mg/dl (b) Creatinine 3.5 mg/dl (c) Sodium 145 mEq/L (d) Potassium 6.8 mEq/L
D. Hyperkalemia can result in serious adverse effects to excitable tissues especially the heart, causing altered cardiac function; the BUN and creatinine are elevated prior to dialysis due to increased circulating wasted in the blood stream; a sodium level of 145 mEq/L is within the normal range of 135-145 mEq/L. Physiological Integrity; Reduction of Risk Potential
The nurse has attended a staff development conference on cultural considerations for clients receiving hospice care. Which of the following statements if made by the nurse would require follow-up? (a) The family of a client of the Buddhist faith may ask for a priest to be present at the time of death (b) The family of a client of the Jewish faith may request to have mirrors covered after the death of the client (c) The family of a client of the Muslim faith may request that the body of the client be turned to face the East at the time of the client's death (d) The family of a client of the Hindu faith may request that the client body be bathe after the client's death*
D. It is customary in the Hindu faith that only family members touch the body after death. the other statements are correct. Follow up is not necessary. Psychosocial Integrity
The nurse is caring for a client who has left ventricular failure. Which of the following should the nurse recognize as being consistent with this diagnosis? (a) 3+ pedal edema (b) jugular vein distention (c) oxygen saturation of 96% (d) wheezing during expiration
D. Key features of left ventricular failure include wheezing or crackles in the lungs, dyspnea, hacking cough and fatigue; pedal edema and jugular venous distention is associated with right ventricular failure; oxygen saturation of 95%-100% is a normal finding. Physiological Integrity; Physiological Adaptation
The nurse has attended a staff development conference on medical treatments for various neurological disorders. Which of the following statements if made by the nurse would require follow-up? (a) "Clients with Guillain Barre syndrome (GBS) often have plasmapheresis prescribed." (b) "Myasthemia Gravis can be treated with short-acting anticholinesterase drugs." (c ) "Parkinson's disease may have catechol O-methyltransferase (COMT) inhibitors prescribed along with levodopoa-carbidopa (Sinemet)." (d)"Clients with Multiple Sclerosis often receive Intravenous immunoglobulin G (IVIG)."
D. Multiple Sclerosis is not managed using IVIg. Common medications that may be prescribed are Avenox (Interferon beta 1a), Betaseron (Interferon beta 1b), Copaxone (Glatiramer), and Rebif (Interferon beta 1a); Corticosteroids are used to limit the severity and duration of exacerbations; the other options are correct statements for those neurological disorders. Physiological Integrity;Physiological Adaptation
The mother of an infant tells the nurse that the baby has not been tolerating feedings lately and she noticed an olive-shaped mass in the infant's abdomen. The nurse recognizes that this could be an expected finding if the infant has (a) intussusception (b) Hirschsprung's disease (c) umbilical hernia (d) pyloric stenosis
D. Pyloric Stenosis is hypertrophy of the muscles of the pylorus causing narrowing of the pyloric canal between the stomach and duodenum. A characteristic olive shaped mass may be palpated in the epigastrium to the right of the umbilicus. Intussusception is characterized by currant jelly stools. Hirschprung's disease (congenital mega colon) results in ribbon-like foul smelling stools; a child with an umbilical hernia has swelling or protrusion around the umbilicus that is reducible. Physiological Integrity; Physiological Adaptation
The nurse on a psychiatric unit is caring for a client with a paranoid schizophrenia who has lost 15 pounds within the past three weeks. The client accuses the staff of trying to poison all of the clients on the unit. Which of the following nursing interventions would be a priority for the nurse to include in the client's plan of care? (a) Determine the client's favorite foods (b) Offer the client small quantities of food at frequent intervals (c) Sit with the client during meals (d) Provide the client with pre-packaged foods that the client likes
D. The client experiencing paranoia is suspicious of the people around them so they may elect not to eat causing alteration in the nutritional status. Providing pre packaged foods will diminish the client's fear of being poisoned by the staff. The other choices are helpful to the paranoid person but not a priority. Psychosocial Integrity
The charge nurse of a medical-surgical unit notices a nurse walking with an unsteady gait, slurred speech and a faint smell of alcohol on the breath immediately following a lunch break. The charge nurse's priority action would be to (a) notify the nursing supervisor (b) asking the nurse about recent alcohol consumption (c) complete an incident report (d) relieve the nurse of assigned clients
D. The priority in this situation is client safety. The nurse should be relieved of their assigned clients since these behaviors suggest that the nurse may be impaired; the charge nurse should not confront the other nurse. Instead, a clear factual description of the situation should be documented then reported to the nursing supervisor. Safe Effective Care Environment; Safety and Infection Control
The nurse is caring for a client with a Vancomycin Resistant Enterococcus (VRE) wound infection. Which of the following actions would be appropriate for the nurse to take? (a) Wear a particulate respirator mask when providing wound care (b) Instruct visitors not to bring flowers into the client's room (c) Place the client in a private room with negative air pressure (d) Wear a disposable gown when changing the client's dressing
D. Use of a gown to prevent contact with the client or client contaminated items is desired; a particulate respirator mask and negative pressure room is used during the care of someone with tuberculosis; prohibition of flowers and live plants is necessary for the client on protective precautions to prevent infection. Safe Effective Care Environment; Safety and Infection Control
The nurse has attended a staff development conference on vitamins and minerals. Which of the following statements if made by the nurse would require follow-up? (a) "Vitamin B12 (cobalamin) supplement may be needed if a client has a gastrectomy." (b) "Vitamin D (calciferol) is necessary for proper utilization of calcium and phosphorous." (c) "Vitamin A can be found in squash, pumpkin, and carrots." (d) "Vitamin B6 (pyridoxine) supplements are given to help prevent macular degeneration
D. Vitamin B6 is not used in the management of macular degeneration; clients who have had gastrectomy may require Vitamin B 12 supplement secondary to the absence of intrinsic factor; Vitamin D is necessary for the proper absorption of calcium; yellow vegetables such as squash, pumpkin, and carrots are good sources of Vitamin A. Physiological Integrity; Basic Care and Comfort
The nurse is reviewing laboratory data of the following clients. It would be a priority for the nurse to follow-up with the primary health care provider if a client with (a) coronary artery disease has a low density lipoprotein (LDL) level of 129mg/dl (b) primary hypertension has a sodium level of 144mEq/L (c) rhinosinusitis has a white blood count (WBC) of 11,500/ul (d) diabetes mellitus type 1 has a glycosylated hemoglobin (hbA1c) level of 12%
D. optimal levels of glycosylated hemoglobin (hgb A1c) is 4%-6% which indicates consistent glycemic control. Levels over 8% indicate poor control and require follow up; the LDL is less than 130mg/dl; normal sodium is 135mEq-145mEq/L; the normal WBC is 5-10,000µL however a client with rhino sinusitis (infection) would be expected to have a slightly elevated WBC. Physiological Integrity; Reduction of Risk Potential