Practice Questions

The nurse notices that the hem of a skirt on a pre-adolescent girl is uneven when she comes to the clinic. What procedure should the nurse follow to examine the girl for scoliosis? (Arrange the examination process from first on top to last on the bottom.) 1. Ask the girl to remove her shirt but leave on her bra or swimsuit top. 2. Instruct the girl to bend at the waist so back is parallel to the floor. 3. Examine for scapular prominence. 4. Look for asymmetry in the hip area.

1. Ask the girl to remove her shirt but leave on her bra or swimsuit top. 2. Look for asymmetry in the hip area. 3. Instruct the girl to bend at the waist so back is parallel to the floor. 4. Examine for scapular prominence.

The nurse receives a telephone call from the laboratory and is told that a client's culture report reveals the presence of methicillin-resistant Staphylococcus aureus (MRSA). The nurse reports the results, and contact precautions are initiated. Which of the following should the nurse use? Select all that apply. 1) remove the gown outside the client's room 2) place the client in a private room 3) place the client in a semiprivate room with another client who has active infection by the same microorganism but no other infection 4) request a negative airflow room 5) wear a gown when caring for the client, and remove the gown immediately before leaving the client's room 6) wear gloves. gown, and goggles when changing the client's colostomy bag

2,3,5,6

The nurse has an order to give 30 mL of an antacid to a client through a feeding tube. Which of the following nursing actions is the priority? A) assess tube placement B) aspirate to determine residual volume C) follow medication administration with 30 mL of sterile saline D) administer the antacid by gravity flow

A) assess tube placement

A nurse, caring for a client with uncontrolled diabetes, suspects that a client is experiencing hypoglycemia in response to insulin administration. What clinical manifestations lead the nurse to this conclusion? Select all that apply. A) headache B) confusion C) extreme thirst D) profuse sweating E) increased urination

A) headache, B) confusion, D) profuse sweating WHY? Neurologic responses occur when there is an insufficient supply of glucose to the brain, thus causing clinical manifestations such as headache and confusion. Profuse sweating is a classic sign of hypoglycemia. This is triggered by lack of glucose to the nerve cells. Thirst (polydipsia) is a classic symptom of hyperglycemia. Increased urination (polyuria) is a classic sign of hyperglycemia.

A student nurse is assigned to work with the charge nurse in caring for a client in DKA. The student tells teh nurse that she plans to present information about the patient to her fellow students during a post clinical conference and asks the charge nurse for permission to copy the lab data to take to the conference. Which response is best for the charge nurse to provide? A) information about the client cannot be removed from the nursing unit B) the lab values can be copied as long as there is no identifying client data C) since this is for educational purposes, you can remove any information you need D) your instructor should tell you what information you are allowed to copy

B

A client has undergone surgery with general anesthesia. Within how many hours after surgery should the nurse notify the health care provider if the client does not void? A) 4 hours B) 8 hours C) 12 hours D) 16 hours

B) 8 hours Rationale: Decreased bladder muscle tone results from the depressant effects of anesthesia and the handling of tissues and adjacent organs during surgery. Catheterization may be necessary to prevent overdistention of the bladder. Four hours may be too early to expect recovery from the depressant effects of anesthesia. Twelve and 16 hours are too long to wait to call the health care provider. This length of time without voiding may result in overdistention of the bladder.

The client with osteoarthritis is receiving diclofenac sodium (Voltaren). The nurse would be concerned about the administration of this medication if the client's history and physical included a diagnosis of: A) grave's disease B) peptic ulcer disease C) coronary artery disease D) benign prostatic hypertrophy

B) peptic ulcer disease

In addition to monitoring the patient in DKA;s blood glucose level, what additional lab values should the nurse monitor carefully? Select all that apply A) uric acid B) hemoglobin C) calcium D) potassium E) BUN

B, C, D, E

The patient recently diagnosed with type 1 diabetes recovering from DKA tells the nurse, "I know that diabetes is a chronic condition, so I've probably had this for a while. Why didn't I experience any symptoms before now?" How should the nurse respond? A) the symptoms were so minor that you just didnt notice them until you got the flu B) the type of diabetes you have is the acute form of diabetes, rather than the chronic form C) the onset of symptoms is so gradual that your body adjusts to the changes D) the symptoms have an abrupt onset that is often brought on by a viral illness, like the flu

D

The client with osteoarthritis is receiving diclofenac sodium (Voltaren). The nurse would be concerned about the administration of this medication if the client's history and physical included a diagnosis of: A) peptic ulcer disease B) Begnign prostatic hypertrophy C) Grave's disease D) coronary artery disease

A) peptic ulcer disease

The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which of the following findings would alert the nurse to a compromise? A) the passage of meconium B) progressive changes in the cervix C) maternal fatigue D) coordinated uterine contractions

A) the passage of meconium

After stabilization of an acute adrenal insufficiency (Addisonian crisis), intravenous medications are decreased gradually, and the client now is receiving hydrocortisone by mouth. What instruction should the nurse include when performing discharge teaching? A) eat a diet high in sodium B) take the medication with food C) maintain the same dose indefinitely D) eliminate a dose if side effects occur

B) take the medication with food WHY? Taking the medication with food minimizes the side effect of gastrointestinal irritation; the health care provider should be notified immediately if abdominal pain or tarry stools occur. The diet should be low in sodium because cortisone can cause fluid retention. The dose may have to be adjusted with health care provider supervision when the client is under physical or emotional stress. Cortisone levels must be maintained; changes in dosage must be supervised by the health care provider.

The nurse is caring for a client with Paget's disease who has an elevated serum calcium level of 12.3 mEq/L. The nurse checks to see that which of the following medications is available in the stock medication supply area for possible use to reverse this elevation? A) calcium gluconate B) vitamin D C) calcitonin D) calcium chloride

C) calcitonin

Baclofen (Lioresal) is prescribed for the client with multiple sclerosis. The nurse evaluates that the medication is having the intended effect if which of the following is noted in the client? A) increased muscle tone B) increased range of motion C) decreased muscle spasms D) decreased local pain and tenderness

C) decreased muscle spasms

A patient recently diagnosed with type 1 diabetes states, "I wish I hadn't gotten the flu, then this diabetes wouldn't have been discovered and I could keep having a normal life." What is the best initial response by the nurse? A) what do you mean when you say a normal life? B) It's better to find out now before complications develop C) perhaps you would like to speak with someone who has diabetes D) it must be quite a shock to learn that you have diabetes

D) it must be quite a shock to learn that you have diabetes Rationale: This statement acknowledges the patient's feelings, and is open ended, allowing the patient to continue to verbalize her feelings if she wishes.

In order to restore a patient in DKA's blood glucose to a normal level, what should the nurse prepare to administer? A) an iIV infusion containing regular insulin B) humulin-N insulin SC before meals C) 50% dextrose IV push D) glucagon subQ PRN per sliding scale

A) an IV infusion containing regular insulin Rationale: Continuous IV infusions containing regular insulin are used to reduce the client's blood glucose level. Lara's IV solution will be changed to one that contains glucose when her blood glucose level reaches 250 mg/dl. Humulin N insulin is not used in the management of DKA because it does not promote consistent, graduate reduction in blood glucose levels. The patient is experiencing hyperglycemia and does not need additional dextrose or glucagon.

The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture report interprets that which of the following organisms is not part of the normal flora of the skin? A) escherichia coli B) candida albicans C) staphylococcus aureus D) staphylococcus epidermidis

A) escherichia coli

Before a client's discharge after a thyroidectomy, the nurse teaches the client to observe for signs of surgically induced hypothyroidism. What clinical indicators identified by the client provide evidence that the nurse's instructions are understood? Select all that apply. A) fatigue B) dry skin C) insomnia D) intolerance to heat E) progressive weight loss

A) fatigue B) dry skin WHY? Fatigue is caused by a decreased metabolic rate. Dry skin is caused by decreased glandular function associated with a decreased metabolic rate. Insomnia is caused by an increased metabolic rate associated with hyperthyroidism, not hypothyroidism. Intolerance to heat is associated with hyperthyroidism. Intolerance to cold is associated with hypothyroidism. Progressive weight loss is associated with hyperthyroidism. Progressive weight gain is associated with hypothyroidism because of the reduced metabolic rate.

A patient who has sleep apnea has been using CPAP for 2 weeks returns to the sleep clinicl and tells the nurse, "My sleep has not improved at all." Which response by the nurse is most appropriate? A) CPAP takes more than a few weeks to achieve he maximum effect B) Have you been using the CPAP every night? C) Do you want to talk to the doctor about surgery? D) Perhaps the CPAP pressure should be increased to a higher level

B) Have you been using the CPAP every night? Although CPAP is very effective in improving sleep quality in patients with sleep apnea, many patients are noncompliant with this therapy. The nurse should be sure that the patient is actually using the CPAP. When CPAP is used, the effects on sleep quality are immediate. Surgery may be an appropriate therapy for the patient, but suggesting surgery would not be an appropriate first action by the nurse in this situation. CPAP using higher pressures will make it more difficult for the patient to exhale and is likely to decrease compliance with therapy.

In the early postoperative period after a transurethral resection of the prostate, the most common complication the nurse should monitor for is: A) sepsis B) hemorrhage C) leakage around the catheter D) urinary retention with overflow

B) hemorrhage Rationale: After transurethral surgery, hemorrhage can occur because of venous oozing and bleeding from many small arteries in the area. Sepsis is unusual and occurs later in the postoperative course. Leaking around the catheter is not a major complication. Urinary retention is unlikely with an indwelling catheter in place.

A sexually active client presents with a sore throat and a generalized rash. The client states that a chancre that had been present healed approximately three months ago. The physical assessment and the serologic test findings indicate a diagnosis of syphilis. The nurse recognizes that the client is experiencing what stage of syphilis? A) primary B) secondary C) latent D) tertiary

B) secondary Rationale: he client has secondary syphilis, which occurs one to three months after healing of the primary lesion and lasts for several weeks to as long as a year; it is the stage at which the individual is most infectious. Primary syphilis is the stage of initial infection and is characterized by the presence of a chancre, a painless lesion at the site of infection. Latent syphilis occurs after the secondary stage and before the late stage of syphilis; in latent syphilis the immune system is able to suppress the infection and there are no clinical signs and symptoms. Tertiary syphilis, also known as late syphilis, is the final stage of syphilis; 20% to 40% do not demonstrate signs and symptoms during this stage. At this stage it is a slowly progressive inflammatory disease that can involve many organs; common complications include paresis, brain attack, dementia, psychosis, aortitis, and meningitis.

A man who was recently diagnosed with Huntington's disease asks the nurse if his adolescent son should be tested for the disease. What response is best for the nurse to provide? A) autosomal dominant disorders such as huntinton's cannot be inherited from the parent B) testing is needed because there is a 50% risk of passing the gene on to each offspring C) genetic counseling should be provided to ensure an informed decision by the family D) positive genetic testing may contribute to insurance discrimination that denies coverage

B) testing is needed because there is a 50% risk of passing on to all offspring WHY Huntington's disease, a progressively incapacitating, fatal neuromuscular disease, is an autosomal dominant inherited disease that has a 50% risk of developing in each child of those who have the disorder. The risk of autosomal dominant inheritance should be explained and emphasized (B). (A) is inaccurate. Although the basic tenet of genetic counseling is to provide families with facts to assist them in making informed decisions (C), the basic laws of inheritance should be explained to direct the client to counseling. (D) provides information that does not address the client's question, and might be considered judgmental.

A 6-year-old child is admitted in the emergency department with a systolic blood pressure of 58 mm Hg. What action should the nurse take first? A) comfort the child B) assess responsiveness C) alert the healthcare provider D) initiate Iv fluid replacement

C) alert the healthcare provider WHY? The lower limit for systolic blood pressure for a child older than 1 year of age is 70 mm Hg plus 2 times the child's age in years, so the healthcare provider should be notified (C) of the child's hypotension, and although comforting measures should be provided (A), physiological needs should be met first. Assessing the child's responsiveness is a component of a neurologic assessment, but asystolic blood pressure of 58 mm Hg is a late sign of shock in children and requires immediate intervention (B). The healthcare provider's prescriptions, including IV fluids (D), should be obtained to address shock.

A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform or insert which of the following airway management techniques or devices? A) oropharyngeal airway B) jaw thrust maneuver C) endotracheal intubation D) cricothyroidotomy

C) endotrachial intubation Rationale: Endotracheal tubes are used in cases when the patient cannot be ventilated with an oropharyngeal airway, which are used in patients who are breathing spontaneously. This makes options A, B, and D incorrect.

A client has been started on therapy with lithium carbonate (Eskalith). The nurse instructs the client to do which of the following? A) limit salt intake B) limit fluid intake C) maintain a fluid intake of 2 to 3 L/day D) stop the medication if grastrointestinal (GI) disturbances occur

C) maintain a fluid intake of 2 to 3 L/day

A nurse is caring for a patient following surgery under a spinal anesthetic. What interventions can the nurse implement to prevent a spinal headache? A) have the patient sit in a chair B) ambulate the patient C) limit fluids D) keep the patient lying flat

D) keep the patient lying flat Rationale: Feedback: Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the patient lying flat, and keeping the patient well hydrated. Options A and B are incorrect; having the patient sit or stand up decreases cerebrospinal pressure and would not relieve a spinal headache. Limiting fluids, option C, is incorrect because it also decreases cerebrospinal pressure and would not relieve a spinal headache.

You are caring for a patient with leg ulcers. You know that the most appropriate dressing to apply on a patient with a superficial, uninfected leg ulcer would be what? A) a hydrocolloid dressing B) a dry gauze dressing C) a dry sterile dressing D) a hydrogen peroxide dressing

A) a hydrocolloid dressing Rationale: A hydrocolloid dressing maintains a moist environment and promotes granulation, but it should not be used if the ulcer is infected. Dry sterile, dry gauze, or hydrogen peroxide dressings should not be used, because they do not provide a moist wound environment.

A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia and thrombosis syndrome (HITTS). The nurse will anticipate a health care provider order to a. use saline for flushing IV lines. b. give low-molecular-weight (LMW) heparin. c. discontinue the warfarin. d. administer platelet transfusions.

A Rationale: All heparin is discontinued when the HITTS is diagnosed. The patient should be instructed to never receive heparin or LMW heparin. Warfarin will be continued because it does not induce thrombocytopenia. The platelet count does not drop low enough in HITTS for a platelet transfusion, and a transfusion will increase the risk for thrombosis

A nurse is caring for a variety of clients. For which client is it most essential for the nurse to implement measure to prevent pulmonary embolism? A) 59 year old who had a knee replacement B) 60 year old who has bacterial pneumonia C) 68 year old who had emergency dental surgery D) 76 year old who has a history of thrombocytopenia

A) 59 year old who had a knee replacement Rationale: Clients who have had joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.

The nurse is caring for a client in a long term care facility. The client's neighbor asks the nurse for information regarding the client's treatment plan. Which of the following responses would be most appropriate for the nurse to make? A) I cannot give you information on the client without the client's consent B) Can you verify the client's date of birth? C) Let me contact the admission department to speak with you D) I will share the client's treatment plan with you after breakfast

A) I cannot give you information on the client without the client's consent

A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective A) I will need to buy a water bottle to carry with me B) I can use lotions to moisturize the skin on my throat. C) Alcohol based mouthwashes will help clean oral ulcers D) Until the radiation is complete, I may have diarrhea

A) until the radiation is complete, I may have diarrhea Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.

Critical thinking is an integral part of nursing care. What does critical thinking do when applied to nursing? (Mark all that apply.) A) enhances clinical decision making B) identifies patient desires C) plans the best nursing actions to assist the patients in meeting their needs D) gradually develops independent judgments and decisions E) helps identify patient needs

A, D, E

A patient is admitted to the emergency department with possible fractures of the bones of the left lower extremity. The initial action by the nurse should be to A) obtain information about the patient's tetanus immunization status B) check the popliteal, dorsalis pedis, and posterior tibial pulses C) splint the lower leg D) elevate the left leg

B) check the popliteal, dorsalis pedis, and posterior tibial pulses A patient is admitted to the emergency department with possible fractures of the bones of the left lower extremity. The initial action by the nurse should be to

A mother brings her 6-month-old infant to the clinic for a well-baby routine exam. Which vaccine(s) should the nurse verify the infant has received? (Select all that apply.) A) MPSV4 B)) Hib C) IPV D) HepB E) DTAP F) MMR

B, C, D, E WHY (B, C, D, and E) should be administered prior to 6 months of age. (A) is administered after 24-months of age. (F) is administered at 12-months of age.

Leadership is inherent to nursing. Every nurse executes leadership when she assumes responsibility for the actions of others involved in determining and achieving patient care goals. What is a component of leadership? A) selecting B) dividing C) relating D) contemporizing

C) relating

A client who has just had an adrenalectomy is told about a death in the family and becomes very upset. What concern about the client requires the nurse to notify the health care provider? A) analgesia and mild sedation will be required to ensure rest B) steroid replacement medication therapy will have to be reduced C) there is a decreased ability to handle stress despite steroid therapy D) feelings of exhaustion and lethargy may result from the emotional stress

C) there is a decreased ability to handle stress despite steroid therapy WHY? Clients with adrenocortical insufficiency who are receiving steroid therapy usually require increased amounts of medication during periods of stress because they are unable to produce the increased levels of glucocorticoids needed by the body at this time. Although sedation may be prescribed, the major concern is the regulation of glucocorticoids in the presence of emotional or physiologic stress. Increased stress requires increased glucocorticoids. Although feelings of exhaustion and lethargy may occur and may be minimized by an increase in glucocorticoids, the primary reason for an adjustment in dosage is to assist the body's ability to adapt to stress.

What should the nurse assess last when examining a 5-year-old child? A) heart B) lungs C) throat D) abdoment

C) throat WHY? Examination of the mouth, throat, and perineum is considered to be more invasive than other parts of a physical examination, so invasive procedures, such as (C), should be left to the end of the examination for a preschooler. Assessment of (A, B, and D) is not considered as invasive or frightening to the child as (C).

The client with myasthenia gravis becomes increasingly weaker. The physician injects a dose of edrophonium (Tensilon) to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which of the following reactions if the client is in cholinergic crisis? A) no change in condition B) complaints of muscle spasms C) an improvement of the weakness D) a temporary worsening of the condition

D) a temporary worsening of the condition

A patient is admitted to the emergency department who has been exposed to a nerve agent. What drug does the nurse expect the patient to be treated with? A) nitrate B) dimercaprol C) erythromycin D) atropie

D) atropine

Blood work has been drawn on a client who has been taking cyclosporine (Sandimmune) following allogenic liver transplantation. The nurse checks the results of which of the following tests to determine the presence of an adverse effect related to this medication? A) hematocrit level B) hemoglobin level C) cholesterol level D) blood urea nitrogen (BUN) level

D) blood urea nitrogen (BUN) level

A nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the most appropriate pulse point to use when determining pulselessness on an infant. The nurse undergoing recertification replies that the correct pulse is the: A) carotid B) popliteal C) radial D) brachial

D) brachial

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess the client? Select all that apply? A) unilateral chest pain B) acute onset of dyspnea C) pain in the residual limb D) absence of the popliteal pulse E) blanching of the affected extremity

A &B Rationale: Emboli can occur with crushing injuries of the extremities. Lodging of a thrombus in the pulmonary system results in a lack of oxygen to pulmonary tissues, causing localized pain. Lodging of a thrombus in the pulmonary system will result in decreased breath sounds and dyspnea. Pain in the residual limb is related not to a pulmonary embolus but to severed nerve endings in the residual limb. A pulmonary embolus will not interfere with arterial circulation to a distal portion of an extremity. Blanching of the affected extremity is associated with interference with arterial circulation to an extremity.

The nurse is reviewing the physician's orders for a child with rheumatic fever (RF) who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which of the following nursing actions is most appropriate? A) adminster the aspirin if the child's temperature is elevated B) administer the aspirin if the child experiences any joint pain C) consult with the physician to verify the prescription D) administer acetaminophen (tylenol) instead of the aspirin for temperature elevation

A) administer the aspirin if the child's temperature is elevated Rationale:Anti-inflammatory agents, including aspirin, may be prescribed for the child with RF. Aspirin should not be given to a child who has chickenpox or other viral infections. The nurse would not administer acetaminophen (Tylenol) without specific physician's orders. Options 1 and 2 are not appropriate actions.

While assessing the apical pulse of a 13-year-old, the nurse determines that the rate is 88 beats/minute, and the rhythm is irregular. The heart rate is phasic with respirations, increasing during inspiration and decreasing with expiration. What action should the nurse take? A) continue the cardiac examination B) inquire about daily caffeine intake C) re-assess the apical pulse in 15 min D) schedule a consultation with a cardiologist

A) continue the cardiac examination WHY Sinus arrhythmia is characterized by phasic irregularity of the heart rate that occurs with changes in intrathoracic pressure during respiration and is a common phenomenon during childhood and adolescence. No intervention is required, and the nurse should continue with the cardiac exam (A). This finding is not related to caffeine intake (B). (C and D) are not indicated because the heart rate is within the normal range.

A nurse instructs a client with a history of frequent urinary tract infections to drink cranberry juice to: A) decreased the urinary pH B) exert a bactericidal effect C) improve glomerular filtration D) relieve the symptoms of dysuria

A) decrease the urinary pH Rationale: Cranberry juice is excreted as hippuric acid, which helps acidify the urine (decrease the pH) and inhibit bacterial growth. Although bacterial growth may be inhibited, bacteria are not destroyed. Glomerular filtration is unaffected by cranberry juice. Cranberry juice acidifies the urine and may increase the burning sensation associated with urination when an infection is present.

The nurse is developing the plan of care for a school-aged boy with a chronic disability. The child frequently cries about being different from his siblings and wants others to do things for him that he is capable of doing for himself. To assist the family in coping with this child's chronic illness, which intervention is most important for the nurse to implement? A) recommend the use of consistent discipline and reward for acceptable behavior B) encourage the parents to role model ways to act when one is disappointed C) suggest that all the children are included in family decision making D) evaluate the proper use of equipment that is provided to improve the child's lifestyle

A) recommend the use of consistent discipline and reward for acceptable behavior WHY Focusing on the child, and not the condition, is essential in assisting the child to adapt to a chronic disability or illness. Consistent family rules (A) should be used with a chronically ill child, such as setting boundaries for acceptable behavior, requiring participation in household activities, and fulfilling school responsibilities. (B, C, and D) may be worthwhile interventions, but do not have the priority of providing the child with consistent expectations of acceptable behavior.

A 7 year old foster child is brought to the clinic. The child was abused by her parents before going into foster care. As part of a psychosocial assessment to rule out any chronic dissociative pattern of coping, the nurse would ask about which of the following? Select all. A) odd, contradictory displays of behavior B) the presece of other siblings in the home C) presence of auditory or visual hallucinations D) ability to play or interact with other children E) 24 hour nutritional intake

A, D, E

A mother is crying as she holds and rocks her child with tetanus who is having muscular spasms and crying. After administering diazepam (Valium) to the child, what action should the nurse implement? A) lay the child down and ask the mother to stay near the child in the crib B) encourage the mother to take a break and leave the room to stop crying C) keep all light sources off and close the window blinds to the room D) use calm reassurance and understanding to comfort the mother

A0 lay the child down and ask the mother to stay near the child in the crib WHY Controlling environmental stimulation such as noise, light, or tactile stimuli helps reduce CNS irritability related to acute tetanus. The mother should be instructed to minimize handling of the child during episodes of muscle spasticity and to stay calmly near the child (A). The mother's presence with the child provides security and support, so (B) is not indicated. Reducing external stimuli (C) may have some effect in reducing the child's distress, but light tends to be less irritating than vibratory or auditory stimuli and is essential for careful observation. Although a calm, reassuring manner and sympathetic understanding (D) can help reduce the mother's anxiety, the most comforting measure for the child is the presence of the mother.

A college student recently diagnosed with type 1 diabetes states "You know I am in college, and I know I will want to go out for a beer every no and again. I understand that a can of beer has a lot of calories, so I'll watch what I eat if I am going to have a drink." What is the best response by the nurse? A) drinking alcohol is prohibited on a diabetic diet because you cannot predict how your blood glucose will react B) alcohol does contain a lot of empty calories but is also likely to cause your blood glucose to decrease C) plan to take extra insulin when you drink beer because drinking will increase your blood glucose D) a can of beer equals one carbohydrate on the exchange so adjust your calories and food intake accordingly

B) alcohol does contain a lot of empty calories but it is also likely to cause your blood glucose to decrease Rationale: twelve ounces of beer is the equivalent of two fat exchanges, which may elevate triglyceride levels, as well as adding empty calories. It is important that the diabetic understand that alcohol may induce hypoglycemia. Therefor, the patient should drink alcohol only in moderation, and with or shortly after meals.

The client complains of chronic pruritus. Which of the following diagnoses would the nurse expect to support this client's complaint? A) anemia B) renal failure C) hypothyroidism D) diabetes mellitus

B) renal failure Rationale: Clients with renal failure often have pruritus, or itchy skin. This is because of impaired clearance of waste products by the kidneys. The client who is markedly anemic is likely to have pale skin. Hypothyroidism may lead to complaints of dry skin. Clients with diabetes mellitus are at risk for skin infections and skin breakdown.

The operating room nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104°F temperature in the operating room and nearly died 15 years ago. What relevance does this information have regarding your patient? A) the patient may be nervous B) the patient may be at risk for developing malignant hyperthermia C) the grandmother's surgery has no relevance to the patient's surgery D) the patient may be at risk for hypothermia

B) the patient may be at risk for developing malignant hyperthermia Rationale: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying patients at risk is imperative because the mortality rate is 50%. Options A, C, and D are incorrect; the patient's nervousness is not relevant, the grandmother's surgery is very relevant, and all patients are at risk for hypothermia

he nurse reviews the complete blood count (CBC) findings of an adolescent with acute myelogenous leukemia (AML). The hemoglobin is 13.8 g/dl, hematocrit is 36.7%, white blood cell count is 8,200 mm3, and platelet count is 115,000 mm3. Based on these findings, what is the priority nursing diagnosis for this client's plan of care? A) impaired gas exchange B) risk for infection C) risk for injury D) risk for activity intolerance

C) risk for injury WHY A client with AML is at risk for anemia, neutropenia, and thrombocytopenia. These CBC findings indicate that the platelet count is low (normal 250,000 to 400,000 mm3), which places this client at an increased risk for injury (C), usually manifested as bruising or bleeding. There is no evidence of impaired gas exchange (A) due to respiratory compromise, risk of infection (B) due to neutropenia, or risk for activity intolerance (D) secondary to anemia and fatigue.

The nurse is discussing the past week's activities with a client receiving amitriptyline hydrochloride. The nurse evaluates that the medication is most effective for this client if the client reports which of the following? A) a decrease in appetite B) sleeping 14-16 hours each day C) ability to get to work on time each day D) having difficulty concentrating on an activity

C) ability to get to work on time each day Rationale:Depressed individuals will sleep for extended periods, have a change in appetite, be unable to go to work, and have difficulty concentrating. They may also experience fatigue, feelings of guilt or worthlessness, loss of interest in activities, and possible suicidal tendencies. Once they have had some therapeutic effect from their medication, they will report resolution of many of these complaints and demonstrate an improvement in their appearance. Test-Taking Strategy: Use the process of elimination to answer the question. Note the strategic words most effective. The symptoms stated in options 1, 2, and 4 are all symptoms of depression. The ability to report to work indicates a therapeutic response to the medication, thus indicating compliance with the medication regimen. Review the intended effect of this medication if you had difficulty with this question.

Your patient has just returned from the PACU following left tibia ORIF. The patient is complaining of pain, and you are preparing to administer a first dose of meperidine. Prior to administering the drug, you would assess for the patient's A) electrolyte values B) blood pressure C) allergies to any medications D) hydration status

C) allergies to any medications Rationale: Feedback: Before administering medications such as narcotics for the first time, the nurse should assess for any previous allergic reactions. Electrolyte values, blood pressure, and hydration status are not what you need to assess prior to giving a first dose of narcotics.

You are the triage nurse in the emergency department (ED). A patient presents complaining of pain and swelling in the right lower leg beginning last night along with fever, chills, and sweating. The patient states that she "hit my leg on the car door 4 or five days ago and it has been sore ever since." The patient has a history of chronic venous insufficiency. You suspect that this might be what? A) thrombocytopenia B) arterial insufficiency C) cellulitis D) phlebothrombosis

C) cellulitis Rationale: Cellulitis is the most common infectious cause of limb swelling. The signs and symptoms include acute onset of swelling, localized redness, and pain; it is frequently associated with systemic signs of fever, chills, and sweating. The patient may be able to identify a trauma that accounts for the source of infection. Option A is incorrect; thrombocytopenia is a loss or decrease in platelets and increases a patient's risk of bleeding. Option B is incorrect; arterial insufficiency would present with pain related to activity. Option D is incorrect but a good answer; phlebothrombosis presents with the same signs and symptoms but is usually associated with mobility limitations and the patient would not be able to identify a trauma that accounts for the source of infection

You have just received report on a 47-year-old woman who is coming to your unit from the emergency department with a severely broken leg. You review her PRN medications and see that she has an NSAID (ibuprofen) ordered every 4 hours. If you wanted to implement preventive pain measures when the patient arrives to your unit, what would you do? A) check for allergies, use a pain scale to assess the patient's pain, and let the patient know ibuprofen is available every 4 hours if she needs it B) do a complete assessment and give pain medication based on the patient's report of pain C) check for allergies, use a pain scale to assess the patient's pain, and offer the ibuprofen every 4 hours until the patient is discharged D) provide medication as per patient request and offer relaxation techniques to promote comfort

C) check for allergies, use a pain scale to assess the patient's pain, and offer the ibuprofen every 4 hours until the patient is discharged Rationale: One way preventive pain measures can be implemented is by using PRN medications on a more regular or scheduled basis to allow for more uniform pain control. Smaller drug doses of medication are needed with the preventive pain method when PRN medications are given around the clock. Options A and B are incorrect; letting the patient know ibuprofen is available every 4 hours if she needs it or when the patient reports pain is simply offering the medication PRN. Option D is incorrect; providing medication as per patient request is simply offering the medication PRN, although offering relaxation techniques to promote comfort would work well along with preventive pain measures.

An infant with developmental dysplasia of the hip is placed in a Pavlik harness. What instructions should the nurse include in a teaching plan for the parents? A) apply lotion or powder to minimize skin irritation B) put clothing over harness for maximum effectiveness C) check for red areas under the straps three times a day D) use a thin absorbent disposable diaper over the harness

C) check for red areas under the straps 3 times a day WHY? The Pavlik harness, which maintains the hips in abduction, is the most widely used device for developmental dysplasia of the hip. An infant who continuously wears a Pavlik harness is at risk for skin breakdown, so parents should be instructed to check two to three times a day for red areas under clothing and harness straps (C). Lotions and powders (A) can cake or irritate the skin and should be avoided. To avoid direct contact with the skin, clothing and diapers should be placed under the straps (B and D).

A nurse is caring for a client with type 1 diabetes who is experiencing a fluid imbalance. Which fluid shift associated with diabetes should the nurse take into consideration when assessing this client? A) intravasculare to interstitial as a result of glycosuria B) extracellular to interstitial as a result of hypoproteinemia C) intracellular to intravascular as a result of hyperosmolarity D) intercellular to intravascular as a result of increased hydrostatic pressure

C) intracellular to intravascular as a result of hyperosmolarity WHY? The osmotic effect of hyperglycemia pulls fluid from the cells, resulting in cellular dehydration. Hyperglycemia pulls fluid from the interstitial compartment to the intravascular compartment. Interstitial fluid is part of the extracellular compartment; the osmotic pull of glucose exceeds that of other osmotic forces. An increase in hydrostatic pressure results in an intravascular-to-interstitial shift.

The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. For which clinical indicator should the nurse assess first? A) cyanosis B) bradycardi C) mental confusion D) distended neck veins

C) mental confusion Rationale: Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

A client, complaining of fatigue, is admitted to the hospital with a diagnosis of chronic obstructive disease (COPD). To prevent fatigue, the nurse should: A) provide small, frequent meals B) encourage pursed-lip breathing C) schedule nursing activities to allow for rest D) encourage bed rest until energy level improves

C) schedule nursing activities to allow for rest Rationale: Rest limits muscle contractions, which diminishes oxygen needs and decreases fatigue. Although small frequent meals may decrease pressure on the diaphragm and facilitate breathing, it does not address the client's fatigue. Although encouraging pursed-lip breathing facilitates gas exchange, it does not reduce the metabolic demand for oxygen. Bed rest promotes pooling of pulmonary secretions, which may aggravate the client's respiratory status.

A nurse is admitting a 45-year-old man to the Medical Surgical unit. The patient has a diagnosis of Buerger's disease. While taking the patient's health history he reveals that he smokes about 2 packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority teaching for this patient? A) the lack of exercise which is the identified cause of Buerger's disease B) the likelihood that drinking alcohol and not exercising may cause his death in the near future without a significant change in behavior C) the cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate Buerger's disease D the fact that alcohol suppresses the immune system creates high glucose levels, and may cause Buerger's disease

C) the cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate Buerger's disease Rationale Tobacco is powerful vasoconstrictor; its use with Buerger's disease is highly detrimental, and patients are strongly advised to stop using tobacco. Symptoms are often relieved by cessation of smoking along with all types of tobacco use. Option A is incorrect; the identified cause of Buerger's disease is believed to be autoimmune in nature, resulting in occlusion of distal vessels. Option B is incorrect; although drinking alcohol is not suggested and exercise is encouraged for patients with Buerger's disease, there is no evidence to suggest that "drinking alcohol and not exercising" dramatically increases the patients' short-term risk of death. Option D is incorrect; alcohol is not a significant factor or cause of Buerger's disease

An immunosuppressed patient is receiving chemotherapy treatment at home. What would the nurse advise the family to do to reduce the risk of infection to the immunosuppressed patient? A) encourage the patient to eat uncooked fruits B) take a strict to cleanliness and risk reduction C) their home needs to be clean but not sterile D) avoid patient contact at all times

C) their home needs to be clean but not sterile Rationale: When assessing the risk of the immunosuppressed patient in the home environment for infection, it is important to realize that intrinsic colonizing bacteria and latent viral infections present a greater risk than do extrinsic environmental contaminants. The nurse should reassure the patient and family that their home needs to be clean but not sterile. Common-sense approaches to cleanliness and risk reduction are helpful

Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes? A) ketones in the blood but not in the urine B) glucose in the urine but not hyperglycemia C)urine negative for ketones and hyperglycemia D) blood and urine positive for both glucose and ketones

C) urine negative for ketones and hyperglycemia WHY? In type 2 diabetes, there is sufficient insulin production to prevent fat breakdown that leads to ketones, but insulin resistance leads to hyperglycemia. Ketones in the blood but not in the urine does not occur with either type. In type 2 diabetes, there is sufficient insulin production to prevent fat breakdown that leads to ketones, but insulin resistance leads to hyperglycemia and diabetes mellitus. Glucose in the urine but not hyperglycemia is impossible; if glycosuria is present, the level of glucose in blood first must exceed the renal threshold of 160 to 180 mg/dL. Blood and urine positive for both glucose and ketones is expected in uncontrolled type 1 diabetes.

A patient visits the clinic and is diagnosed with acute sinusitis. To promote sinus drainage, the nurse instructs the patient to A) apply a cold pack to the affected area B) apply a mustard poultice to the forehead C) perform postural drainage D) increase fluid intake

D) increase fluid intake Rationale: For a patient diagnosed with acute sinusitis, the nurse should instruct the patient that hot packs, increasing fluid intake, and elevating the head of the bed can also promote drainage. Applying a mustard poultice and postural drainage will not promote sinus drainage

The client with human immunodeficiency virus (HIV) infection has been started on therapy with zidovudine (AZT, Retrovir). The nurse reviews the physician's orders, expecting to noted that which of the following laboratory tests have been ordered? A) blood culture B) blood glucose level C) blood urea nitrogen level (BUN) D) complete blood cell count (CBC)

D) complete blood cell count (CBC)

A client's blood gases reflect diabetic ketoacidosis. Which clinical indicator should the nurse expect to identify when monitoring this client's laboratory values? A) increased pH B) decreased PO2 C) increased PCO2 D) decreased HCO3

D) decreased HCO3 WHY? The bicarbonate-carbonic acid buffer system helps maintain the pH of body fluids; in metabolic acidosis there is a decrease in bicarbonate because of an increase of metabolic acids. The pH is decreased. The PO2 is not decreased in diabetic acidosis. The PCO2 may be decreased by the body's attempt to eliminate CO2 to compensate for a decreased pH.

An ultrasound is performed on a client with a suspected abruptio placentae, and the results indicate that a placental abruption is present. The nurse would prepare the client for: A) complete bed rest for the remainder of the pregnancy B) strict monitoring of intake and output C) the need for weekly monitoring of coagulation studies until the time of delivery D) delivery of the fetus

D) delivery of the fetus

A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the health care provider, which action should the nurse take? A) place the client on the unaffected side B) administer 60% oxygen via venturi mask C) prepare for IV administration of electrolytes D) give oxygen 2L per minute via nasal cannula

D) give oxygen 2L per minute via nasal cannula Rationale: Oxygen is supplied to prevent anoxia, but not in high concentrations without a prescription. In an individual with emphysema, a low oxygen level, not high carbon dioxide level, may be the respiratory stimulus. Another reason is the Haldane effect; as hemoglobin molecules become more saturated with high concentrations of oxygen, they are unable to transport carbon dioxide out of the body, leading to hypercapnia. Placing the client on the unaffected side might increase the risk for mediastinal shift and interfere with expansion of the unaffected lung. Although oxygen is administered to prevent hypoxia, this concentration is too high for a client with emphysema because it may precipitate carbon dioxide narcosis. Preparing for an IV administration of electrolytes requires presciptions as to specific electrolytes.

A nurse is caring for a client who had a hypophysectomy. For which complication specific to this surgery should the nurse assess the client for early manifestations? A) urinary retention B) respiratory distress C) bleeding at the suture line D) increased intracranial pressure

D) increased intracranial pressure WHY? Because the pituitary gland is located in the brain, edema after surgery may result in increased intracranial pressure. Early signs include decreased visual acuity, papilledema, and unilateral pupillary dilation. Urinary retention may follow any surgery because of the effects of anesthesia and is not a specific occurrence following cranial surgery. Respiratory distress is a later, not early, sign of increased intracranial pressure. This is a decompensated response indicated by altered respiratory pattern, decreased respiratory rate, and, finally, respiratory arrest. This occurs because of increasing pressure on the medulla. Bleeding at the suture line may occur with any surgery, not just a hypophysectomy.

A health care provider prescribes furosemide (lasix) for a client with hypervolemia. The nurse revalls that furosemide exerts its effects in what part of the renal system? A) distal tubule B) collecting duct C) golmerulus of the nephron D) loop of henle

D) loop of henle Rationale: Furosemide acts in the ascending limb of the loop of Henle in the kidney. Thiazides act in the distal tubule in the kidney. Potassium-sparing diuretics act in the collecting duct in the kidney. Plasma expanders and xanthines act in the glomerulus of the nephron in the kidney.

The nurse is speaking with a female client taking phenytoin (Dilantin) for seizure control. The client states that she has started using birth control pills to prevent pregnancy. Which of the following would be an important point for the nurse to stress to the client? A) oral contraceptives decrease the effectiveness of phenytoin B) severe grastrointestinnal side effects can occur when phenytoin and oral contraceptives are taken together C) there is an increased risk of thrombophlebitis when phenytoin and oral contraceptives are taken at the same time D) phenytoin may decrease effectivenss of birth control pills, and additional measures should be taken to avoid pregnancy

D) phenytoin may decrease effectivenss of birth control pills and additional measures should be taken to avoid pregnancy Rationale: Phenytoin (Dilantin) enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options 1, 2, are 4 are not accurate.

The nurse is assigned to a client who is psychotic, pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines that the priority of care at this time is which of the following A) providing the other clients on the unit with a sense of comfort by isolating the client B) offering the client a less stimulated area in which to calm down and gain control C) assisting in caring for the client in a controlled environment, such as a quiet room D) providing safety for the client and other clients on the unit

D) providing safety for the client and other clients on the unit the only answer that addresses the needs of the client and other client's safety needs

A client has a chest tube inserted to treat a right hemopneumothorax. In which position should the nurse place the client to facilitate chest drainage? A) supine B) left sims C) immobilized D) right side lying

D) right side lying Rationale: Lying on the affected right side increases drainage from the pleural space and allows the unaffected lung to expand to the fullest extent. The supine position is undesirable because this may not allow the unaffected lung to fully expand and provide maximum oxygenation. The left Sims position is undesirable because this may not allow the unaffected lung to fully expand and provide maximum oxygenation. Immobilization promotes stasis of respiratory secretions. The client should be encouraged to perform deep breathing and coughing exercises and periodically move around in bed.

The home health nurse is developing a care plan for an alert and active 85-year-old patient who takes multiple medications for chronic cardiac and respiratory disease. The patient lives with family members who work during the day. An appropriate nursing diagnosis is A) compromised family coping related to the patient's many care needs B) caregiver role strain related to need to adjust family employment schedule C) social isolation related to weakness and fatigue D) risk for injury related to drug-drug interactions

D) risk for injury related to drug-drug interactions

The client tentatively diagnosed with a borderline personality is admitted to the psychiatric unit for control of symptoms. Based on a thorough understanding of personality disorders, the nurse would select which nursing diagnosis as the priority? A) social isolation B) chronic low self esteem C) ineffective coping D) risk for self mutliation

D) risk for self mutilation

The nurse obtains the following data when caring for a patient who experienced an AMI 2 days previously. Which information is most important to report to the health care provider? A) the oral temperature is 100.8 F (38.2 C) B) The patient denies ever having a heart attack C) the white blood cell count (WBC) is 12,000 /ml. D) the lunfs have crackles audible to the midline

D) the lungs have crackles audible to the midline The crackles indicate that the patient may be developing heart failure, a possible complication of MI. The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. The fever and elevated WBC are normal occurrences after MI as a result of inflammation that occurs after tissue necrosis. Denial is a common response in the immediate period after the MI.

Which clinical finding should the nurse expect a child with nephrosis to exhibit? A) elevated blood pressure B) blood tinged urine C) elevated temp D) urine protein 3+ to 4+

D) urine protein 3+ to 4+ WHY In nephrosis, renal tubules become permeable to proteins, causing massive proteinuria (D). (A and B) are characteristic of acute glomerulonephritis. Infection, indicated by (C), is not the cause of nephrosis, but may occur secondary to immunosuppressive therapy.

The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse positions the infant: A) in a supine, side lying position B) prone, with the head of the bed elevated 15 degrees C) with the head at a 60 degree angle with the neck slightly flexed D) with the head and chest at a 30 degree angle with the neck slightly extended

D) with the head and chest at a 30 degree angle with the neck slightly extended