Prep-Us

A woman who was raped in her home was brought to the emergency department by her husband. After being interviewed by the police, the husband talks to the nurse. "I do not know why she did not keep the doors locked like I told her. I cannot believe she has had sex with another man now." The nurse should respond by saying:

"Let us talk about how you feel. Maybe it would help to talk to other men who have been through this."

What is the priority nursing measure for a client with von Willebrand's disease who is having epistaxis?

Apply pressure to the nose

A nurse should assess the maturity of enzyme systems (kidney and liver) in which pediatric population before administering medications?

Premature infants

Parents of a 3-week-old healthy newborn ask the nurse why their daughter is intermittenly cross-eyed. The nurse's best response is:

"It is normal to have eye crossing in the newborn period."

Which statement by the client indicates an understanding of teaching regarding use of corticosteroids during preterm labor?

"The corticosteroids may help my baby's lungs mature."

A client taking oral contraceptives is placed on a 10-day course of antibiotics for an infection. Which instruction should the nurse include in the teaching plan?

"Use a barrier method of birth control for the rest of your cycle."

A premature infant has been placed on a home apnea monitor. The nurse is giving discharge instructions to the parents. The nurse begins teaching by stating:

"Using the monitor will help your physician determine the frequency of apneic events and how long monitoring is required."

A 74-year-old client receiving fluphenazine decanoate therapy develops pseudoparkinsonism, and is ordered amantadine hydrochloride. With the addition of this medication, the client reports feeling dizzy when standing. Which response by the nurse is best?

"When you change positions, do so slowly."

A new mother asks the maternity nurse about sudden infant death syndrome (SIDS). The nurse tells the mother that SIDS most likely to occur at what age?

1 week to 1 year, peaking at 2 to 4 months

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit?

A sunken fontanel

Which drugs may be abused because of tolerance and physiologic dependence.

Alprazolam and phenobarbital

What is the priority nursing assessment of a client with an eating disorder?

Level of danger to self

Which of the following actions is correct when the student nurse assesses the fontanels of a 6-week-old infant?

Palpating the fontanels gently while the infant sits on the parent's lap

Prior to the client having a pleural effusion drained, and after verifying client identification, the nurse should take the actions in what priority from first to last? All options must be used.

Check the primary health care provider's prescription. Gather drainage kit supplies. Perform hand hygiene. Assess the client's respiratory rate, status, breath sounds, and discomfort level.

An infant boy has just had surgery to repair his cleft lip. Which nursing intervention is important during the immediate postoperative period?

Cleaning the suture line carefully with a sterile solution after every feeding

The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital?

Decrease the client's feelings of isolation and loneliness.

A client suddenly behaves in an impulsive, hyperactive, unpredictable manner. Which approach would be best for the nurse to use first if the client becomes violent?

Get help to handle the situation safely.

A client who reports consuming 1 qt (1 L) of vodka daily is admitted for alcohol detoxification. The nurse anticipates the need to teach the client about which medication?

Lorazepam

After teaching a group of students who are volunteering for a local crisis hotline, the nurse judges that further education about crisis and intervention is needed when a student makes which statement?

Most people in crisis will be calling the line once every day for at least a year."

The nurse should ensure that which item is placed when the client is to receive intravascular therapy for more than 6 days?

PICC

A hospitalized infant, age 10 months, begins to choke while eating and quickly becomes unconscious. A foreign object isn't visible in the infant's airway, but respirations are absent and the pulse is 50 beats/minute and thready. The nurse attempts rescue breathing, but the ventilations are unsuccessful. What should the nurse do next?

Perform chest compressions.

A client with AIDS develops a fever, severe headache, and stiff neck and begins to vomit. Family members state they have noticed that the client does not seem to be as alert and oriented as before. Which of the following is the nurse's priority intervention?

Protecting the client's airway

Which nursing intervention is priority for a pregnant adolescent during her first trimester?

Refer the client to a dietitian for nutritional counseling

Family members of a dying patient have asked for the hospital chaplain's help in having a member of the clergy come to the patient's bedside to perform anointing of the sick. The nurse who is providing care for the patient should recognize that the family is likely:

Roman Catholic.

A nurse is caring for a client receiving lidocaine I.V. Which factor is most relevant to administration of this medication?

Runs of ventricular tachycardia on a cardiac monitor

For children from infancy through the preschool years, what is the major stressor posed by hospitalization?

Separation from the family

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm?

The client reports increasing severe back pain.

Nurse researchers have proposed a study to examine the efficacy of a new wound care product. Which of the following aspects of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence?

The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention.

A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?

Urine output of 20 ml/hour

Which complication does a third heart sound (S3) indicate?

Ventricular dilation

Which information obtained during the nursing history would help support a child's diagnosis of hemophilia?

a maternal uncle with prolonged postoperative bleeding

A physician writes a medication order for meperidine 500 mg. The nurse's appropriate action would be to:

clarify the order with the physician.

A client with aplastic anemia is instructed to eat foods rich in iron. The nurse should instruct the client to include which food in the diet to increase iron intake?

dark green leafy veggies

The wife of a client with alcohol dependency tells the nurse, "I am tired of making excuses for him to his boss and coworkers when he cannot make it into work. I believe him every time he says he is going to quit." The nurse recognizes the wife's statement as indicating which behavior?

enabling

The client approaches various staff with numerous requests and needs to the point of disrupting the staff's work with other clients. The nurse meets with the staff to decide on a consistent, therapeutic approach for this client. Which approach will be most effective?

having the client discuss needs with the staff person assigned

What should a nurse expect to find while assessing the vital signs of a client who has abruptly stopped taking his beta-adrenergic blocker?

irregular pulse

To ensure safety for a hospitalized blind client, the nurse should:

orient the client to the room environment.

While the nurse is assisting a client to ambulate as part of a cardiac rehabilitation program, the client has midsternal burning. The nurse should:

stop and assess the client further.

A client is taking large doses of aspirin daily to treat rheumatoid arthritis. The nurse should instruct the client to tell the health care provider (HCP) when having:

tinnitus.

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement made by the client about safer sex practices for persons with HIV is accurate?

"A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse."

The parents of an infant with myelomeningocele ask the nurse about their child's future mental ability. What is the nurse's best response?

"About one-third have an intellectual disability, but it is too early to tell about your child."

When a client expresses feelings of unworthiness, the nurse should respond by saying:

"As you begin to feel better, your feelings of unworthiness will begin to disappear."

After a client reveals a history of childhood sexual abuse, what question should the nurse ask first?

"Does your abuser still have contact with young children?"

The nursing team consists of one RN, one LPN, and one unlicensed assistive personnel (UAP). Which assignment should the RN delegate to the LPN?

Administering daily am medications

During the recuperation phase, a client with severe burns has become withdrawn. What concerns should the nurse explore?

Concerns about body image and self esteem

A client has a nasogastric (NG) tube. How should the nurse administer oral medication to this client?

Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube.

A nurse is working in a clinic where a family member's spouse is treated for a sexually transmitted disease. The nurse is concerned about the risk to her family member. What is the most appropriate action for the nurse to take?

Encourage the client to speak with the family member about the diagnosis if he or she has not already done so.

A client is brought to the emergency department after a house fire. What is the priority intervention by the nurse?

Ensure a patent airway

The nurse is caring for a client with a Jackson-Pratt drain. Which of the following would be the most appropriate action by the nurse?

Ensure that the drainage receptacles are kept compressed to maintain suction.

The children of an elderly male client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their father's bedside tomorrow to make recommendations for his care. Which of the following considerations should the nurse prioritize in light of the practitioner's planned visit?

Ensuring any complementary therapies are safe when combined with his prescribed therapy.

A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution?

I.V. tubing with a volume-control chamber

A client reports an inability to sleep while on the medical unit. Which intervention should the nurse perform first?

Inquire about the client's sleeping habits

Which factor should a nurse anticipate having the most influence on the outcome of a client facing a crisis situation?

Previous coping skills

A client changes topics quickly while relating past psychiatric history. This client's pattern of thinking is called:

flight of ideas

Which is least likely a danger associated with pancytopenia?

hypothyroidism

The nurse should instruct the client with vitamin B12 deficiency to eat which foods to obtain the best supply of vitamin B12?

meats and dairy products

The healthcare provider prescribes venlafaxinefor the client. The nurse explains the purpose of the medication to the client. The client asks the nurse, "If I start taking the pills, will I have to take them the rest of my life?" Which would be the nurse's most accurate and therapeutic reply?

"After your symptoms decrease, the need for medication will be reevaluated."

A nurse is providing discharge instructions to a client with peripheral vascular disease that include stress-reduction techniques. The client asks the nurse, "Why is reducing stress so important?" What is the nurse's best response?

"Stress reduction techniques are helpful because stress stimulates the release of vasoconstricting catecholamines."

A female client with the beta-thalassemia trait plans to marry a man of Italian ancestry who also has the trait. Which client statement indicates that she understands the teaching provided by the nurse?

"We'll need more genetic counseling in the future."

The nurse is caring for a client admitted to the emergency department after being found lying on the bathroom floor with several empty pill bottles around her. While waiting for a psychiatric consult, the nurse discovers that the client's boyfriend has recently broken up with her. Which response is most likely is to build and maintain a therapeutic relationship within the emergency department?

"What can I do to help while you are here?"

The client was admitted to the psychiatric unit yesterday evening. In the morning, the client approaches the nurse and states, "The psychiatrist all of you nurses are conspiring against me. I have been warned and I know it is true. You know what I mean." Which response by the nurse would be most therapeutic?

"You must feel very frightened. You are safe here."

The nurse observes that a client is very sad and dejected after a myocardial infarction. What is the best response to the statement, "Life will never be the same"?

"You're very concerned when you think about how this will change your life."

When the nurse is assessing a client's cultural adaptation, which statement is least sensitive to the client's needs?

"Your eyes look dark; is this normal for you?"

The nurse is assigned to care for four clients. Which client should the nurse assess first?

A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem

A charge nurse is developing the client care assignments for the shift. Which client is most appropriately assigned to a licensed practical nurse (LPN)?

A client who experienced a cerebral vascular accident and has a do-not-resuscitate (DNR) status

Which situation demonstrates correct principles of confidentiality?

An emergency department nurse reports suspected child abuse.

A nurse suspects a client is experiencing alcohol withdrawal syndrome. What is the nurse's priority action?

Ask the client about his drinking

While listening to a taped-report at shift change, one of the other team members remarks that "My mother lives near this client, and his yard is always full of junk." What should the nurse assigned to provide care to this client do in this situation?

Ask the team member what the purpose was in sharing the information.

The nurse is conducting walking rounds and observes the client (see figure). What should the nurse do?

Assess the client to determine why she wants to sit up.

The health care provider (HCP) has prescribed ciprofloxacin for a client who takes warfarin. What should the nurse instruct the client to do? Select all that apply.

Avoid exposure to sunlight. Report unusual bleeding.

What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele?

Carefully position and handle the omphalocele

A nurse is preparing a teaching plan for a male client newly prescribed atenolol. Which information is important for the nurse to teach this client?

Causes and treatments for erectile dysfunction

A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse?

Collaborate with the interprofessional team to make a referral to social services

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action?

Contact the physician and obtain necessary orders.

The nurse is working with a highly culturally diverse group of mostly young adult clients who have substance abuse issues. Many clients in the group have had difficult social circumstances and experience relapses. What would be the most appropriate nursing intervention in dealing with these clients?

Encourage motivation and confidence so that the clients can better deal with the triggers that cause them to repeat their behaviors.

Which would be most helpful when coaching a client to stop smoking?

Establish the client's daily smoking pattern.

A client of Anglo-Saxon descent (e.g., Anglo-American or English Canadian) reports to the primary health care facility with symptoms of fever, cough, and running nose. While interviewing the client, which of the following points should the nurse keep in mind?

Maintain eye contact while talking.

A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When asking this client to complete a task, what techniques should the nurse use to communicate most effectively with him?

Obtain eye contact before speaking, use simple language, and have him repeat what was said. Praise him if he completes the task.

A nurse working on a surgical unit administers an intramuscular medication to a client and is stuck with the used hypodermic needle while walking to the sharps container. This unit has a higher incidence of needle stick injuries than other units within the agency. Which of the following actions by the nurse manager would demonstrate advocacy for a quality practice environment?

Obtain suggestions from staff on decreasing needle stick injuries.

A nurse needs to obtain an accurate blood pressure on a client. Which of the following is the most important action for the nurse to take to ensure an accurate reading?

Palpate the brachial artery and then place the arrow on the cuff over the palpated artery.

When providing care to Aboriginal clients, it may be important for the nurse to elicit help from the

Spiritual Healer

A client with a panic disorder is having difficulty falling asleep. Which nursing intervention should be performed first?

Teach the client progressive relaxation

A client is 2 days post small bowel resection with a placement of an ostomy in the right lower quadrant. The nurse is teaching the client to apply an ostomy appliance to the client's abdomen. Which of the following would indicate to the nurse that the teaching was successful?

The client assesses the stoma and the surrounding skin before replacing the new appliance.

Following abdominal surgery, which factor predisposes a client to deep vein thrombosis?

The client will be immobile during and shortly after surgery.

In which of the following parts of the body should the nurse administer an intramuscular injection to a 6-month-old infant?

The lateral middle third of the thigh between the greater trochanter and the knee

A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which of the following should the nurse keep in mind?

The nurse needs to be creative in integrating the technical and relational aspects of care.

A nurse is instructing an unlicensed assistive personnel (UAP) on the proper care of a client in Buck's extension traction following a fracture of the left fibula. Which observation would indicate that teaching has been effective?

The weights are allowed to hang freely over the end of the bed.

A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures have been completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the rationale for communicating these planned nursing interventions?

To attempt to establish a trusting relationship

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action?

To clear secretions from the tubing

The nurse is caring for an elderly client with a fractured hip who is on bed rest. Which nursing interventions would be included on the plan of care?

Turn the client every 2 hours, and encourage coughing and deep breathing.

Which laboratory tests should the nurse expect the physician to routinely order for a client prescribed carbamazepine? Select all that apply.

Urine glucose Complete blood count (CBC) Electrolyte tests Serum iron

When assessing a client with an acute infection, the nurse would expect which laboratory results?

White blood cell count 14,000 cells/mcL (14 X10/L)

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps?

Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

A client tells the nurse that "the hospital food is horrible." What should the nurse tell the client?

Would you like to speak with the dietitian about the food and meal selection?"

An infant is being admitted to the hospital with dehydration secondary to viral gastroenteritis. Which room assignment is the most appropriate for this infant?

a private room

A woman is taking oral contraceptives. The nurse teaches the client that medications that may interfere with oral contraceptive efficacy include:

antibiotics.

The nurse is assessing the infant shown in the figure. On observing the client from this angle, the nurse should document that this infant has which finding?

asymmetric gluteal folds

A client is receiving vincristine. Client teaching by the nurse should include instructions on:

bowel regimen.

The nurse judges that the mother has understood the teaching about care of an infant with colic when the nurse observes the mother doing which action?

burping the infant during and after the feeding

A mother asks the nurse when she should wean her 4-month-old infant from breast-feeding and begin using a cup. What should the nurse explain as the best indication of the infant's readiness to be weaned?

decreased interest in nursing

Before the nurse administers IV replacement of 5% dextrose in water with potassium chloride, what nursing intervention must be completed first?

evaluating laboratory results for electrolytes

Interferon alfa-2b has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which common adverse effects?

flulike symptoms

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:

forcing blood into the deep venous system.

The most effective way for a nurse to set limits for a newly admitted client who puts out cigarettes on the floor of the designated smoking room is to:

hand the client an ashtray and state that he must use it or he won't be allowed to smoke.

A client was discharged from an alcohol rehabilitation program on clonazepam 0.5 mg three times a day. Several months later he reports having insomnia, shakiness, sweating, and one seizure. The nurse should first ask the client if he:

has stopped taking the clonazepam suddenly.

A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled dress with stains on the front. Assessment also reveals a flat affect, confusion, and slow movements. Which goal should the nurse identify as the initial priority when planning this client's care?

helping the client feel safe and accepted

A client undergoing chemotherapy tells the nurse, "I do not want to get out of bed in the morning, because I am so tired." The nursing plan of care should include:

individually tailored exercise program.

A client has a reddened area over a bony prominence. The nurse finds an unlicensed nursing personnel (UAP) massaging this area. The nurse should:

instruct the UAP that massage is contraindicated because it decreases blood flow to the area.

Which symptom is an early indication that the client's serum potassium level is below normal?

muscle weakness in the legs

The parents of a child with sickle cell anemia ask about the chances of sickle cell disease occurring in future children. The nurse responds based on the knowledge that both parents are carriers. What is the risk of one of their children having the disease?

one chance in four for each pregnancy

The mother of an infant with hemophilia tells the nurse that she is planning to do home teaching when the child reaches school age. She does not want her child in school because the teacher will not watch the child as well as she would. The mother's comments represent what common parental reaction to a child's chronic illness?

overprotection

The most common issue associated with sleep disturbances in the hospitalized client with cancer is:

psychological.

During a physical examination, the nurse observes a copper bracelet on a client's wrist. The client states that she is wearing it to treat her arthritis. The nurse should:

recognize that the client is wearing a protective object she believes wards off illness.

A successful real estate agent brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, "He is fine except for this irrational belief that we will remarry." When collaborating with the health care provider (HCP) about a plan of care, which intervention would be most effective for the client at this time?

referral to an outpatient therapist

Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to:

revascularize the blocked coronary artery.

Which food would be appropriate for a 12-month-old child with celiac disease?

rice cereal

Which is a priority for exercising for a client who has just had a myocardial infarction?

risk modification education

The basis for building a strong, therapeutic nurse-client relationship begins with a nurse's:

self-awareness and understanding.

A client is complaining to other clients about not being allowed by staff to keep food in her room. The nurse should:

set limits on the behavior

When helping the client who has had a cerebrovascular accident (CVA) learn self-care skills, the nurse should:

teach the client to put on clothing on the affected side first.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:

use an alternating air pressure mattress.

When changing a sterile surgical dressing, a nurse first must:

wash her hands.

A client with granulocytopenia has many visitors. The most important measure to prevent infection is for the visitors to:

wash their hands

A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply.

weighing and recording all wet diapers obtaining an accurate daily weight obtaining an accurate stool count

The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to 30 minutes." The nurse explains that this variation is based on the fact that nurses:

work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation.

A nurse is assessing the family of a 10-year-old male child brought into the emergency department with severe injuries. Which statements made by the parents could indicate child abuse?

His injury happened a few days ago, but I didn't think it was bad."

After surgery to repair a cleft lip, an infant has a Logan bow in place. Which postoperative nursing action is appropriate?

Holding the infant semi-upright during feedings

The nurse is teaching a client with rheumatoid arthritis about how to manage the fatigue associated with this disease. Which statement by the client indicates she understands how to manage the fatigue?

I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night."

The nurse is caring for a client in the coronary care unit when the cardiac monitor reveals ventricular fibrillation. The nurse should anticipate which of the following interventions?

Immediate defibrillation

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction?

In a widening circle around the drain, outward from the center

A client has a respiratory rate of 4 breaths/min. What are this nurse's priority assessments?

Level of consciousness and a pulse oximetry value

A primary unit nurse tells the nurse-manager that a newly hired registered nurse needs an additional week of orientation in order to function effectively on the staff. Which action is most appropriate for the nurse-manager to take?

Meet with the new nurse and the primary nurse and help set up an additional week of orientation.

A client's arterial blood gas values are as shown on the accompanying chart. These findings indicate which of the following acid-base imbalances?

Metabolic acidosis.

A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention?

Prepare the client for surgical intervention

Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis?

Signs of increased intracranial pressure (ICP)

Which intervention should the nurse employ to reduce trauma caused during vaccine administration to a 6-month-old infant?

Simultaneously administer vaccines at separate sites with a second nurse.

The nurse understands that client position is important when treating dyspnea. What position would be contraindicated for a client who has dyspnea?

Supine

A parent tells the nurse that their 8-month-old infant is anxious. Which suggestion by the nurse is most appropriate to help the parent lessen anxiety in the infant?

Talk quietly to the infant while he is awake.

The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. Then nurse informs the parents that the development of a child's spirituality is best accomplished by:

Teaching through parental behaviors.

When assessing an infant with suspected inguinal hernia, which finding would be most significant?

The inguinal swelling is reddened, and the abdomen is distended.

The nurse is assessing a child one hour after a cardiac catheterization. For which finding would the nurse immediately alert the provider?

Weak, thready, unequal dorsalis pedis pulses

A 24-year-old client comes into the clinic reporting sudden-onset, right-sided chest pain and shortness of breath. While assessing the client, the nurse determines that the most important intervention is to:

auscultate the breath sounds.

A client's face is flushed. The client is swearing, yelling, and pushing chairs around the day room of a mental health center. The nurse judges the client to be in which phase of the assault cycle?

escalation

At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase. At a follow-up visit, which finding in the infant suggests that the parents require more teaching about administering the pancreatic enzymes?

fatty stools

The nurse manager of a psychiatric unit notices that one of the nurses commonly avoids a 75-year-old client's company. Which factor should the nurse manager identify as being the most likely cause of this nurse's discomfort with older clients?

fears and conflicts about aging

A nurse is administering an IV antineoplastic agent when the client says, "My arm is burning by the IV site." What should the nurse do first?

stop infusing the medication

A hospitalized client craves a drink after withdrawing from alcohol. Which measure is the best way to help the client resist the urge to drink?

support from other alcoholic clients

Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur?

talking with the nurse

A client with rheumatoid arthritis tells the nurse that she feels "quite alone" in adjusting to changes in her lifestyle. The nurse should respond by:

telling the client about her community's arthritis support group.

A client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl)(43.2 mmol/dL). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in his hands and feet. The nurse realizes that these symptoms probably result from:

thiamine deficiency.

Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate?

urine output greater than 30 ml/hour

A nurse is teaching the mother of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective?

"I know that this disease is serious and can lead to asthma."

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

"I will receive parenteral vitamin B12 therapy for the rest of my life."

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

"It will get better and worse again."

A client has been using Chinese herbs and acupuncture to maintain health. What is the best response by the nurse when asked if this practice could be continued during recuperation from a long illness?

"Let's discuss your desire to integrate these practices with the physician and advocate on your behalf."

After having trouble breastfeeding, a 6-week-old female infant exhibits dry, scaly skin and a protruding tongue. A diagnosis of congenital hypothyroidism is made. The mother asks the nurse why the child was not diagnosed with this condition at birth. What would be the nurse's best response?

"Newborns generally receive enough thyroid hormone from the mother to get by the first few weeks."

A client is 36 weeks gestation and has been admitted to the antenatal unit for gestational hypertension. The client states that she is alone because she has recently moved from another country, and she begins to cry. What is the best response by the nurse?

"Tell me more about how you are feeling."

A registered nurse (RN) is supervising the work of a licensed practical nurse (LPN) who's caring for a client diagnosed with a terminal illness. Which statement by the LPN should be corrected by the RN?

"The law says you must write a new living will each time you're admitted to the hospital."

A 35-year-old man was experiencing martial discord with his wife of 4 years. When his wife walked out, he became angry, throwing things and breaking dishes. A friend talked him into seeking help at the local mental health center. Which question should the nurse ask initially to begin to assess this man's immediate problem?

"What led you to come in for help today?"

A 6-month-old child is taken to the pediatrician, and the mother states that the child is not growing like other children of similar age in families she knows. The birth weight of the child was 7 pounds 11 ounces, (3,495 g) and the current weight is 11 pounds 2 ounces (5,057 g). Based on these findings, the nurse tells the mother:

"Your infant's weight is below the normal range based on the infant's age. Let's start with a few questions regarding your infant's eating habits".

A nurse prepares a client's medication by reconstituting a multi-dose vial of medication. What other nursing intervention should the nurse take? Select all that apply.

- Label the vial with the strength of the medication. -Store the multi-dose vial in a secure place. -The person reconstituting the medication should place their initials on the vial.

Which client would require one-on-one contact with a staff member?

A client with borderline personality disorder who has acted on suicidal ideation, and has cut herself

A nurse is employed at an outpatient rehabilitation facility caring for the client with opioid addiction who is in withdrawal. When assessing clients who present for their counseling session, which findings would be commonly observed? Select all that apply.

Abdominal cramps Rhinorrhea Dilated pupils

A 35-year-old female client is diagnosed with aplastic anemia. Which is the most important nursing measure to incorporate into the client's plan of care?

Alternate periods of activity with rest to decrease fatigue.

The nurse is documenting the assessment of a wound on a client's foot. Which of the following assessments would be included as subjective data?

Area around the wound is tender to touch.

After undergoing a cardiac catheterization, a client has a large puddle of blood under his buttocks. What is the nurse's priority action?

Assess the groin site

A 49-year-old client is admitted to the emergency department frightened and reporting that he hears voices telling him to do bad things. Which intervention should be the nurse's priority?

Assess the nature of the commands by asking what the voices are saying

The nurse is caring for a client in the post anesthesia care unit (PACU) following an adrenalectomy. What is the nurse's priority action?

Assessing blood pressure

A nurse is conducting an examination of a 6-month-old baby. During the examination, the nurse should be able to elicit which reflex?

Babinski's

A client comes to the emergency department reporting of severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). Which of the following should the nurse do first when the client is admitted to the coronary care unit?

Begin telemetry monitoring.

Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant?

Completion of range of motion on limbs restrained

A nurse working on a new unit is required to administer an unfamiliar medication to a client. How should the nurse proceed with the medication administration?

Consult a formulary or drug handbook to learn about the medication.

A nurse has migrated to a different country and started working there. Which of the following factors is important for effective functioning?

Cultural habituation

When working with clients in crisis, the nurse must be aware that crisis intervention differs from other forms of therapeutic intervention in that crisis intervention focuses on which concern(s)?

Determining immediate problems, as perceived by the client, with the short-term goal of problem solving

A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first?

Elevate the affected part

A client had a spontaneous vaginal birth after 18 hours of labor. Her vaginal bleeding is estimated to be 550 ml. Which nursing intervention should be a priority while caring for this client?

Empty the client's bladder

A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants?

Encourage parents to be present during the treatment.

A nurse is preparing a client for bronchoscopy. Which of the following instructions is appropriate for the nurse to give to the client?

"Don't eat for 6 hours prior to the procedure."

Which statement indicates to the nurse that the client is progressing toward recovery from a somatoform disorder?

"I understand my pain will feel worse when I am worried about my divorce."

After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an intravenous line with dextrose in 5% water infusing at 40 ml/hour and a triple-lumen urinary catheter with normal saline solution infusing at 200 ml/hour. The nurse empties the urinary catheter drainage bag three times during an 8-hour period for a total of 2,780 ml. How many milliliters would the nurse calculate as urine? Record your answer as a whole number.

1180

A nurse is caring for an infant who weighs 8 kg and is ordered to receive ampicillin 25 mg/kg intravenously every 6 hours. How many milligrams would a nurse administer per dose? Record the answer as a whole number.

200

The nurse is preparing to administer 500 mL of whole blood to a client. The blood is to be infused over 4 hours. The infusion tubing delivers 10 gtt/mL. How many drops of blood per minute must the nurse infuse to complete the infusion in 4 hours? Record your answer using a whole number.

21

A physician orders codeine, ½ grain every 4 hours, for a client experiencing pain. How many milligrams of codeine should the nurse administer?

30mg

During the nurse's assessment of a client who has been diagnosed with bulimia nervosa, the nurse evaluates certain assessment findings that accompany binge eating. Which are most applicable? Select all that apply.

Guilt Dental caries Self-induced vomiting Normal weight

A client receiving hemodialysis treatments arrives at the hospital with a blood pressure of 200/100 mmHg, a heart rate of 110 bpm, and a respiratory rate of 36 breaths/min. Oxygen saturation on room air is 89%. The client reports shortness of breath, and has + 2 pedal edema. The last hemodialysis treatment was yesterday. Which intervention should be done first?

Administer oxygen

A client who lives with his spouse and two adolescent children is being treated for alcoholism. After a family meeting, the client's wife asks a nurse about ways to help the family deal with the effects of her husband's alcoholism. Which organizations should the nurse suggest that the family join? Select all that apply.

Al-Anon Alateen

A client prescribed propranolol calls the clinic to report a weight gain of 3 lbs (1.36 kg) within 2 days, shortness of breath, and swollen ankles. What is the nurse's best action?

Have the client come to the clinic in order to assess the lungs.

How should a nurse position a 4-month-old infant when administering an oral medication?

Held in the bottle-feeding position

A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer?

Help the client dangle his legs.

The nurse is assessing a child, with type 1 diabetes mellitus, who recently came to the emergency department with signs and symptoms consistent with diabetic ketoacidosis. What is the nurse's priority when planning care for this child?

Prepare to administer intravenous fluids and insulin per order

Which action demonstrates the role of the psychiatric nurse in primary prevention?

Providing sexual education classes for adolescents

A nurse is caring for a client returning from cardiac catheterization. The nurse helps transfer the client back to bed. Which transfer technique uses appropriate ergonomic principles?

The nurse raises the bed for transfer, maintains a wide base of support during transfer, and lowers the bed before leaving the room

A client scheduled for a total laryngectomy and radical neck dissection begins talking rapidly, commenting, "I'm really nervous and scared about the operation." What is the most therapeutic action by the nurse?

The nurse should listen attentively and provide realistic verbal reassurance.

Upon assessment, the patient reports he does not belong to an organized religion. The nurse is correct to interpret this statement as which of the following?

The patient is not affiliated with a specific system of belief regarding a higher power.

The nurse is preparing to administer digoxin to an infant. What is the most important intervention by the nurse?

Withhold the dose if the apical pulse rate is less than 90/bpm

A loading dose of digoxin is given to a client newly diagnosed with atrial fibrillation. The nurse begins instructing the client about the medication and the importance of monitoring his heart rate. An expected outcome of this instruction is:

a return demonstration of palpating the radial pulse.

A client who was involved in a motor vehicle accident is admitted to the hospital. His wife arrives on the unit 6 hours after her husband's accident, explaining that she has been out of town. She is distraught because she was not with her husband when he needed her. The nurse should:

allow her to verbalize her feelings and concerns.

A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is assisting with his care, says, "He is doing too much. I told him to let me help, but he will not let me." The nurse says to the wife, "It sounds like you need to feel you can be more helpful to him." In order to make the nonverbal behavior complement the words, the nurse should:

direct the body and eyes at the wife and client.

Following a myocardial infarction, a client develops an arrhythmia and requires a continuous infusion of lidocaine. To monitor the effectiveness of the intervention, the nurse should focus primarily on the client's:

ecg

A nurse is administering indomethacin to a neonate. What should the nurse do to ensure that the nurse has identified the neonate correctly? Select all that apply.

Check the neonate's identification band against the medical record number. Verify the date of birth from the medical record with the date of birth on the client's identification band.

What action should the nurse take first when a client is coughing up pink, frothy sputum?

Place the client in high-Fowlers position

A client says he's stressed by his job but enjoys the challenge. What should the nurse suggest?

Take stress-management classes.

A client with alcohol dependency is started on a regimen of disulfiram. Which statement should the nurse include when teaching the client about the intended effects of the drug?

Disulfiram acts to deter alcohol consumption.

When administering an IM injection to a neonate, which muscle should the nurse consider as the best injection site?

vastus lateralis

A nurse knows that the major clinical use of dobutamine is to:

increase cardiac output.

A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer?

"Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs."

A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents:

"Do you give the baby a bottle to take to bed?"

A staff member on the transplant unit is having problems logging into the computer to chart client information. The staff member asks a nurse for her personal identification number (PIN) to log in. What is the nurse's best response?

"I'll be happy to contact Information Services to assist you with the problem."

A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding?

tachycardia

A client with peripheral vascular disease is recovering from surgery to insert an aortofemoral-popliteal bypass graft. When developing a postoperative education plan, which question by the nurse will provide the most helpful information?

"How did you manage your health before admission?"

A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the client indicates the need for additional teaching?

"I can eat whatever I want as long as it's low in fat."

A nurse is teaching a new mother how to prevent burns in the home. Which statement by the mother indicates more teaching is required?

"I will heat my infant's formula in the microwave."

A client is participating in a cardiac research study in which his physician is directly involved. Which statement by the client indicates a need for additional teaching about his rights as a research study participant?

"I'll have to find a new physician if I don't complete this study."

A community nurse is working with the family of an infant and teaching the parents about preventative health practices. Which of the following is a priority for the nurse to include in the teaching?

Introducing screening tests

A nurse is caring for a client exhibiting mild contractions and a cervical dilation of 4 cm. Using an external fetal monitor, the nurse observes variable decelerations. Which action should the nurse take first?

Place the client on her left side

The nurse should dispose of a used needle and syringe by:

Placing uncapped, used needles and syringes immediately in the universal precaution container in the client's room.

The delivery of culturally competent nursing care incorporates the concept of:

Planning and implementing care in a way that is sensitive to the needs of individuals, families, and groups from diverse cultural populations.

The nurse is aware that a client receiving morphine sulfate intravenously post-surgical repair of a hip fracture may exhibit which of the following outcomes when getting out of bed for the first time?

Postural or orthostatic hypotension

While preparing a client for surgery, the nurse assesses for psychosocial problems that may cause preoperative anxiety. Which is believed to be the most distressing fear a preoperative client is likely to experience?

fear of the unknown

A client says, "I hate the idea of being an invalid after they cut off my leg." Which response by the nurse would be the most therapeutic?

"Tell me more about how you are feeling."

A nurse walks into the room of a client diagnosed with congestive heart failure (CHF). The client is lying supine and is diaphoretic, anxious, and dyspneic. What is the nurse's priority action?

Raise the head of the bed to 45°

The client has had a myocardial infarction, and the nurse has instructed the client to prevent Valsalva's maneuver. The nurse determines the client is following the instructions when the client:

avoids holding the breath during activity.

When starting the client's intravenous infusion line, the nurse applies a tourniquet and selects the site for inserting the needle. When should the nurse remove the tourniquet?

as soon as the needle is in the vein

A client is taking verapamil hydrochloride as an antihypertensive. Which statement made by the nurse instructs the client about an adverse effect of verapamil?

"Take your pulse and report any irregular heartbeats."

On the second day of hospitalization, a client is discussing with the nurse his concerns about unhealthy family relationships. During a nurse-client interaction, the client changes the subject to a job situation. The nurse responds, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use?

Focusing

A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The health care provider (HCP) is calling in a telephone prescription for ampicillin. The nurse should take which actions? Select all that apply.

Ask the HCP to confirm that the prescription is correct as understood by the nurse. Repeat the prescription to the HCP.

A client's friend is visibly distressed by the client's condition and lack of improvement. He says he feels powerless and unable to help his friend. How should the nurse respond?

Ask the client's friend if he'd like to help with comfort measures.

The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first?

Assess the client's orientation and vital signs.

The nurse is reconstituting a powdered medication in a vial. After adding the solution to the powder, the nurse should:

roll the vial gently between her palms.

When doing discharge planning for a hospitalized client with impulse control disorder, a nurse explains how family members can participate effectively in the client's ongoing care. What instruction should the nurse include?

"Consistently reward positive behavior and reinforce consequences of negative behavior.

A mother and grandmother bring a 2-month-old infant to the clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate?

"Babies can't digest solid food properly until they're 3 or 4 months old."

Before discharge, which instruction should a nurse give to a client receiving digoxin?

"Call the physician if your heart rate is above 90 beats/minute."

A client comes to the physician's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse takes this opportunity to evaluate the client's knowledge of the ordered cardiac rehabilitation program. Which evaluation statement suggests that the client needs more instruction?

"Client walks 4 miles (6.4 kilometers) in 1 hour every day."

A client with rheumatoid arthritis has been on aspirin therapy for an extended time. Which assessment is the most important for the nurse to obtain?

hearing

A 68-year-old client is admitted to the addiction unit after treatment in the emergency department for an overdose of oxycodone. Her son calls the unit and expresses intense anger that his mother is being treated as a "common street addict." He says she has severe back pain and was given that prescription by her health care provider (HCP). "She just accidentally took a few too many pills last night." Which reply by the nurse is most therapeutic?

"I can hear how upset you are. You sound very concerned about your mother."

The nurse understands that the client who is undergoing induction therapy for leukemia needs additional instruction when the client makes which statement?

"I cannot wait to get home to my cat!"

An older adult who experienced a brief delirium realizes that the condition was caused by prescription medication intoxication. Which of the following statements indicates the need for further education?

"I get medicines from three different doctors and they don't all know what I'm taking."

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement?

"I sleep on three pillows each night."

The parent brings a child to the clinic after discharge from the hospital for Guillain-Barré syndrome. Which statement by the parent indicates that the discharge plan is being followed?

"I take her to the pool where she can exercise with other children."

After an episode of severe pain, a client says to the nurse, "The pain really frightened me. I thought I was going to die." Which statement is the most appropriate response from the nurse?

"I understand that pain can be a frightening experience."

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teachin

"I will administer the enema while lying on my left side with my right knee flexed."

A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which statement made by the nurse is appropriate?

"I would like to refer you to a support group so that you can speak with others with similar problems."

A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching?

"I'll eat four servings of fresh, dark green vegetables every day."

A client requested a do-not-resuscitate (DNR) order upon admission to the hospital. He now tells the nurse that he wants the medical team to do everything possible to help him get better and is concerned about the DNR order. Which response by the nurse is best?

"It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away."

A 7-month-old female infant is admitted to the hospital with a tentative diagnosis of Hirschsprung's disease. When obtaining the infant's initial health history from the parents, which statement made by the mother would be most important?

"She gets constipated often."

The nurse has been able to draw the daily blood specimen from a client's Hickman catheter only after requesting that the client raise the arms and cough. The client asks the nurse why this is necessary. The nurse should tell the client:

"The catheter may be lodged against a blood vessel wall."

A client with mild dementia related to end-stage acquired immunodeficiency syndrome is preparing for discharge. He has decided against further curative treatment and wishes to return home. Before discharge, he develops ocular cytomegalovirus (CMV). His physician recommends treatment with a ganciclovir-impregnated implant, which requires a surgical procedure. The client's partner feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which answer from the nurse best answers the partner's question reflecting client advocacy?

"The implant won't cure the virus, but it may help preserve his vision. Not being able to see you or his surroundings may worsen his dementia and make caring for him at home more difficult."

As the nurse helps the client prepare for discharge, the client says, "You know, I have been in lots of hospitals, and I know when I am sick enough to be there. I am not that sick now. You do not need to worry about me." What would be the most therapeutic response by the nurse?

"We are concerned about you. How can we help you before you leave?"

The mother of an infant being admitted to the hospital is crying and very upset. What would be the nurse's best response?

"What is it that is making you cry right now?"

A client is entering rehabilitation for alcohol dependency as an alternative to going to jail for multiple DUIs (driving under the influence). While obtaining the client's history, the nurse asks about the amount of alcohol he consumes daily. He responds, "I just have a few drinks with the guys after work." Which response by the nurse is most therapeutic?

"You say you have a few drinks, but you have multiple arrests."

An 8-month-old infant is admitted with a febrile seizure. The infant weighs 17 lb (7.7 kg). The physician orders ceftriaxone, 270 mg I.M. every 12 hours. (The safe dosage range is 50 to 75 mg/kg daily.) The pharmacy sends a vial containing 500 mg, to which the nurse adds 2 ml of preservative-free normal saline solution. The nurse should administer how many milliliters?

1.08 ml

A client has a chest tube inserted for the treatment of a pneumothorax. While turning in the bed, the client dislodges the tube and it is found in the bed. As the registered nurse is directing the health care team, place the actions of the registered nurse in the correct order. All options must be used.

1.Apply an occlusive dressing over the puncture site 2.Tape the dressing on three sides 3.Direct the licensed practical/vocational nurse (LPN/VN) to notify the health care provider. 4.Assess the client's respiratory status. 5.Assess vital signs and await further medical orders

The nurse is assessing the development of a 7-month-old. The child should be able to:

sit without support.

A physician orders the following preoperative medications to be administered to a client by the I.M. route: meperidine, 50 mg; hydroxyzine pamoate, 25 mg; and glycopyrrolate, 0.3 mg. The medications are dispensed as follows: meperidine, 100 mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many milliliters in total should the nurse administer?

2.5 ml

The nurse is caring for a client with an order for an intravenous infusion of dextrose with 5% normal saline at 1500 mL over 8 hrs. The drip administration is set at 10 drops/mL. How fast will the IV infuse (drops/minute)? Record your answer using a whole number.

31 ; 1500 × 10 gtts = 15,000 gtts/8 hr = 1875 gtts/60 min = 31.25 gtts/min=31 gtts/min.

The nurse is caring for a client being discharged following kidney transplantation. The client is ordered mofetil to prevent organ rejection. Which nursing instruction is essential regarding medication use?

Contact the health care provider at first signs of an infection.

Which statement is a correct reason for nurses to become culturally sensitive and develop their cultural competency skills?

Cultural sensitivity and consideration of client diversity are necessary to provide ethical nursing care.

The nurse has just admitted a client with sickle cell crisis. What is the nurse's priority intervention?

Increasing fluid intake and giving analgesics

The nurse is admitting a client who takes digoxin daily, reported seeing green halos around the lights, and has not wanted to eat his breakfast. The laboratory report shows that serum sodium = 135 mEq/L, potassium = 3.2 mEq/L, magnesium = 2.5 mg/dL, and calcium = 10.2 mg/dL. Which of the following is the appropriate nursing action?

Administer a potassium supplement

A client receiving intravenous heparin has developed hematuria and petechiae. What is the nurse's best action?

Administer protamine sulfate

A nurse assigns beds to four new clients admitted to the cardiac telemetry floor. Which client should the nurse assign to the bed farthest from the nurses' station?

A 24-year-old client with unstable hyperthyroidism and sinus tachycardia

Which client is most likely to develop systemic lupus erythematosus (SLE)?

A 27-year-old black female

The nurse is examining charts to identify clients at risk for developing multiple myeloma. Which client is most at risk?

A 60-year-old black man

A nurse, working in the triage area of an emergency department, sees several pediatric clients arrive simultaneously. Which client should be treated first?

A two-year-old child with stridorous breath sounds, sitting up and drooling

A six-week-old infant is brought to the emergency department not breathing. A preliminary finding of sudden infant death syndrome (SIDS) is made to the parents. Which initial intervention should the nurse take?

Allow them to see their infant

Which of the following nursing actions would be most beneficial to a client and her husband who state they wish to go through labor without the use of analgesics or anesthetic agents?

Act as an advocate for the couple and verbalize their wishes to nurses and physicians.

A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client?

Acute respiratory distress syndrome (ARDS)

A client has an order for a clear liquid diet. The nurse is assisting the client to complete a menu. Which of the following would be appropriate for the client to order?

Apple juice Broth Tea

An infant is receiving rehydration therapy via the intravenous (IV) route for treatment of dehydration related to diarrhea. The parent informs the nurse she wants to hold the infant but is afraid of dislodging the IV. Which of the following interventions should the nurse provide to alleviate this fear and promote bonding?

Apply a stabilization device so that the IV will not dislodge.

A nurse is caring for a client with moderate RA. Which nonpharmacological interventions would a nurse include in the care plan? Select all that apply.

Applying splints to inflamed joints Selecting clothing that has Velcro fasteners Applying moist heat to joints

A parent brings her 2-month-old infant to the clinic for a well-baby checkup. To assess the interaction between parent and infant, in which of the following settings should the nurse should observe the parent and infant?

As the parent feeds the infant

Which of the following is an important consideration when the nurse is providing culturally competent care in a community clinic?

Asking about cultural beliefs related to health, illness, treatments, and dietary practices

A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care?

Asking the physician to write an order for home skilled nursing assessments and intervention

A nursing assessment for a client with alcohol abuse reveals a disheveled appearance and a foul body odor. What is the best initial nursing plan that would assist the client's involvement in personal care?

Assisting the client with bathing and dressing by giving clear, simple directions

The physician has indicated that a client has a poor prognosis for recovery, and the family is very concerned. How would the nurse best support the family?

Attune to their grieving, explain what is happening, and encourage involvement in the care.

A nurse is planning preoperative care for a child diagnosed with Wilms' tumor. What is the nurse's most important intervention?

Avoid abdominal palpation or manipulation

A client with a personality disorder is upset and calls the nurse a "stupid cow." Which of the following is the most effective initial response by the nurse to this client's behavior?

Calmly discuss the inappropriateness of displacing anger to others.

The nurse is caring for a client with type 1 diabetes mellitus. At 3:00 AM, the nurse finds the client disoriented to time and place, diaphoretic, and complaining of palpitations. What is the nurse's priority intervention?

Check blood glucose level

A client is two days postoperative from a femoral popliteal bypass. During assessment, the nurse finds the client's left leg is cold and pale. What is the nurse's initial action?

Check distal pulses

A nurse is caring for several clients on an oncology unit. Which client should the nurse see first?

Client with a white blood cell count of 2000 µL

The nurse in the emergency department is administering a prescription for 20 mg intravenous furosemide, which is to be given immediately. The nurse scans the client's identification band and the medication barcode. The medication administration system does not verify that furosemide is prescribed for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. What should the nurse do next?

Contact the pharmacist immediately to check the order and the barcode label for accuracy.

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which of the following is the priority intervention?

Control the pain and support breathing and oxygenation

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance?

Demonstrating control over aggressive behavior

A nurse is developing a care plan for a client who is a single parent. The client is experiencing anxiety after the loss of a job and is verbalizing concerns regarding the ability to meet role expectations and financial obligations. Which of the following is most important for the nurse to include in the plan of care?

Determine the client's ability to cope with the job loss and family obligations.

When teaching a client with bulimia nervosa about possible complications, which condition should the nurse emphasize?

Diabetes mellitus

A nurse is caring for a female client who is receiving antibiotics to treat a gram-negative bacterial infection. The client experiences an adverse effect related to the destruction of the normal flora in the GI tract. What finding does the nurse expect to assess?

Diarrhea

A graduate nurse is reviewing the procedure for removing a peripherally inserted central catheter (PICC) with her preceptor. Which planned action by the graduate nurse should the preceptor correct?

Discarding the catheter in a trash container

A teenage client is a high school wrestler who fasts before every wrestling tournament and then binges immediately after the tournament. On the way to each tournament, the client walks rapidly up and down the bus aisle and spits repeatedly into a cup. Which of the following is the best initial intervention for this client?

Discuss secondary gains that are unconsciously driving the client's behavior.

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia?

Dyspnea, tachycardia, and pallor

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Encouraging increased fluid intake

Nurses are aware that variety and diversity occur both within and across groups. Which of the following factors leads to cultural benefits as a result of diversity?

Equal opportunity exists for various cultural perspectives.

Which of the following is an example of social interaction, rather than a therapeutic professional nursing interaction, between a nurse and a client?

Equal sharing of time for discussion of problems so there is mutuality in the relationship

A two-year-old child comes to the emergency department with inspiratory stridor and a barking cough. A preliminary diagnosis of croup has been made. What is the nurse's most important intervention?

Establish and maintain the airway

Parents tell a nurse that they have not met their goal of home management of their son with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make?

Evaluate the client for voluntary admission to a mental health facility.

Assessment of a 6-week-old infant reveals weight and length in the 50th percentile for his age and a head circumference at the 95th percentile. What should the nurse do first?

Examine the fontanels and sutures.

The nurse starts an infusion of tissue plasminogen activase (tPA) for a client with a cerebrovascular accident (CVA). What are the priority nursing interventions during treatment with this medication?

Frequent neurologic assessment is necessary to determine whether the stroke is evolving or acute complications are developing.

A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1° F (39.5° C) rectally. What is the most appropriate initial nursing intervention?

Give acetaminophen

An elderly client with primary degenerative dementia is slow in following simple directions and is indecisive selecting clothes to be worn for the day. What is the best approach for the nurse to take?

Give the client the opportunity to select from two outfits and cue follow-through instructions.

An order has been written to discontinue an infusion of total parenteral nutrition (TPN) for a child. What is the priority nursing action?

Gradually reduce the rate of the TPN per health care provider order

A normal, healthy infant is brought to the clinic for the first diptheria, tetanus, acellular pertussis (Dtap) immunization. Which route is appropriate to administer this vaccine?

IM

In developing a security plan for a pediatric unit, a nurse must consider which factors? Select all that apply.

Identification of neonates, infants, toddlers, children, and adolescents at all times The facility's physical layout Available resources to obtain and maintain the security plan Methods for educating all staff regarding the security plan

A client scheduled to have a surgery for a hernia the next day is anxious about the whole procedure. The nurse assures the client that surgery for hernias is very common and that the prognosis is very good. What skills of the nurse are reflected here?

Interpersonal skills.

A client comes to the clinic for diagnostic allergy testing. The nurse understands that intradermal injections are used for such testing based on which principle?

Intradermal drugs diffuse more slowly.

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

Intrinsic factor

A client in the intensive care unit has a nursing diagnosis of Social isolation. Which action should the nurse include in the care plan?

Involving the family and the client in planning care

A mother is discontinuing breast-feeding after 3-1/2 months. The mother is seeking education on what to feed her baby now that she is no longer breast-feeding. The nurse teaches the mother about infant feeding and suggests the following:

Iron-fortified formula alone

An IV infusion is to be administered through a scalp vein on an infant's head. What should the nurse tell the parents to prepare them for the procedure?

It may be necessary to remove a small amount of hair from the infant's scalp.

Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting?

K+, 3.2; Cl-, 92; Na+, 120

The nurse is caring for an infant with a congenital heart defect. What priority health teaching should the nurse offer to the parents of this infant?

Keep feedings small, but frequent.

A nurse is performing an assessment of a postpartum client two hours after birth, and notes heavy bleeding with large clots. What should be the nurse's initial action?

Massaging the fundus firmly

When assessing the chest of a 4-month-old infant, the nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:1. What action should the nurse take next?

No action is needed; this is a normal finding.

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?

Normal saline solution as this is considered an isotonic solution

The health care provider (HCP) prescribes IV cefazolin 1 g for a client. In preparing to administer the cefazolin, the nurse notes that the client is allergic to penicillin. Based on this information, what is an appropriate action for the nurse to take?

Notify the HCP of the client's allergy to penicillin.

A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic. The infant's anterior fontanel is sunken. What other assessment data are a priority for the nurse to collect?

Number of wet diapers the in the last 24 hours

A nurse is caring for a 12-month-old infant with dehydration with resulting metabolic acidosis. The infant exhibits lethargy and poor skin turgor. Which of the following actions by the nurse takes priority?

Obtaining a patent intravenous site

A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation?

Offer a face mask to the person with the cold and use this as an opportunity for further teaching.

The nurse is teaching a group of high school students about risk-taking behaviors. Which of the following topics would be considered an example of healthy behaviors?

Preventative vaccinations

The parents of a 3-month-old infant have been told that their infant has died of sudden infant death syndrome. Which intervention is most important to include in the plan of care to assist the parents with their grieving process?

Provide an opportunity for them to see the infant.

A nurse is caring for a client who has been hospitalized with schizophrenia. The client has had this disorder for 8 years and is now displaying regression, increased disorganization and inappropriate social interactions. Which nursing intervention will best help this client meet self-care needs?

Provide client with assistance in hygiene, grooming, and dressing.

A 26-year-old is being treated for delirium due to acute alcohol intoxication. The client is restless, does not want to stay seated, and has a staggering gait. What should the nurse do first?

Provide one-to-one supervision of the client until detoxification treatment can begin.

A client is admitted to the labor and delivery unit for birth of a known anencephalic fetus. What is the most appropriate intervention by the nurse?

Provide privacy and emotional support

A 2-month-old infant is brought to the clinic by his mother. His abdomen is distended, and he has been vomiting forcefully and with increasing frequency over the past 2 weeks. On examination, the nurse notes signs of dehydration and a palpable mass to the right of the umbilicus. Peristaltic waves are visible, moving from left to right. The nurse should suspect which condition?

Pyloric stenosis

The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following?

Reed-Sternberg cells.

A mother reports that her school-age child has been reprimanded for daydreaming during class. The mother is concerned because her other child has been diagnosed with absence seizures. This behavior is new, and the child's grades are dropping. What is the most appropriate action by the nurse?

Refer the child to the primary health care provider to assess for absence seizures

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do?

Remove any unsafe items from the area in which the infant is mobile.

After an infant undergoes surgical repair of a cleft lip, the physician orders elbow restraints. For this infant, the postoperative care plan should include which nursing action?

Removing the restraints every 2 hours

A nurse is developing a care plan for a client who has undergone electroconvulsive therapy (ECT). The nurse should include which intervention?

Reorienting the client to time and place

Which term refers to the primary unconscious defense mechanism that blocks intense, anxiety-producing situations from a person's conscious awareness?

Repression

Values are known to affect a person's functional health. Which of the following values may be related to the perception of health? Select all that apply.

Responsibility. Discipline. Cooperation.

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?

Shift your weight every 15 minutes.

A nurse finds a client crying after she was told by the health care provider that she is to start hemodialysis to treat her acute renal failure. What is the nurse's most important intervention?

Sit quietly with the client

A client on a surgical unit asks for the nurse's opinion of the surgeon. The nurse replies, "He is rude. His patients always end up with infections." The nurse is at risk of being accused of which of the following?

Slander

A client hints that he would like to discuss his spiritual and religious beliefs with someone. What is the best nursing intervention at this point?

Speak with the client further about his needs to assess how best to intervene.

A client is being admitted to the psychiatric unit. She responds to some of the nurse's questions with one-word answers. Her eyes are downcast and her movements are very slow. Later that morning, the nurse approaches the client and asks how she feels about being in the hospital. The client does not respond verbally and continues to gaze at the floor. Which action should the nurse take first?

Spend time sitting in silence with the client.

An appropriate nursing diagnosis for a bedridden and hospitalized client who tells the nurse that he is upset because he has not missed a Methodist church service in 50 years is

Spiritual distress related to inability to attend church services evidenced by verbal states of guilt

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions?

Stabilizing heart rate and blood pressure and easing anxiety

During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and foul smelling diarrhea. Which priority order should the nurse anticipate from the health care provider?

Stool sample for a Clostridium difficile

A 17-year-old primigravida with severe hypertension of pregnancy has been receiving magnesium sulfate IV for three hr. The latest assessment reveals deep tendon reflexes (DTR) of +1, flushing, blood pressure of 150/100 mmHg, a pulse of 92 beats/min, a respiratory rate of 10 breaths/min, and urine output of 20 ml/hr. Which action would be most appropriate?

Stop the magnesium sulfate infusion

A charge nurse enters a client's room and observes a physician instructing another nurse on how to insert a central line into the client's neck. The nurse is holding the cannula and inserting the line. What would be the appropriate response by the charge nurse?

Stop the procedure and inform the nurse that he/she is practicing outside of a nurse's legal scope of practice.

A physician treating a client in the cardiac care unit for atrial arrhythmia orders metoprolol, 25 mg P.O. two times per day. Metoprolol inhibits the action of sympathomimetics at beta1-receptor sites. Where are these sites mainly located?

heart

A client is having a blood transfusion reaction. What must the nurse do in order of priority from first to last? All options must be used.

Stop the transfusion. Keep the IV open with normal saline infusion. Notify the health care provider (HCP) and blood bank. Complete the appropriate Transfusion Reaction Form(s).

The nurse in pediatric intensive care is caring for an infant whose respiratory rate is 50 with nasal flaring, grunting and experiencing thick yellow nasal discharge. Vital signs are stable with oxygen saturation of 96% on 0.25 L of oxygen via face mask. Chest physiotherapy has been completed, and the infant is sleeping in the supine position. What should be the nurse's next intervention?

Suction the nares

Which principle should a nurse consider when administering pain medication to a client?

Sustained-release oral formulations should be given around the clock, if possible, for control of chronic pain.

A nurse has been asked to insert peripheral IV lines in several clients on the nursing unit. Which of the following sites would the nurse need to avoid in order to maintain client safety?

The arm of a client where an arteriovenous shunt has been inserted

The treatment team recommends that a client take an assertiveness training class offered in the hospital. Which behavior indicates that the client is becoming more assertive?

The client asks his roommate to put away his dirty clothes after telling the roommate that this bothers him.

A female client who is hospitalized for an eating disorder weighs 15 pounds less than ideal body weight. Which goal is a priority for this client?

The client gains 1 pound per week.

When teaching a client who is to receive methadone therapy for opioid addiction, the nurse should instruct the client that methadone is useful primarily for what reason?

The client may work and live normally.

Which activity indicates that the client with cancer is adapting well to body image changes?

The client serves as a volunteer in a client-to-client visitation program.

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client?

The client should begin coughing and deep-breathing exercises as soon as he's able to follow instructions.

A client's cultural beliefs view emotional or mental illnesses as behavior that is out of control and that brings shame upon the family. Which of the following responses to psychological distress would be most likely to occur by the client given this cultural view?

The client states symptoms of headache and vague gastrointestinal issues.

The nurse is caring for an infant who exhibits the above characteristics. When planning care, which would be the best long term client goal?

The client will reach his/her optimal level of functioning.

What short-term goal for a client hospitalized with a stress related disorder is most realistic?

The client will write a list of strengths and needs.

A client on the adolescent psychiatric unit was admitted with a diagnosis of body dysmorphic disorder. The client has not been able to attend school or his/her part-time work over the past year as a result of certain body obsessions. Recently, the client shaved the hair all over his/her body, claiming, "It is all growing weird." What component of therapy would be most important for the nurse to apply to this client?

The client's body image is real to the client.

The nurse is assessing a client with chronic hepatitis B who is receiving lamivudine. What information is most important to communicate to the health care provider (HCP)?

The client's daily record indicates a 3-kg weight gain over 2 days.

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing?

The granulation tissue is at the wound edges.

The nurse teaches the father of an infant hospitalized with gastroenteritis about the next step of the treatment plan once the infant's condition has been controlled. The nurse should determine that the father understands when he explains that which intervention will occur with his infant?

The infant will receive clear liquids for a period of time.

A client reports for a preoperative appointment in preparation for surgery that will change the client's body from female to male. The client, who was born biologically female, has expressed to the nurse and physician the wish to have been born with the body of a man. What identity is the client demonstrating?

Transsexual

The mother of a 2-month-old child calls stating that her child is "fussy and has a runny nose." The mother states that the child has been sleeping poorly at night and is not eating as well. Which of the following interventions will the nurse teach the mother?

Use a bulb syringe to suction out the nasal passages.

Which instructions should the nurse include in the teaching plan about skin care for the mother of a child with atopic dermatitis?

Use a mild soap followed by patting the skin to dry it.

When administering an oral medication to an infant, the nurse should take which action to decrease the risk of aspiration?

Use an oral syringe to place the medication beside the tongue, and administer the medication slowly.

A nurse is caring for a three-year-old child following the removal of a Wilms' tumor. The mother states that her child is in pain, and requests pain medication. What is the nurse's priority in regards to this mother's request?

Use the Faces Pain Scale to assess the child's degree of pain

A client is about to undergo cardiac catheterization for which he signed an informed consent. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed?

Withhold the medication and notify the physician immediately.

The wife of a client with end-stage acquired immunodeficiency syndrome (AIDS) is caring for her husband at home. The hematologist recommends hospice care and the couple agrees. During the initial admission visit, the hospice nurse provides information to the client and his family about an advance directive. During the next day's visit, the client states that since he and his wife filled out the advance directive form, he feels abandoned by his physician. Which statement by the hospice nurse best addresses the client's concerns?

Your physician will continue to care for you. The advance directive simply puts in writing the care you want, so he will be able to provide it if you can't tell him yourself."

The nurse reviews the peak and trough serum levels from a client who is receiving gentamicin sulfate in order to:

adjust the dosage to the therapeutic range.

When preparing a teaching plan for a client about imipramine, which substance should the nurse tell the client to avoid while taking the medication?

alcohol

After receiving a report, the nurse is making out assignments. Which client would be appropriate to assign to unlicensed assistive personnel?

an 8-month-old with pneumonia who will be discharged today

A mother and infant are admitted to the emergency department following a motor vehicle crash. The infant is unresponsive to verbal and tactile stimuli, his pupils are dilated, and a nurse observes lacerations on his head, neck, and upper torso. The infant's mother is experiencing respiratory distress and is being treated in another room in the emergency department. The nurse learns that the parents are divorced and have joint custody of the infant. The father arrives in the emergency department. The nurse should:

ask the infant's father to sign consent for emergency treatment of the infant.

Which assessment should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?

auscultation of bowel sounds

The nurse teaches the client with iron deficiency anemia that food sources with high iron content include:

beef

Which parental characteristic is least likely to be a risk factor for child abuse?

being a member of a large family

When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which physiologic functions?

bleeding tendencies

A new nurse has transferred to the chemical dependency rehabilitation unit. Which action if performed by the new nurse would warrant the change nurse to intervene?

calling the Narcotics Anonymous group for the client

A nurse is providing wound care to a client 1 day following an appendectomy. A drain was inserted into the incisional site during surgery. When providing wound care, the nurse should:

clean the area around the drain moving away from the drain.

After suctioning a client, a nurse should expect to find:

clear breath sounds.

One of the myths about sexual abuse of young children is that it usually involves physically violent acts. Which behavior is more likely to be used by the abusers?

coercion as a result of the trusting relationship

The nurse is reviewing laboratory reports for a client who is taking allopurinol. Which finding indicates that the drug has had a therapeutic effect?

decreased serum uric acid level

Which client is at risk for pulmonary embolism? A client with:

deep vein thrombosis (DVT).

To decrease a female client's anxiety about being placed in the lithotomy position for surgery, the nurse should:

determine what the client is concerned about.

When planning the care for a client who is being abused, which measure is most important to include?

develop a safety plan

Following cardiac bypass surgery, the client has been referred to a cardiac rehabilitation exercise program. The client has type 1 diabetes and has bilateral leg discomfort with walking. The nurse should advise the client to exercise using a stationary bicycle and intermittent training because of the client's:

diabetic neuropathy.

A client has a history of heart failure and has been prescribed furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of:

digoxin toxicity.

The health care provider (HCP) refers a client diagnosed with somatization disorder to the outpatient clinic because of problems with nausea. The client's past symptoms involved back pain, chest pain, and problems with urination. The client tells the nurse that the nausea began when his wife asked him for a divorce. Which intervention is most appropriate?

directing the client to describe his feelings about his impending divorce

A nurse must assess a client's judgment to determine his mental status. To best accomplish this, the nurse should have the client:

discuss hypothetical ethical situations.

The nurse is assessing a client who has had a stent inserted in a coronary artery via the right femoral artery. The client is receiving intravenous heparin sodium at 1000 units per hour. During the second postprocedure check, the nurse notes that the puncture site at the groin has begun to steadily ooze blood. The nurse should first:

don gloves and apply direct pressure over the site.

A client diagnosed with bulimia tells the nurse she only eats excessively when upset with her best friend, and then she vomits to avoid gaining a lot of weight. The nurse should next:

enroll the client in a coping skills group.

When preparing for the discharge of a neonate who has undergone corrective surgery for tracheoesophageal fistula, the nurse teaches the parents about the need for long-term health care because their child has a high probability of developing which complication?

esophageal stricture

The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates:

evidence of a bleb or wheal.

A 5-month-old infant is brought to the clinic by his parents because he "cries too much" and "vomits a lot." The infant's birth weight was 6 lb, 10 oz (3,000 g), and his current weight is 7 lb, 4 oz (3,289 g), falling below the 5th percentile on a standard growth chart. Which data should the nurse identify as the priority?

feeding pattern

A nurse is caring for a client diagnosed with bulimia nervosa. The most appropriate initial goal for this client is to:

identify a connection between anxiety and eating behaviors.

A client arrives in the emergency department with an ischemic stroke. Because the health care team is considering administering tissue plasminogen activator (t-PA) administration, the nurse should first:

identify the time of onset of the stroke.

According to hospital protocol, after a client is restrained, the staff meet and discuss the restraint situation. In addition to sharing feelings and offering support, what should the nurse identify as the long-term goal for the debriefing?

improving the staff's use of restraint procedures

The correct landmark for obtaining an apical pulse is the:

left fifth intercostal space, midclavicular line.

A client experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mm Hg, and pulse is 92 bpm. Which medication should the nurse expect to administer?

lorazepam

A client with schizophrenia started risperidone 2 weeks ago. Today, he tells the nurse he feels like he has the flu. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing:

neuroleptic malignant syndrome.

A nurse is teaching the families of clients with chronic mental illnesses about causes of relapse and rehospitalization. What should the nurse include as the primary cause?

noncompliance with medications

A 79-year-old client has been admitted to the unit. The client is diagnosed with a left hip fracture secondary to a fall, and is scheduled for a left total hip replacement (LTHR). The client's comorbidities are hypertension and diabetes. The client is a full code with no known allergies (NKA). What is the nurse's priority action for this client?

pain management

The nurse is developing a care plan for a client who has had radiation therapy for Hodgkin's lymphoma. What is the primary goal of care for this client?

prevent infection

The nurse is caring for a client with terminal lung cancer. What is the priority nursing intervention for this client?

provide pain control

A client refuses his evening dose of haloperidol and then becomes extremely agitated in the day room while other clients are watching television. He begins cursing and throwing furniture. The nurse's first action is to:

remove all other clients from the day room.

Before applying nitroglycerin ointment, the nurse should

remove the ointment previously applied.

After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective in the client does not develop:

seizures.

In her first postpartum month, a client has developed mastitis secondary to breast-feeding. Her nurse, a mother who developed and recovered from mastitis after the birth of her third child, says, "I remember the discomfort I had and how quickly it resolved when I began getting treatment." The therapeutic communication the nurse is using is:

self-disclosure.

When discussing an infant's motor skill development with the mother, the nurse should explain that by age 7 months, an infant most likely will be able to:

sit alone using the hands for support.

A client is admitted to the psychiatric hospital for evaluation after numerous incidents of threatening others, angry outbursts, and two episodes of hitting a coworker at the grocery store where he works. The client is very anxious and tells the nurse who admits him, "I did not mean to hit him. He made me so mad that I just could not help it. I hope I do not hit anyone here." To ensure a safe environment, the nurse should first:

tell him that hitting others is unacceptable behavior and asking him to tell a staff member when he begins feeling angry.

For the last 6 days, a 7-month-old infant has been receiving amoxicillin trihydrate to treat an ear infection. Now the parents report redness in the diaper area and small, red patches on the infant's inner thighs and buttocks. After diagnosing Candida albicans, the physician orders topical nystatin to be applied to the perineum four times daily. The nurse should focus her assessment on:

the inside of the infant's mouth.

The client has tearfully described her negative feelings about herself to the nurse during their last three interactions. Which goal would be most appropriate for the nurse to include in the plan of care at this time? The client will:

verbalize three things she likes about herself

A client with chronic heart failure is receiving digoxin, 0.25 mg by mouth daily, and furosemide, 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause:

visual disturbances.

A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to the bed. How should the nurse plan to direct the transfer to prevent skin shearing?

with two people, one at each side using a drawsheet, one person at the head, and one person at the feet