Q Bank 2

The health care provider orders cefdinir 300 milligrams in oral suspension every 12 hours. The label reads 125 mg/5mL. How many mL should the nurse administer for each dose?

Correct answer: 12

The nurse cares for the client diagnosed with herpes zoster. Which client statements are consistent with this diagnosis? Select all that apply. 1. "The antibiotics make me nauseated." 2. "Only one side of my face hurts." 3. "I caught this from my partner." 4. "This pain may linger for months." 5. "I'm trying not to scratch."

Strategy: Think about each answer. Does it indicate herpes zoster? 1) antivirals, not antibiotics, are used to treat viral infections like herpes zoster (shingles) 2) CORRECT — herpes zoster follows dermatomes on one-half of the body 3) not possible to catch shingles from another person 4) CORRECT — herpes zoster may lead to postherpetic neuralgia 5) CORRECT — lesions are known to cause itching as well as pain

The nurse is reviewing orders for a newly admitted client. According to quality and safety standards, which orders, written by the health care provider, require the nurse to verify the order? Select all that apply. 1. Famotidine 20 mg PO qd. 2. Docusate 100 mg PO b.i.d. 3. Captopril 25.0 mg PO q 8h. 4. MS Extended Release 30 mg po BID. 5. Tetracycline 250 mg PO q.i.d.

Strategy: Think about each answer. Is it an appropriate order? 1) CORRECT — "qd" is a JCAHO Do Not Use abbreviation 2) appropriate order 3) CORRECT — use of a trailing zero is on the list of JCAHO Do Not Use abbreviations 4) CORRECT — "MS" is a JCAHO Do Not Use abbreviation 5) appropriate order

A client comes to the outpatient clinic for evaluation of a possible basal cell carcinoma of the nose. The nurse should consider which client statement is significant? 1. "I am a meat cutter at the local packing plant." 2. "My hobby is raising Great Danes." 3. "My parents came from Sicily." 4. "I spend weekends sailing with my family."

Strategy: Think about the client's words. 1) no relationship to skin cancer 2) no relationship to skin cancer 3) no relationship to skin cancer 4) CORRECT - exposure to sun increases risk of skin cancer; use sunscreen with SPF (solar protection factor) to block harmful rays (especially important for children); reapply sunscreen after swimming or prolonged time in sun; use lip balm with sunscreen protection; teach client to examine skin surfaces monthly

A client is placed on gentamicin sulfate IV q 8 hours. It is most important for the nurse to respond to which statement made by the client? 1. "My wife tells me my hearing has changed." 2. "My vision is blurred when I read the paper." 3. "Food just doesn't taste as good to me." 4. "Look at this rash on my arms."

Strategy:"MOST important to respond"indicates a potential complication. 1) CORRECT—decreased hearing and vertigo occur as a result of involvement of the eighth cranial nerve, which is caused by gentamicin toxicity 2) gentamicin is an aminoglycoside; nephrotoxic 3) not toxic effect of this antibiotic 4) rash may indicate hypersensitivity reaction; more important to respond to changes in hearing

The nurse receives an order to administer amikacin sulfate 15 mg/kg/day intravenously, in three divided doses to the client. The client's current weight is 176 lbs. How much does the nurse administer to the client at each dose? Do not round. Place the answer in the box.

400

The nurse assesses a client diagnosed with chronic lung disease. The data collected reveals respiratory rate of 50, pulse 140 and irregular, skin pale and cool to touch, and client confused to person, place, and time. Orders include oxygen per nasal cannula at 2 L/min, bedrest, soft diet, and pulmonary function tests in the A.M. Place these nursing activities in the proper sequence beginning with most important.

Strategy: Determine the outcome of each answer. 1) place the client in semi-Fowler position; allows for maximal lung expansion (2) administer oxygen at 2 L/min; oxygenates the client 3) ask a staff member to stay with the client; do not leave the client alone 4) contact the health care provider; client appears unstable; support respiratory function first

The nurse cares for the client with an intact immune system. The client is diagnosed with localized herpes zoster. The nurse determines care is appropriate if which findings are observed? Select all that apply. 1. The client is placed on airborne precautions. 2. The client receives acyclovir orally. 3. The nurse keeps the client's door closed at all times. 4. The nurse caring for the client has a positive history for chicken pox. 5. The client engages in slow, rhythmic breathing.

Select all that apply question, ask; is this an appropriate action to take for the client with localized herpes zoster 1) not necessary, standard precautions are recommended for localized herpes zoster and non-immunocompromised clients; private room with negative air pressure used if airborne precautions required, appropriate if client has disseminated zoster 2) CORRECT — antiviral medication; administered to decrease pain and slow the progression of the disease 3) not necessary for standard precautions 4) CORRECT — health care worker has immunity to varicella virus; susceptible health care workers should not enter room if immune caregiver available 5) CORRECT — encourage relaxation to help client cope with discomfort

The parent tells the nurse, "My partner has a positive Mantoux test. What are the risks to our 2-year-old child?" Which response by the nurse is best? 1. "If your child is in good health, there is little risk because of low communicability of tuberculosis (TB)." 2. "Your child should have an immediate chest x-ray." 3. "Bring your child in for a PPD test as soon as possible." 4. "Children should not receive skin testing before 4 years of age."

Strategy: "BEST" indicates discrimination is required to answer the question. 1) TB has increased significantly in childhood populations; communicability is higher among household members 2) parent with the suspected TB diagnosis needs a chest x-ray; the child requires skin testing at this point 3) CORRECT - contacts of persons with confirmed or suspected infectious tuberculosis require immediate skin testing; includes children identified as contacts of family members or associates in jail or prison in the last 5 years 4) infants may receive skin testing

The school nurse conducts a workshop on eating disorders for parents and teens. Which participant statements indicate correct understanding of the teaching? Select all that apply. 1. "I do not need to worry as long as my child's BMI stays between 20 and 25." 2. "I will set healthy goals for my food and fluid intake." 3. "It is important to weigh or measure all of the food my child eats." 4. "I will keep a food journal in which I will write down what I'm eating and how I'm feeling." 5. "Our family needs to eat every meal together each day." 6. "Medical treatment of anorexia will not be effective unless my child participates willingly."

Strategy: "Correct understanding of the teaching" indicates correct information. Determine the outcome of each answer. Is it desired? 1) clients with bulimia may maintain a normal BMI, but they still need intervention 2) CORRECT — when clients with eating disorders participate in goal setting, their chances of successful treatment increase 3) this level of involvement by family members is often counterproductive 4) CORRECT — recognizing feelings of anxiety or powerlessness often leads to insight into maladaptive eating behaviors 5) although family involvement is a necessary part of treatment, it is not reasonable to expect families to eat all meals together 6) in cases of extreme malnutrition or dehydration emergency, medical care is required; the client may not desire this

The community health nurse provides education about influenza treatment and prevention at a local health fair. Which statements made by citizens demonstrate correct understanding of oseltamivir? Select all that apply. 1. "I will begin taking the medication as soon as I experience flu symptoms." 2. "The capsules must be swallowed whole and never opened." 3. "If the medication upsets my stomach, I can take it with food." 4. "Children younger than 12 should not take this medication." 5. "After I complete the full course of medication, I will no longer need to get a yearly flu shot." 6. "I should not take this medication if I am allergic to eggs."

Strategy: "Correct understanding" indicates correct information. Determine the outcome of each answer. Is it correct ? 1) CORRECT — to lessen the severity of flu symptoms, flu sufferers should take oseltamivir as soon as symptoms appear 2) capsules may be opened and mixed with flavoring if needed 3) CORRECT — oseltamivir may cause stomach upset; taking it with food should decrease this adverse effect 4) children as young as 1 year of age may take oseltamivir 5) annual flu shots are still recommended as the virus changes from year to year 6) there is no contraindication for taking oseltamivir in persons allergic to eggs

The nurse cares for a client diagnosed with a detached retina. Postoperatively, which medication orders does the nurse correctly question? Select all that apply. 1. Droperidol. 2. Polyethylene glycol 3350. 3. Morphine sulfate. 4. Benzonatate. 5. Hydromorphone. 6. Clonidine.

Strategy: "Does the nurse correctly question" indicates an inappropriate order. Determine the outcome of each answer choice. It is inappropriate for this situation? 1) droperidol prevents vomiting, thus preventing increased intraocular pressure 2) polyethylene glycol 3350 prevents constipation, thus preventing increased intraocular pressure 3) CORRECT — morphine sulfate can cause constipation, which should be avoided after detached retina repair 4) benzonatate suppresses cough, thus preventing increased intraocular pressure 5) CORRECT — hydromorphone can cause constipation, which should be avoided after detached retina repair 6) CORRECT — clonidine can cause constipation, which should be avoided after detached retina repair

A client is admitted to the hospital with a diagnosis of dehydration secondary to diarrhea. A nursing history reveals that the client has been on daily medications of digoxin 0.25 mg and furosemide 40 mg, which are to be continued according to the health care provider's orders. Which symptom is most important for the nurse to report to the next shift? 1. Confusion and reports of yellow halos around lights. 2. Character and time of daily stools. 3. Intake and output for the last 24 hours. 4. Irritability toward friends and family.

Strategy: "MOST important" indicates discrimination is required to answer the question. 1) CORRECT - describes characteristic signs and symptoms of digoxin toxicity; digoxin toxicity is a great concern in the presence of diarrhea or any circumstances that lead to alteration in fluid and electrolytes 2) appropriate for this client, but is not as high a priority 3) appropriate for this client, but is not as high a priority 4) appropriate for this client, but is not as high a priority

The nurse cares for the client diagnosed with active tuberculosis. It is MOST important for the nurse to take which action? 1. Restrict visitors to immediate family only. 2. Wear a gown and gloves at all times. 3. Wear a mask and gloves when in direct contact with the client. 4. Dispose of waste articles more frequently.

Strategy: "MOST important" indicates priority. 1) immediate family has probably already been exposed to the client's tuberculosis 2) requires airborne precautions; wear respiratory protection; place client in private room with monitored negative air pressure 3) CORRECT airborne precautions required 4) appropriate action to prevent spread of TB; priority is for the staff to maintain airborne precautions

The nurse instructs a client about how to determine urine glucose using a reagent strip. Which statement, if made by the client to the nurse, best indicates correct understanding of the procedure? 1. "I will put 5 drops of urine on the test strip, wait 7 seconds, and then hold it to the light." 2. "I will test my urine as soon as I wake up in the morning and before I eat anything." 3. "I will dip the strip into the urine and compare the color change with the color chart on the strip container." 4. "I will store the strip dispenser on the counter of the bathroom sink so it is right there when I need it."

Strategy: Determine the outcome of each answer. Is it desired? 1) test strip is dipped in the urine 2) a specimen obtained 10 to 20 minutes after the first specimen is more accurate because it has not been accumulating in the bladder 3) CORRECT — proper procedure 4) strips are ineffective if they become wet; discard if strips become wet or discolored

The client starts metformin. It is most important for the nurse to respond to which client statement? 1. "I will be sure to carry a chocolate candy bar with me at all times." 2. "If I get abdominal cramps and a metallic taste in my mouth, I will call the health care provider." 3. "I am glad this medication will not cause me to gain weight." 4. "I will take the metformin when I first get up and just before I go to bed."

Strategy: "MOST important" indicates that discrimination is required to answer the question. 1) further teaching needed, but not most important; metformain is a biguanide oral hypoglycemic agent, does not cause hypoglycemia; does not increase insulin secretion from the pancreas but helps tissues respond to insulin, decreases gluconeogenesis, and increases glucose uptake into muscles and fat 2) further teaching is needed, but not most important; bitter or metallic tastes and abdominal cramps are two common side effects of this medication, which can be addressed by the health care provider possibly adjusting the dose and/or client taking the medication with meals 3) appropriate understanding, does not cause weight gain 4) CORRECT - take with meals to reduce side effects of the medication - e.g., nausea, vomiting, anorexia, abdominal cramps, fatigue; these effects tend to be mild and to resolve as therapy continues

One day after a coronary artery bypass graft (CABG), the nurse discovers a client sitting in a chair. The client is cold and pale, and responds to loud verbal stimuli. Which action by the nurse is most appropriate? 1. Perform cardiac assessment. 2. Review chart for prior sedative administration. 3. Administer oxygen per nasal cannula. 4. Transfer client back to bed.

Strategy: "Most appropriate" indicates priority. 1) transient changes in LOC can be due to hypotension; check neurological function every 2 to 4 hours 2) alternation in LOC due to hypothermia 3) no information to indicate oxygenation issue; more important to put client back to bed 4) CORRECT — cold, pale client needs to be reclining in bed; hypothermia causes vasoconstriction and hypertension; hypertension causes leakage from suture lines and may cause bleeding

The nurse observes an LPN/LVN set up a sterile field in preparation for a sterile dressing change. It is most important for the nurse to intervene if what is observed? 1. The LPN/LVN includes extra 4×4s to wipe up any spills on the sterile field. 2. The LPN/LVN sets up the sterile field in front of an open window. 3. The LPN/LVN sets up the sterile field on a waist-level table. 4. The LPN/LVN sets up the sterile field immediately in front of the nurse.

Strategy: "Nurse should intervene" indicates a wrong action. (1.) spills on sterile field cause contamination; discard all supplies and establish a new sterile field; potential problem, not priority (2.) CORRECT - free air flow can result in microorganisms in air current contaminating sterile field; close windows, doors (3.) appropriate behavior (4.) appropriate behavior; face sterile field, do not reach across sterile field

The nurse observes the nursing assistive personnel (NAP) caring for the immunocompetent client diagnosed with shingles. Which actions require the nurse to intervene? Select all that apply. 1. The NAP ambulates the client to the nurse's station. 2. The NAP gowns and gloves prior to entering the client's room. 3. The NAP, who had chicken pox as a child, refuses to enter the room. 4. The NAP accomplishes hand hygiene in the client's room. 5. The NAP uses the unit equipment to monitor the client's vital signs.

Strategy: "Nurse to intervene" indicates incorrect actions. Determine the outcome of each answer. Is it an incorrect action for the NAP to perform? 1) CORRECT — herpes zoster client should be placed in isolation 2) contact precautions appropriate for shingles 3) CORRECT — NAP is naturally immune to varicella (chicken pox); discussion about precautions should be completed 4) CORRECT — hand hygiene should be done prior to entering contact precaution room 5) CORRECT — isolation rooms should have dedicated equipment

Under the supervision of the registered nurse, a student nurse changes the dressing of a client with a newly inserted peritoneal dialysis catheter. Which activity, if performed by the student nurse after removal of the old dressing, requires an intervention by the registered nurse? 1. The student nurse cleans the catheter insertion site using a sterile cotton swab soaked in povidone-iodine. 2. The student nurse applies two sterile precut 4×4s to the catheter insertion site. 3. The student nurse cleans the insertion site using a circular motion from the outer abdomen toward the insertion site. 4. The student nurse securely tapes the edges of the sterile dressing with paper tape.

Strategy: "Requires an intervention" indicates incorrect behavior. All answers are implementations. Determine outcome of each answer. Is it desired? (1) appropriate procedure (2) appropriate procedure (3) CORRECT - should clean from insertion site outward toward outer abdomen (4) appropriate procedure

The nurse educates a group of high school parents at a local health fair. Which statements by the parents during the discussion period require follow up by the nurse? Select all that apply. 1. "My teenager is very independent and doesn't need constant supervision after school." 2. "My teenager can be impulsive at times but is improving on problem solving skills." 3. "Although I've made some mistakes in my life, I feel that I am a good role model for my teenager." 4. "My child is moody and requires some guidance when frustrated with homework." 5. "It is important to consistently tell my teenager what to do every day."

Strategy: "Requires follow-up" indicates something is wrong. Answers are client quotes. Think about what the words indicate and how the client statements relate to the topic of the question. 1) assurance of healthy developmental growth does not require constant supervision of teenagers and does not require follow-up 2) CORRECT — impulsiveness should be explored in greater detail and requires follow-up 3) parents should understand that they are seen as role models for this age group; good parental observation 4) anticipatory guidance can help with this age group; do not look at the "moody" teenager as a problem 5) CORRECT — constant direction does not contribute to an ideal level of development with this age group

The nurse identifies that which client statement is a contraindication to receiving the influenza vaccine? 1. "I am allergic to neomycin." 2. "I am allergic to penicillin." 3. "I am allergic to shellfish." 4. "I am allergic to eggs."

Strategy: Think about each answer. 1) allergy to neomycin is contraindication to MMR, IPV, and varicella vaccines 2) potential cross-allergy to cephalosporins 3) contraindication to diagnostic testing using dyes 4) CORRECT - only contraindication to the flu vaccine is an allergy to eggs; given to people 6 months and older

The nurse provides education to the client about valsartan. The client asks the nurse, "Why do I need this medicine? I just have a little swelling in my legs when I'm on them too long." Which responses does the nurse include? Select all that apply. 1. "This medication improves blood flow to the kidneys, and that will decrease the swelling in your legs." 2. "This medication helps slow and strengthen your heartbeat, and that will give you more energy." 3. "Do you have a bathroom scale at home?" 4. "You may feel dizzy at first when taking this medication. Get up slowly to avoid falls." 5. "This medication is prescribed with a large dose at first, and then it is tapered off as the symptoms improve." 6. "If you are careful to elevate your legs for 30 minutes of each hour, this medication will not be required."

Strategy: "Responses does the nurse include" indicates desired outcomes. Answer choices are quotations, so think about why the nurse makes the statement. Then determine the outcome of each answer. Is it a desired outcome for this medication? 1) CORRECT — valsartan acts by increasing blood flow to the kidneys and allows for fluid reduction 2) slowing and strengthening the heartbeat describes cardiac glycosides 3) CORRECT — daily weight is an important to measure changes in fluid volume of heart failure 4) CORRECT — valsartan lowers blood pressure and can cause orthostatic hypotension 5) low dose initially, increased or changed if heart failure is refractory 6) this action may be helpful but will not eliminate the need for pharmacologic treatment in heart failure

The nurse returns to a senior center to evaluate the effectiveness of a presentation about how to prevent falls among seniors. The nurse determines that teaching was effective if which responses are stated by the seniors? Select all that apply. 1. "I started taking tai chi classes." 2. "I have a new pair of athletic shoes with deep treads." 3. "I went to the eye doctor to have my vision checked." 4. "My physician reviewed all of my medications." 5. "I stopped exercising so I won't fall." 6. "I bought some new lamps for my home."

Strategy: "Teaching is effective" indicates correct information. 1) CORRECT — exercise is one of the most important ways to decrease the chance of falling; tai chi improves balance and coordination 2) shoes with thin, nonslip soles are the safest; avoid slippers and athletic shoes with deep treads 3) CORRECT — ensures that glasses are correct and will rule out glaucoma and cataracts, which limit vision 4) CORRECT — medications can cause client to be drowsy or light-headed, which can contribute to falls 5) not exercising causes weakness and increases a senior's chance of falling 6) CORRECT — older clients needs brighter lights to see well

The client undergoes a total laryngectomy. The nurse instructs the client and spouse how to suction the laryngectomy tube. Which observation indicates to the nurse that teaching is effective? 1. The client takes several deep breaths before the suction catheter is inserted. 2. The spouse selects a Yankauer tonsil tip catheter to suction the laryngectomy tube. 3. The spouse applies suction while introducing the sterile catheter into the stoma. 4. The spouse suctions the mouth and then the laryngectomy tube

Strategy: "Teaching was effective" indicates a correct action. (1) CORRECT - hyperoxygenates and prevents anoxia (2) used for oral suctioning of mouth and prevents anoxia (3) apply suction only as catheter is withdrawn (4) suction laryngectomy tube and then mouth

The nurse cares for a client with a history of peripheral arterial disease. The client is receiving thrombolytic therapy for a clot in the left calf. Which assessment finding indicates the treatment is effective? (Select all that apply.) 1. Dorsal pedal pulses are +1 bilaterally. 2. Constant numbness and tingling occur in the left foot. 3. Left foot is slightly pink. 4. Capillary refill is 4 seconds. 5. Client reports feeling pinprick on left great toe.

Strategy: "Treatment is effective" indicates desired outcomes. Determine the outcome of each answer. Is it desired? 1) CORRECT — this assessment data indicates adequate blood flow to both legs and feet 2) this assessment data indicates impaired neurovascular status; therefore, does not indicate treatment is effective 3) CORRECT — this assessment data indicates adequate blood flow past the clot to the left foot 4) this assessment data indicates impaired vascular status; therefore, does not indicate treatment is effective; capillary refill should be less than 2 seconds 5) CORRECT — this assessment data indicates adequate circulation

A client is admitted with a diagnosis of a subdural hematoma and cerebral edema after a motorcycle accident. Which symptoms should the nurse expect to see initially? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4. Decreased level of consciousness.

Strategy: All answers are assessments. Determine how each relates to increased intercranial pressure. (1) indicates brainstem damage (2) late sign of brainstem damage (3) late sign of increased intracranial pressure (4) CORRECT - may be confused and stuporous

The nurse performs a health screening at a senior citizen facility. The client has been taking oral iron supplements for a month and reports constipation. The nurse should adapt a diet plan to include which food? 1. Oatmeal, green beans, and celery. 2. Strawberries and mushrooms. 3. Grits, orange juice, and cheddar cheese. 4. Pasta, buttermilk, and bananas.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) CORRECT - contains foods highest in fiber (green vegetables and grains) to assist in counteracting constipation (2) does not have as high a fiber content (3) does not have as high a fiber content (4) does not have as high a fiber content

The client has an order for hydrochlorothiazide 50 mg PO daily. The nurse knows the teaching is successful if the client makes which statement? 1. "I should not operate heavy machinery." 2. "I should drink five glasses of liquid per day." 3. "This medication will cause my urine to turn orange." 4. "I should eat dried apricots each day."

Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? 1) medication does not cause drowsiness 2) there are no specific restrictions on fluid at this time 3) does not occur 4) CORRECT — continued use of this diuretic may cause a loss of potassium; dietary intake of foods such as bananas or dried apricots, which are high in potassium, should be encouraged

The nurse cares for a client diagnosed with Clostridium difficile. The nurse will follow which transmission-based precaution? 1. Standard precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.

Strategy: Think about each answer. 1) barrier precautions used for all clients to prevent health care-associated infections 2) used with pathogens transmitted by airborne route 3) used with pathogens transmitted by infectious droplets 4) CORRECT - causes pseudomembranous colitis; contact precautions required for all client care activities that require physical skin-to-skin contact or those that require contact with contaminated inanimate objects

A woman delivers an 8 lb, 1 oz, infant via spontaneous vaginal delivery. The nurse assists the patient with her first breast-feeding experience. Which of the following should be the priority action of the nurse? 1. Instruct the mother to use an antiseptic soap on her breasts. 2. Teach the mother how to position the baby. 3. Allow the mother and the baby time alone. 4. Include the infant's father or other caregiver.

Strategy: All the answer choices are implementations. Determine the outcome of each answer. Is it desired? 1) implementation; should just use water on the breasts because soap can be drying; dry thoroughly; expose to air 2) CORRECT - implementation; can use side-lying, sitting upright, or with infant facing mother (tailor position); rotate breast-feeding positions; position nipple so that infant's mouth covers a large portion of the areola and release infant's mouth from nipple by inserting finger to break suction 3) implementation; stay with the patient; should assess effectiveness of newborn's suck, swallow, gag reflex; instruct mother how to position baby and nipple 4) implementation; not highest priority

The home care nurse organizes the visits for the day. Place the clients in order of priority, beginning with the highest priority client to be seen.

Strategy: Consider the ABCs when ranking the answers in the correct order. 1) first priority; weight gain of >3 lbs within 2 days indicates heart failure exacerbation, possibly emergent 2) second priority; wound odor indicates infection, requires follow-up 3) third priority; ACE inhibitors can cause persistent nonproductive cough; needs follow up, not urgent 4) lowest priority; clients with COPD commonly utilize oxygen at lower flow rate; expected

The nurse reviews the history obtained from a client diagnosed with degenerative joint disease (DJD) of the right hip. The nurse identifies which are risk factors for developing degenerative joint disease? Select all that apply. 1. The client had a transurethral resection of the prostate (TURP) 2 years ago. 2. The client worked as a carpet installer for 40 years. 3. The client is a 65-year-old male, height 6 ft, weight 280 lb. 4. The client was a marathon runner at ages 25 - 40. 5. The client had a myocardial infarction at age 37. 6. The client was diagnosed with ulcerative colitis at age 22.

Strategy: Determine how each answer relates to degenerative joint disease. 1) no relationship with prostatic hypertrophy and joint disease 2) CORRECT — occupation that causes increased mechanical stress to joints, also would be 60+ years old 3) CORRECT — seen after age 60 years, obesity causes stress to weight-bearing joints 4) CORRECT — continued physical stress can increase risk of degenerative joint 5) myocardial infarction is caused by coronary artery disease 6) ulcerative and inflammatory disease of the mucosal and submucosal layers of colon and rectum, not a risk factor

After receiving report, which client should the nurse see first? 1. A client in sickle-cell crisis with an infiltrated IV. 2. A client with leukemia who has received 0.5 unit of packed cells. 3. A client scheduled for a bronchoscopy. 4. A client complaining of a leaky colostomy bag.

Strategy: Determine the least stable client. (1) CORRECT - IV fluids are critical to reduce clotting and pain (2) no indication client is unstable (3) stable client (4) stable client

The home care nurse plans activities for the day. Which client should the nurse see first? 1. A client who is breastfeeding a 2-day-old infant born 5 days before the due date. 2. A client discharged yesterday after IV heparin therapy for a deep vein thrombosis. 3. An elderly client discharged from the hospital 3 days ago with pneumonia. 4. An elderly client who used all the diuretic medication and is expectorating pink-tinged mucus.

Strategy: Determine the least stable client. Think ABCs. 1) stable situation, not a priority 2) assess for bleeding gums, hematuria, not the priority 3) assess breath sounds, encourage fluids, cough and deep breathe 4) CORRECT - symptoms of pulmonary edema; requires immediate attention

The nurse receives a report on the medical/surgical unit. Which of the following clients should the nurse see FIRST? 1. A client post-appendectomy waiting for discharge instructions. 2. A client diagnosed with Graves'disease being evaluated for a possible thyroidectomy. 3. A client admitted from the emergency department 1 hour ago with multiple injuries due to a motor vehicle accident. 4. A client diagnosed with peptic ulcer disease scheduled for a subtotal gastrectomy (Billroth II) procedure in 4 hours.

Strategy: Determine the most unstable client. (1.) stable client (2.) indications include difficulty sleeping, weight loss, intolerance to heat, irritability, rapid pulse (3.) CORRECT - least stable; requires further assessment of injuries, potential complication (4.) preoperative teaching needs to be reinforced; not most unstable client

The triage nurse at a busy urgent care center prioritizes clients for evaluation. The nurse determines that which of the following clients should be seen FIRST? 1. A woman at 6 weeks'gestation who complains of left lower quadrant abdominal pain and vaginal spotting. 2. A toddler whose parents report nausea and vomiting for 2 hours and a fever of 102.8°F (39.0°C). 3. A patient diagnosed with renal disease who missed his dialysis appointment the day before and who complains of swelling in his feet and ankles. 4. A toddler who has a forehead laceration from a fall and who is smiling and playful.

Strategy: Determine the most unstable client. 1) CORRECT—symptoms of ectopic pregnancy, which may result in death if allowed to progress 2) though at risk for dehydration, short duration of the child's symptoms indicate a potential and not actual risk at this time; nurse likely to obtain an order for an antipyretic while the patient waits for evaluation 3) likely requires dialysis; ectopic pregnancy is an actual risk 4) level of consciousness is appropriate

A psychiatric home health nurse is planning client visits for the day. Which of the following patients should the nurse see FIRST? 1. A 16-year-old who refuses to attend school today. 2. A 30-year-old patient diagnosed with bulimia who ate two large pizza pies for lunch. 3. A 45-year-old patient diagnosed with schizophrenia who is hearing voices telling him to hurt his mother. 4. A 50-year-old male who is depressed over his wife's recent death.

Strategy: Determine the most unstable patient. 1) stable patient 2) assess client's anxiety level and whether the client purged; stable patient 3) CORRECT - safety issue; prevent client from hurting himself or others 4) requires further assessment; see this patient second

The nurse cares for a client after abdominal surgery. The client suddenly vomits. The nurse checks the abdominal dressing and notes a separation of the incision staples. The nurse should take which actions? Select all that apply. 1. Place a sterile saline dressing over the wound. 2. Position the client in a supine position without a pillow. 3. Place the client in a semi-Fowler's position with knees bent. 4. Explain to the client that this is a common occurrence that can be easily repaired at the bedside. 5. Use an abdominal binder to stabilize the incision. 6. Ask the nursing assistive personnel (NAP) to stay with the client, then contacting the health care provider.

Strategy: Determine the outcome of each answer choice. Is it appropriate for this situation? 1) CORRECT — nurse should use a sterile dressing to cover the wound 2) position may stretch the edges of the incision and would likely increase client anxiety and wound separation 3) CORRECT — client should be placed in a position that decreases pressure on the wound 4) false reassurance; nurse should prepare client for surgical wound closure 5) nurse should not use abdominal binder; apply sterile dressings to protect wound and contact health care provider 6) nurse should stay with the client

A client with a history of pulmonary disease comes to the emergency room with pronounced wheezing and mild dyspnea. The nurse obtains arterial blood gases and the results are: pH 7.32, PaCO248, HCO324, PaO251. The client is given 1 L/min of oxygen per nasal cannula and placed in Fowler position. An hour later the ABGs are: pH 7.35, PaCO238, HCO324, PaO260. Which of the following actions, if taken by the nurse, is BEST? 1. Increase the oxygen flow rate. 2. Prepare the client for ICU admission. 3. Continue to monitor the client. 4. Place the client in semi-Fowler position.

Strategy: Determine the outcome of each answer. 1) CORRECT - acidosis has improved, but PaO2remains decreased; normal is 80-100 2) not a life-threatening event 3) intervention is required; PaO2of 60 is too low 4) in respiratory distress; do not lower head of bed

The pediatric nurse cares for a 3-month-old infant diagnosed with developmental dysplasia of the left hip. The health care provider orders the infant to be placed in a Pavlik harness, and the nurse instructs the mother about how to care for the infant. Which statement by the infant's mother to the nurse indicates further teaching is necessary?/P>Select all that apply. 1. "My baby should always wear an undershirt under the chest straps." 2. "I should check for reddened areas under the straps several times each day.' 3. "I should place my baby's diaper over the straps." 4. "We should adjust the harness every couple of weeks because of the baby"s growth." 5. "I should massage under the straps once a day." 6. "My baby will always wear knee socks."

Strategy: Determine the outcome of each answer. 1) appropriate action; prevents skin breakdown; symptoms of developmental dysplasia of the hip include uneven gluteal folds and thigh creases, Ortolani sign, shortened limb on affected side 2) appropriate action; prevents skin breakdown 3) CORRECT - diaper should be placed under the straps; Pavlik harness is an abduction device; infant wears it for 3-5 months 4) CORRECT - the straps of the harness may require adjustment every 1-2 weeks because of infant's growth, but this should be done by a health care professional; some harnesses are not removed, even for bathing 5) appropriate action; do not use lotions or powders because they can cause irritation to the skin 6) appropriate action; prevent skin breakdown

The nurse instructs a client diagnosed with gout about how to prevent recurrent attacks. It is most important for the nurse to include which statement? 1. "Increase your intake of dried peas, beans, and lentils." 2. "Drink at least 2,000-3,000 mL of fluid every day." 3. "Decrease your intake of milk, cheese, and yogurt." 4. "Follow a low-carbohydrate diet."

Strategy: Determine the outcome of each answer. 1) gout is characterized by overproduction or underexcretion of uric acid; high purine foods increase incidence of gout; foods include organ meats, meat soups, gravy, anchovies, sardines, fish, seafood, asparagus, spinach, peas, dried legumes, wild game 2) CORRECT - increases urinary uric acid excretion; eliminate or restrict alcohol intake; drug therapy includes colchicine, allopurinol, and NSAIDs 3) foods high in calcium can provide moderate protein; appropriate for diet 4) cause formation of ketones that inhibit uric acid excretion; high-carbohydrate diet increases uric acid excretion

The nurse cares for a 2-month-old infant immediately after a surgical procedure. Which is the priority nursing action? 1. Minimize stimuli for the infant. 2. Restrain all extremities. 3. Encourage the parents to stroke the infant. 4. Explain to the mother how she can assist with her infant's care.

Strategy: Determine the outcome of each answer. 1) sensory deprivation can cause failure to thrive 2) might cause failure to thrive 3) CORRECT - tactile stimulation is imperative for infant's emotional development 4) important, but not as important as providing tactile stimulation to the infant

The nurse supervises care of a client who just had a short leg cast applied. The nurse determines that care is appropriate if which is observed? Select all that apply. 1. The cast is covered with a light sheet. 2. The staff handles the cast using the palms of their hands. 3. The affected limb is elevated to the level of the heart. 4. The nurse compares the toes of the casted leg with the opposite leg. 5. The staff places a fan in the client's room. 6. The staff turns the client every 4 hours.

Strategy: Determine the outcome of each answer. Is it desired? 1) leave cast uncovered and exposed to the air 2) CORRECT — prevents development of pressure area 3) CORRECT — decreased edema 4) CORRECT — assess for neurovascular functioning; also assess circulation, motion, and sensation in the casted extremity 5) CORRECT — increases circulation of air in room to facilitate drying the cast 6) turn the client every 2 hours to facilitate drying the cast, support major joints when turning

A patient complains of pain at the IV site. The nurse notes tenderness and redness at the IV insertion site and redness proximally along the vein. Which of the following interventions is the nurse MOST likely to perform? 1. Slow the infusion rate and monitor the patient's response. 2. Stop the infusion and notify the physician. 3. Remove the IV and apply a pressure dressing. 4. Remove the IV and apply warm soaks.

Strategy: Determine the outcome of each answer. Is it desired? 1) symptoms indicate phlebitis and will only progress with continued infusion 2) inadequate intervention; catheter should be removed and warm soaks applied; physician should be notified if the signs and symptoms are severe, if they persist, or as is indicated by the facility's policy; document appropriately on the patient's chart and monitor the site 3) inadequate intervention; should also apply warm soaks 4) CORRECT - IV catheter should be removed to prevent further damage to the vein; warm soaks decrease inflammation, swelling, and discomfort

The nurse prepares assignments for a group of clients. Which care does the nurse delegate to the nursing assistive personnel (NAP)? Select all that apply. 1. Collect a stool specimen from a client with suspected Clostridium difficile. 2. Obtain and documenting blood pressure readings on an adult with hypertension. 3. Obtain a pain scale rating for a postoperative client preparing for discharge. 4. Collect a complete blood count (CBC) from a client with symptoms of anemia. 5. Show the client with a fractured ankle how to use crutches. 6. Provide a back massage to a client with chronic pain.

Strategy: Nursing assistive personnel are assigned to clients requiring standard, unchanging procedures. 1) CORRECT — this task may be delegated to the NAP; nurse is responsible for instructing the NAP how and when to collect the specimen 2) CORRECT — this task may be delegated; NAP is trained to take blood pressures 3) pain assessment must be done by the nurse 4) venipuncture must be performed by the nurse or by a trained phlebotomist from the lab 5) client teaching must be done by the nurse, or in the case of crutch training, by the physical therapy staff; NAP may reinforce teaching but not provide the initial instruction 6) CORRECT — this task may be delegated, after the nurse ensures the NAP is trained and if the client is willing

The infant tested positive for phenylketonuria (PKU). The nurse determines which is the PRIORITY for this infant? 1. Offer the infant Lofenalac. 2. Administer a middle-chain triglyceride (MCT) oil with each feeding. 3. Provide genetic counseling for the family. 4. Place infant on a mixture of oleic and erucic acids, Lorenzo's Oil.

Strategy: Physical needs take priority. 1) CORRECT - infant lacks the enzyme necessary to convert phenylalanine to tyrosine; phenylalanine accumulates in the tissues and leads to mental retardation; Lofenalac is low in phenylalanine but contains minerals and vitamins required by the infant 2) MCT (medium chain triglyceride) is made from coconut and can be added to the formula to provide adequate calories; more important to offer Lofenalac 3) PKU is an autosomal-recessive trait; take care of physical needs first 4) given to children diagnosed with adrenoleukodystrophy (ALD), a hereditary disease of children

The nurse cares for infants in the pediatric clinic. The nurse discusses developmental milestones with the parent of an infant. Arrange the developmental milestones in the proper order beginning with the first milestone. Doll's-eye reflex disappears. Begins drooling. Responds to own name. Takes deliberate steps when standing. Picks up bite-size pieces of cereal.

Strategy: Picture an infant. 1) Doll's eye reflex disappears at 2-3 months 2) Begins drooling at 4 months 3) Responds to own name at 6-8 months 4) Takes deliberate steps when standing at 9-10 months 5) Picks up bite-size pieces of cereal at 11 months

The pediatric nurse performs a developmental age assessment on a 2-month-old infant. Which will the nurse MOST likely document as being consistent with the infant's chronological age? 1. The infant lifts the head 45 degrees when in prone position. 2. The infant rolls over from front to back and from back to side. 3. The infant plays with her own hands and toes. 4. The infant grasps objects with both hands.

Strategy: Picture the infant. (1.) CORRECT - usually occurs between 1 and 3 months (2.) usually occurs between 4 and 6 months (3.) usually occurs between 4 and 6 months (4.) usually occurs between 4 and 6 months

The nurse leads a family therapy session for the family of an adolescent diagnosed with depression. During the first session, the teen's mother dominates the discussion. Which response by the nurse is MOST appropriate? 1. "Please let some of the other family members speak." 2. "You appear to be frustrated about dealing with your teen." 3. "You and I will speak privately after the session is over." 4. "How do the rest of you feel about what your Mother is saying."

Strategy: Remember therapeutic communication. 1) nontherapeutic response 2) is therapeutic; one purpose of family therapy is to help members develop their own sense of identity 3) important to give every member in the group a chance to talk as a group 4) CORRECT—allows every member of group to offer feedback about the effect the mother's monopoly of the session has on each person

The nurse supervises the staff caring for clients on the medical/surgical unit. The nurse observes the student nurse enter wearing a gown, gloves, and a facemask. The nurse determines that the precautions are correct if the student nurse is caring for which client? 1. An infant diagnosed with respiratory syncytial virus. 2. A school-aged child diagnosed with hepatitis A. 3. A teenager diagnosed with toxic shock syndrome. 4. A teenager diagnosed with influenza.

Strategy: Remember transmission-based precautions. 1) requires contact precautions, no mask 2) requires standard precautions 3) standard precautions 4) CORRECT - droplet precautions used for organisms that can be transmitted by face-to-face contact; door may remain open

The nurse cares for a client receiving potassium chloride 25 mEq IV piggyback. The potassium chloride is labeled 10 mL = 40 mEq. Record the number of milliliters of potassium chloride that the nurse should add to the IV solution. Type the correct answer into the blank. Do not round.

Strategy: Set up a ratio. 40 mEq/10 mL= 25 mEq/ x mL = 6.25 mL

Which fact in the health history of an adult client should cause the nurse to question an order for aspirin? 1. An allergy to tartrazine. 2. A history of lead poisoning in childhood. 3. Maternal grandfather died of complications from diabetes. 4. Allergies to bee venom and to milk.

Strategy: Think about each answer. (1.) CORRECT - there is cross-sensitivity between tartrazine and aspirin; an allergic response to one indicates a possible allergic response to the other (2.) no relationship with or contraindications to aspirin usage; usual body system most affected by lead poisoning is neurologic (3.) no contraindication (4.) no contraindications to the use of aspirin by the client, taking aspirin with milk may decrease GI irritation

Following a train accident, the nurse triages a group of survivors with minimal physical injuries. In response to the nurse's question about how he is feeling, a teenager states matter-of-factly,"Look at all the rescue trucks. It's like watching a movie."The nurse identifies that the client is using which of the following defense mechanisms? 1. Dissociation. 2. Regression. 3. Projection. 4. Denial.

Strategy: Think about each answer. 1) CORRECT - unconscious separation of painful feelings from a difficult situation, idea, or object 2) return to an earlier level of development and the comfort measures associated with that level of functioning 3) attributing one's own feelings that are unacceptable to someone else, or blaming someone else for one's own problems 4) unconscious refusal to admit an unacceptable idea or behavior or the feelings associated with it

The nurse cares for a client receiving haloperidol by intramuscular injection. The client develops a fever of 103.6°F (40°C), pulse 110, muscle rigidity, and incontinence. The nurse knows that the client is experiencing which symptom? 1. Tardive dyskinesia. 2. Pseudoparkinsonism. 3. Acute dystonic reaction. 4. Neuroleptic malignant syndrome

Strategy: Think about each answer. 1) characterized by abnormal facial and tongue movements 2) characterized by tremors, rigidity, and shuffling gait; administer an anticholinergic agent 3) characterized by severe muscle contractions of the head and neck; administer diphenhydramine hydrochloride 4) CORRECT - severe reaction to antipsychotic medication as a result of dopamine blockade in the hypothalamus; fatal in approximately 10% of cases; stop medication; transfer to medical unit, cool body; administer bromocriptine to treat muscle rigidity and dantrolene to reduce muscle spasms

The nurse cares for a client diagnosed with a draining abdominal abscess. What is the MOST important information for the nurse to assess? 1. Amount. 2. Character. 3. Consistency. 4. Amount of suction on system.

Strategy: Think about each answer. 1) important to measure amount of drainage 2) CORRECT—assessing whether the drainage is purulent, sanguinous, serosanguineous, etc. 3) character is most important 4) not relevant to the drainage

The nurse in the emergency department cares for a client diagnosed with a heroin overdose. The nurse administers naloxone to the client. The nurse anticipates which response? 1. Decreased pulse and pallor. 2. Decreased urinary output and hypotension. 3. Lethargy and stupor. 4. Nausea and vomiting.

Strategy: Think about each answer. 1) is a narcotic antagonist; will cause tachycardia 2) will cause hypertension due to opioid withdrawal 3) does not cause lethargy and stupor 4) CORRECT—will cause signs and symptoms of opioid withdrawal: nausea, vomiting, restlessness, abdominal cramping

A 45-year-old client experiences a pathologic fracture of the left tibia. The nurse expects to find which information in the client's history? 1. That client was diagnosed with type 2 diabetes 1 year ago. 2. The client has played doubles tennis twice a week for the past 2 years. 3. The client has been taking cortisone for 3 years. 4. The client has been a practicing vegetarian for 5 years.

Strategy: Think about each answer. 1) no relationship to pathologic fractures 2) weight bearing on long bones keeps them strong, would not expect client to experience pathologic fractures 3) CORRECT - long-term cortisone therapy can cause osteoporosis, weakness, muscle-wasting, depression, alopecia, buffalo hump, obesity, mood swings, slow wound healing 4) no relationship to the development of pathological fractures

The nurse presents a program at the community center about the risk factors for colorectal cancer. The nurse includes which as a risk factor for colorectal cancer? 1. Age 18-25. 2. Diet high in fat and low in fiber. 3. A distant relative diagnosed with colorectal cancer. 4. Appendectomy during the teen years.

Strategy: Think about each answer. 1) risk is greater for people over the age of 50 2) CORRECT — high-protein, high-fat, low-fiber diet is a risk factor 3) family history (first-degree relative) of colorectal cancer or polyps 4) history of chronic inflammatory bowel disease is a risk factor

Four clients are admitted at the same time to the medical unit. Which clients should be admitted to the only private room available? 1. The client diagnosed with bacterial gastroenteritis. 2. The client diagnosed with hepatitis A. 3. The client diagnosed with scabies. 4. The client diagnosed with cirrhosis.

Strategy: Think about the disease process. 1) acute diarrheal illness, often caused by E. coli, which is transmitted by the fecal-oral route; standard infection control procedures are sufficient unless client is diapered or incontinent, in which case contact precautions are required 2) hepatitis A is a form of viral hepatitis transmitted by the fecal-oral route; standard infection control procedures are sufficient unless client is diapered and incontinent, in which case contact precautions are required 3) CORRECT - contagious skin disease caused by mites; transmitted by close contact, either directly person-to-person or via contaminated personal items such as clothing, bedding; requires a private room and contact precautions 4) cirrhosis is not an active infective process and does not require tier 2 transmission-based precautions

The nurse on the pediatric unit cares for a 7-year-old girl under observation for cerebral concussion after being struck by her 10-year-old brother's bicycle. The parents are at the bedside and begin to discuss the cause of the accident. Which of the following statements, if made by the parents, validates the nursing diagnosis of dysfunctional family process? 1. "Our daughter never watches where she's going. She doesn't pay attention." 2. "It was an accident. I don't want to hear that our son has always been jealous of her." 3. "This would not have happened if you had not stopped at the bar on the way home." 4. "We are going to have to talk to our son about bicycle safety."

Strategy: Think about what the parents' words mean. (1.) suggestive of attention deficit, not necessarily a sign of family dysfunction (2.) suggestive of possible sibling rivalry (3.) CORRECT - blaming a spouse plus potential substance abuse indicate dysfunctional family process; substance abuse is primary cause of dysfunctional family systems (4.) appropriate parental response

Which information is essential to report when communicating client information at the change of shift? Select all that apply. 1. The client is newly diagnosed with type 1 diabetes and needs follow-up teaching about insulin administration. 2. The client is seemingly more confused and has been attempting to get out of bed without assistance. 3. The attending health care provider ordered lorazepam PRN for restlessness. 4. The client has a 20-year history of smoking. 5. The client receives carvedilol, benztropine mesylate, and losartan on a daily basis.

Strategy: Unsure about what the question is asking? Read answer choices to determine topic. Evaluate the information listed in each answer choice. Does it indicate an emergent or potentially emergent situation? 1) CORRECT — client teaching needs related to discharge are important in continuum of care 2) CORRECT — a behavior change and/or new symptom is essential to report 3) CORRECT — new health care provider orders are essential to communicate 4) not essential information that can be attained in medical record; don't read into the question; no information that smoking history presents an immediate need 5) routine medications do not need to be included in report and can be obtained from medical record; new medication orders, pertinent PRN medications recently administered, or symptoms unrelieved by medications should be included in report

The nurse receives report from the previous shift. The nurse plans to see these clients in which order? Prioritize the order in which each client should be seen from first seen to last seen. - A client with a subdural hematoma who has a sudden onset of acute confusion. - A client who has a new order to insert a nasogastric (NG) tube with low intermittent suction. - A client requesting pain medication for post surgical pain rated "7" on a 0-10 scale. - A client with Alzheimer's disease who is disoriented to place, time, and event.

Strategy: Utilize the ABCs, real vs. potential, and stable vs unstable. When determining the order of the nurse's actions, determine the outcomes and make the decision based on outcomes. 1) indicates potential increased ICP; client has a new and acute symptom; should be seen first 2) client has a real issue and should be seen in a timely manner 3) no indications of immediate problems but needs an intervention (NG tube); see third 4) normal finding for Alzheimer's disease, see last

The nurse is working with a battered woman who is living in a domestic violence shelter after having left her partner. The woman states to the nurse,"I don't know what I keep doing wrong to get beaten this way."Which of the following responses by the nurse is BEST? 1. "Can you remember what you said or did just before he hit you?" 2. "Let's focus on getting your face and ribs healed first." 3. "We can help you when you're ready; you do not deserve to be abused." 4. "Only your husband can tell us what made him lose his temper."

Strategy:"BEST response"indicates discrimination is required to answer the question correctly. 1) yes/no question is nontherapeutic; implies that the woman did something wrong to cause the abuse 2) closed statement is nontherapeutic; focuses on physical healing; emotional work should not be delayed if the woman indicates a willingness to start 3) CORRECT - reflective statement is therapeutic, also provides information; should offer support and a path to help, coupled with reinforcement that the woman does not deserve to be abused 4) focus is on the husband, not the patient; gives power to the abuser to place blame on the victim, and implies to the woman that she is to blame

The nurse observes a nursing student assess a client's mobility. The client is lying in the bed and the nursing student asks the client to sit in the chair so the nursing student can complete the assessment. Which of the following responses by the nurse is BEST? 1. Instruct the nursing student to continue the assessment. 2. Ask the nursing student to report any difficulties the client may have sitting in a chair. 3. Tell the nursing student to begin the assessment while the client is lying in bed. 4. Talk with the nursing student at the completion of the assessment.

Strategy:"BEST"indicates that discrimination is required to answer the question. 1) should begin the assessment with the client in the most supportive position 2) to ensure client safety, begin assessment with client lying in bed; should anticipate difficulties 3) CORRECT - to ensure client safety, begin assessing client's movement when the client is lying in bed, then ask client to sit on side of bed, transfer to the chair, and then observe the client's gait 4) client safety is priority, nurse should intervene immediately

The mother of a 5-month-old contacts the nurse to report that she has a dry cough, fever, headache, and muscle aches. The client breast-feeds her infant. Which of the following actions by the nurse is BEST? 1. Suggest the client discontinue breastfeeding during the illness. 2. Ask the client to increase her fluid intake. 3. Instruct the client to wear a surgical mask. 4. Inform the client to uncover her breasts before washing her hands.

Strategy:"BEST'indicates discrimination is required to answer the question. 1) may continue breastfeeding 2) appropriate action; priority is to prevent spread of flu 3) CORRECT—put on mask, wash hands, and uncover breasts; wear mask until the feeding is finished and the mom has put the baby down 4) incorrect action

The nurse at a community health center is notified that a group of clients has been exposed to a hazardous chemical. Which of the following clients should the nurse see FIRST? 1. A client who says the chemical spilled onto his legs. 2. A client who says he inhaled the chemical. 3. A client who says she has hypertension and type 2 diabetes. 4. A client who says he swallowed the chemical.

Strategy:"FIRST"indicates priority. 1) although serious, skin exposure results in a slower absorption rate 2) CORRECT - results in immediate absorption and can impair oxygen exchange 3) no indication that client is unstable 4) not as life-threatening as impaired gas exchange

The nurse cares for a client diagnosed with COPD who is brought to the hospital by EMS for increasing shortness of breath. The client is placed on a cardiac monitor and an IV access is established. The client's vital signs are: B/P 130/70, HR 84, RR 26, and oxygen saturation is 100% on 6 L oxygen per nasal cannula. Which intervention should the nurse perform FIRST? 1. Attempt to wean the client's supplemental oxygen. 2. Elevate the head of the bed to 45°. 3. Administer theophylline. 4. Obtain arterial blood gases as ordered.

Strategy:"FIRST"indicates priority. 1) appropriate action because high oxygen flow rate may decrease the COPD patient's stimulus for breathing; proper positioning improves respiratory functioning; if positioned incorrectly, other interventions would be less effective 2) CORRECT—proper positioning maximizes respiration and decreases respiratory effort 3) appropriate action but is less effective without proper positioning 4) appropriate action; however, proper positioning maximizes respiration and decreases respiratory effort while additional interventions are performed

The nurse instructs a client diagnosed with COPD about how to perform pursed lip breathing. Which of the following statements by the client to the nurse indicates further teaching is necessary? 1. "I will tighten my stomach muscles as I finish breathing out." 2. "I will take twice as long to breathe out as I did to breathe in." 3. "I will breathe in deeply through my nose, hold it, and then breathe out." 4. "I will pretend I am whistling when I breathe out."

Strategy:"Further teaching is necessary"indicates incorrect information. 1) using abdominal muscles helps to squeeze out all of the air 2) appropriate action; exhalation should be at least twice as long as inhalation; mild resistance of partially opposed lips prolongs exhalation and increases airway pressure 3) CORRECT—incorrect action; breath should never be held during pursed lips breathing 4) ensures slow, soft, and steady exhalation

The nurse prepares a client for computerized axial tomography (CAT) scan without the use of contrast dye. It is MOST important for the nurse to assess for which of the following? 1. Problem client may have with being in a closed space. 2. Allergies to medication. 3. Intact swallow and gag reflex. 4. Range of motion of all extremities.

Strategy:"MOST important"indicates priority. 1) CORRECT - provides three-dimensional assessment of the lungs and thorax; if client is claustrophobic, scan may cause severe anxiety 2) not important 3) not necessary 4) client has to lie still for half an hour

The nurse on the medical unit administers acetaminophen with codeine #3 tab ii PO to a client. The health care provider ordered acetaminophen 325 mg tab ii PO. Because the client is allergic to codeine, the health care provider orders diphenhydramine 50 mg IM. After informing the client of the error and administering the IM medication, it is most important for the nurse to take which action? 1. Apologize to the client for administering the wrong medication. 2. Ask the client to remain in bed for 3-4 hours. 3. Explain to the client the signs/symptoms of a reaction to codeine. 4. Clarify why the nurse administered the diphenhydramine.

Strategy:"MOST important"indicates priority. 1) priority is client safety 2) CORRECT —acetaminophen with codeine and diphenhydramine cause drowsiness; maintain client safety 3) first concern is informing client to stay in bed 4) was explained prior to administering diphenhydramine

The nurse supervises care of a client after a laminectomy. Three staff members who have completed training prepare to turn the client. Which of the following observations by the nurse requires an immediate intervention? 1. One staff member stands alone holding the draw sheet. 2. Two staff members stand side by side supporting the client's head, neck, shoulders, hips, and knees. 3. The arms of the client are crossed on the chest. 4. The legs of the client are straight and in contact with each other.

Strategy:"Requires an intervention"indicates something is wrong. 1) appropriate action; rolling draw sheet closely toward client and holding it firmly supports client's torso and maintains body alignment 2) appropriate action; client movement is coordinated to move all body parts at same time to prevent injury to neck and spinal column 3) appropriate action; keeps body straight and prevents arms from becoming trapped under the body 4) CORRECT - pillow should be placed longitudinally between legs to prevent hip and lower leg adduction and spinal torque

A 45-year-old patient with leukopenia is in protective isolation. The nurse should intervene if which of the following is observed? 1. The patient's wife enters the patient's room wearing a mask, gown, and gloves. 2. The patient's food is delivered to the patient's room on china with nondisposable eating utensils. 3. A basket of fresh fruit is delivered to the patient's room. 4. A large card signed by the patient's coworkers is delivered to the patient's room.

Strategy:"Should intervene"indicates something is wrong. 1) expected precautions for protective isolation; monitor for s/s infection; place in private room 2) unnecessary to use disposable utensils for meals; do not share supplies with other patients; clean bathroom daily 3) CORRECT - fresh fruit or flowers should not be allowed in the room with a patient with leukopenia because it is a possible source of infection; no potted plants 4) no risk to patient on protective isolation; limit visitors to healthy adults, limit number of health-care workers entering the room; inspect client's mouth, skin, and mucous membranes every 8 hours

The nurse cares for a client with a history of a heart murmur who has been receiving clozapine for 2 weeks. The nurse reviews discharge instructions. The nurse knows that teaching is successful if the client makes which statement? 1. "I will return to the lab in one week to have my white blood count taken." 2. "I can take 2 pills the next morning if I miss my dose." 3. "I will limit my intake of sodium to 2 mg a day." 4. "I will increase my dose if I am feeling moody."

Strategy:"Teaching is successful"indicates correct information. 1) CORRECT - if WBCs fall below 2000/mm3, the drug will be discontinued; risk of agranulocytosis, potentially life threatening; clozapine is an atypical antipsychotic; side effects include leukopenia, gram-negative septicemia, drowsiness, tachycardia, and hypotension 2) must take medication as directed by health care provider and not increase or decrease dose 3) sodium intake does not change the efficacy of the medication 4) don't increase or decrease dosage; notify health care provider of changes in behavior