Saunder's NCLEX review-Fundamentals

Penicillin V (potassium), 75 mg orally every 8 hours, is prescribed for a child with a respiratory infection. The medication label reads penicillin V, 125 mg per 5 mL. The nurse has determined that the dosage prescribed is safe for the child. The nurse prepares to administer how many milliliters per dose to the child? Fill in the blank.

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The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply. 1.Tetany 2.Lethargy 3.Tingling 4.Confusion 5.Numbness 6.Restlessness

1, 3, 5, 6 A client's reaction to alkalosis causes tingling and numbness of the fingers, restlessness, and tetany caused by irritability of the central nervous system (CNS) results. If the severity of alkalosis increases, convulsions and coma may occur.

The nurse is assessing a client newly diagnosed with mild hypertension. Which assessment finding should the nurse expect? 1.Asymptomatic 2.Shortness of breath 3.Visual disturbances 4.Frequent nosebleeds

1.Asymptomatic Hypertensive clients often have no symptoms until target organ involvement, which happens with very high blood pressure. This is why it is often noted as the "silent killer." The remaining options are incorrect because those clinical manifestations occur with severely high hypertension.

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client? 1."Take a deep breath when I tell you, and hold it while I remove the tube." 2."Take a deep breath when I tell you, and bear down while I remove the tube." 3."Take a deep breath when I tell you, and slowly exhale while I remove the tube." 4."Take a deep breath when I tell you, and breathe normally while I remove the tube."

1."Take a deep breath when I tell you, and hold it while I remove the tube." The client should take a deep breath because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it) while the breath is held. Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation.

A postoperative client has been tolerating a full liquid diet, and the nurse plans to advance the diet to solid food as prescribed. Which assessment is most important for the nurse to make before advancing the diet to solids? 1.Ability to chew 2.Food preferences 3.Cultural preferences 4.Presence of bowel sounds

1.Ability to chew It may be necessary to modify a client's diet of solid food to a soft or chopped (pureed) diet if the client has difficulty chewing. Food and cultural preferences should be ascertained on admission. Bowel sounds should have previously been assessed and present before introducing any diet.

The nurse is reviewing the health care provider's prescription sheet for a preoperative client, which states that the client must be NPO (nothing by mouth) after midnight. Which medication should the nurse clarify to be given and not withheld? 1.Atenolol 2.Atorvastatin 3.Cyclobenzaprine 4.Conjugated estrogen

1.Atenolol Atenolol is a beta-blocker. Beta-blockers should not be stopped abruptly, and the health care provider should be contacted about the administration of this medication before surgery. If a beta-blocker is stopped abruptly, the myocardial need for oxygen is increased. Atorvastatin is a cholesterol-lowering medication used to treat high cholesterol. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. The other three medications may be withheld before surgery without undue effects on the client.

The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? 1.Continue with the instructions, verifying client understanding. 2.Walk around the client so that the nurse constantly faces the client. 3.Give the client a dietary booklet and return later to continue with the instructions. 4.Tell the client about the importance of the instructions for the maintenance of health care.

1.Continue with the instructions, verifying client understanding. Rationale: Most Chinese Americans maintain a formal distance with others, which is a form of respect. Many Chinese Americans are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Walking around the client so that the nurse faces the client is in direct conflict with this cultural practice. The client may consider it a rude gesture if the nurse returns later to continue with the explanation. Telling the client about the importance of the instructions for the maintenance of health care may be viewed as degrading. Test-Taking Strategy: Note the strategic word, best. Focus on the subject, the behavior of a Chinese American client. Eliminate options 3 and 4 first because these actions are nontherapeutic. To select from the remaining options, think about the cultural practices of Chinese Americans and recall that direct eye contact may be uncomfortable for the client.

The nurse is preparing an intravenous (IV) set before starting the infusion. After removing the cap from the IV tubing port on the IV bag, the nurse removes the cover from the tubing insertion spike but then touches the spike with a finger. What should the nurse do next? 1.Discard the IV tubing and use a new set for the infusion. 2.Continue with the procedure and then flush the tubing thoroughly. 3.Clean the spike with an alcohol swab for 15 seconds and then continue. 4.Clean the spike and the IV bag tubing port with alcohol and then continue.

1.Discard the IV tubing and use a new set for the infusion. The IV tubing's insertion spike must remain sterile. If it is touched during the preparation of the infusion, the tubing must be discarded and replaced with a sterile set. Otherwise, the infusion set is contaminated, which could cause infection in the client. Therefore, the remaining actions are incorrect.

A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply. 1.Ensures that a close relative stays with the client 2.Makes a referral for a Catholic priest to visit the client 3.Removes the crucifix from the wall in the client's room 4.Administers the sacrament of the sick to the client if death is imminent 5.Offers to provide a means for praying the rosary if the client wishes 6.Reminds the dietary department that meals served on Fridays during Lent do not contain meat

1.Ensures that a close relative stays with the client, 2.Makes a referral for a Catholic priest to visit the client, 5.Offers to provide a means for praying the rosary if the client wishes Rationale: In times of illness, a Roman Catholic client may turn to prayer for spiritual support. This may include rosary prayers or visits from a priest, who is the spiritual leader in the Roman Catholic faith. Close family members usually want to stay with a dying family member in order to hear the wishes of the client, allowing the soul to leave in peace. A priest, not a nurse, would administer the sacrament of the sick. Roman Catholics would not ask for the crucifix to be removed. Members of other religious groups such as Islam or Judaism may request the removal of the crucifix. Dietary rituals are not a concern at this time. Test-Taking Strategy: Focus on the subject, the Roman Catholic religion. Consider the role of the spiritual leader and family in the Catholic faith. This will assist in selecting options 2 and 5. For the remaining options, recall that the presence of family is a source of support.

Which clients have a high risk of obesity and diabetes mellitus? Select all that apply. 1.Latino American man 2.Native American man 3.Asian American woman 4.Hispanic American man 5.African American woman

1.Latino American man 2.Native American man 4.Hispanic American man 5.African American woman Rationale: Because of their health and dietary practices, Latino Americans, Native Americans, Hispanic Americans, and African Americans have a high risk of obesity and diabetes mellitus. Owing to dietary practices, Asian Americans have a lower risk for obesity and diabetes mellitus. Test-Taking Strategy: Focus on the subject, those with a high risk for diabetes mellitus and obesity. Think about the health and dietary practices of each cultural group in the options to answer correctly.Review: The health risks for various ethnic groups

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply. 1.Peas 2.Nuts 3.Cheese 4.Cauliflower 5.Processed oat cereals

1.Peas 2.Nuts 4.Cauliflower Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 150 mEq/L (150 mmol/L) indicates hypernatremia. On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. Peas, nuts, and cauliflower are good food sources of phosphorus and are not high in sodium (unless they are canned or salted). Peas are also a good source of magnesium. Processed foods such as cheese and processed oat cereals are high in sodium content. Test-Taking Strategy: Focus on the subject, foods acceptable to be consumed by a client with a sodium level of 150 mEq/L (150 mmol/L). First, you must determine that the client has hypernatremia. Select peas and cauliflower first because these are vegetables. From the remaining options, note the word processed in option 5 and recall that cheese is high in sodium. Remember that processed foods tend to be higher in sodium content.

The nurse is caring for a child with a diagnosis of neutropenia. Which nursing interventions are most appropriate for a child placed in protective isolation for neutropenia? Select all that apply. 1. Place the child on a low-bacteria diet. 2. Change dressings using sterile technique. 3. Put flowers in a vase with water before placing in the room. 4. Peel fruits and vegetables before allowing the child to eat them. 5. Allow individuals who are ill to visit as long as they wear a mask.

1.Place the child on a low-bacteria diet. For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillusand Pseudomonas species, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed using sterile technique. Individuals who are ill are not allowed to visit the client.

The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? 1.Reassess the client. 2.Conduct a staff meeting to describe the fall. 3.Document in the nurse's notes that an incident report was completed. 4.Contact the nursing supervisor to update information regarding the fall.

1.Reassess the client. Rationale: After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary. Test-Taking Strategy: Note the strategic word, next. Using the steps of the nursing process will direct you to the correct option. Remember that assessment is the first step. Additionally, use Maslow's Hierarchy of Needs theory, recalling that physiological needs are the priority. The correct option is the only option that addresses a potential physiological need of the client.

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? 1.Reflecting a cultural value 2.An acceptance of the treatment 3.Client agreement to the required procedures 4.Client understanding of the preoperative procedures

1.Reflecting a cultural value Rationale: Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement with the speaker, or understanding of the procedure. Test-Taking Strategy: Eliminate options 2 and 3 first because they are comparable or alike and are incorrect. From the remaining options, note that the client is Japanese American and think about the characteristics of this group. This will direct you to option 1. In addition, option 4 is an incorrect interpretation of the client's nonverbal behavior.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1.U waves 2.Absent P waves 3.Inverted T waves 4.Depressed ST segment 5.Widened QRS complex

1.U waves 3.Inverted T waves 4.Depressed ST segment Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia Test-Taking Strategy: Focus on the subject, the ECG patterns that may be noted with a client with a potassium level of 2.5 mEq/L (2.5 mmol/L). From the information in the question, you need to determine that the client is experiencing severe hypokalemia. From this point, you must know the electrocardiographic changes that are expected when severe hypokalemia exists.

An adult client with a history of seizure disorder is having a routine serum phenytoin level drawn. Which serum phenytoin result indicates that the client is having a therapeutic effect of the medication? 6 mcg/mL (23.8 mcmol/L) 16 mcg/mL (63.4 mcmol/L) 28 mcg/mL (110.9 mcmol/L) 36 mcg/mL (142.6 mcmol/L)

16 mcg/mL (63.4 mcmol/L) The therapeutic range for serum phenytoin level is 10 to 20 mcg/mL (39.6 to 79.2 mcmol/L). A level below the therapeutic range could place the client at risk for seizures. If a level is too high, the client is at risk for toxicity. At levels above 20 mcg/mL (79.2 mcmol/L), toxicity can occur with nystagmus, sedation, ataxia (staggering gait), diplopia (double vision), and cognitive impairment.

The nurse should include which item in a list of the most helpful foods for a vegan client wishing to increase foods high in vitamin A? 1.Peas 2.Carrots 3.Potatoes 4.Green beans

2. Carrots Foods that are high in vitamin A include carrots, green leafy vegetables, and yellow vegetables. The other vegetables are high in vitamins but do not necessarily have the highest amount of vitamin A.

The community health nurse is conducting an education session for community members regarding measures to prevent skin cancer and is providing instructions for use of sunscreen protection. The nurse determines that teaching was effective if a community member states that chemical sunscreens are most effective when applied at what time? 1.Immediately after swimming 2.One hour before exposure to the sun 3.Immediately before exposure to the sun 4.Five minutes before exposure to the sun

2. One hour before exposure to the sun Sunscreens are most effective when applied about 30 minutes to 1 hour before exposure to the sun, so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator should make which most appropriate response? 1."A group of individuals identifying as a part of the Iroquois tribe among Native Americans." 2."A person who moves from China to the United States (U.S.) and learns about and adapts to the culture in the U.S." 3."A group of individuals living in the Azores that identify autonomously but are a part of the larger population of Portugal." 4."A person who has grown up in the Philippines and chooses to stay there because of the sense of belonging to his or her cultural group."

2."A person who moves from China to the United States (U.S.) and learns about and adapts to the culture in the U.S." Rationale: Acculturation is a process of learning a different culture to adapt to a new or changing environment. Options 1 and 3 describe a subculture. Option 4 describes ethnic identity. Test-Taking Strategy: Note the strategic words, most appropriate.Focus on the subject, acculturation. Note the words a person who moves and adapts in the correct option and relate this to the definition of acculturation.

The nurse is preparing to administer a 50-mcg dose of medication to a client. The medication is available in 100 mcg/5 mL. How many mL should the nurse administer? Fill in the blank.

2.5 Use the medication calculation formula for calculating the appropriate medication dosage.Desired --------- × Volume = mL/dose Available 50 mcg ------- × 5 mL = 2.5 mL 100 mcg

When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly.

2.Arrange for an interpreter to translate. Rationale: Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 4 are inappropriate and ineffective ways to communicate. Option 3 is inappropriate because it violates privacy and does not ensure correct translation. Test-Taking Strategy: Note the strategic word, best, in the question and note the subject, communicating with a client of a different culture. Eliminate option 3 first because this action can constitute a violation of the client's right to privacy, and does not represent best practice. Next, eliminate options 1 and 4, noting the word loudly in these options and because they are nontherapeutic actions and also are not best practices.

The nurse has a prescription to remove the nasogastric (NG) tube from a client on the firstpostoperative day after cardiac surgery. The nurse should question the prescription if which finding was noted on assessment of the client? 1. The client is drowsy. 2. Bowel sounds are absent. 3. The abdomen is slightly distended. 4. NG tube drainage is Hematest negative.

2.Bowel sounds are absent. The NG tube should remain in place until the client has bowel sounds. If NG suction is being used, the nurse should turn off the suction before listening to bowel sounds to prevent mistaking the sound of the suction for bowel sounds. If bowel sounds do not return, the client could have a paralytic ileus, which could result in distention and vomiting if the NG tube is discontinued. It is likely that the client may be drowsy after experiencing a stressor such as cardiac surgery. The abdomen is likely to be slightly distended after surgery, and it is normal for NG tube drainage to be Hematest negative.

The nurse is reviewing the laboratory test results for a client who takes 325 mg of acetylsalicylic acid, or aspirin, daily and has been having frequent nosebleed episodes. What blood level should the nurse review? 1.Hemoglobin (Hgb) 2.Prothrombin time (PT) 3.Red blood cell (RBC) level 4.Partial thromboplastin time (PTT)

2.Prothrombin time (PT). PT is used to evaluate the adequacy of the extrinsic system and common pathway in the clotting mechanism. When clotting factors exist in deficient quantities, the PT is prolonged. Many diseases and medications such as salicylates are associated with decreased PTs. PT is also used to monitor the adequacy of warfarin therapy. The Hgb level is related to oxygen and carbon dioxide transport. Hgb concentration serves as the oxygen-carrying capacity of the blood and also acts as an important acid-base buffer system. The RBC level is helpful in identifying the cause of anemia and the presence of other diseases. The PTT is used to evaluate the intrinsic system and the common pathway of clot formation and is most commonly used to monitor heparin therapy.

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. 1.Peas 2.Raisins 3.Potatoes 4.Cantaloupe 5.Cauliflower 6.Strawberries

2.Raisins 3.Potatoes 4.Cantaloupe 6.Strawberries Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium. Test-Taking Strategy: Focus on the subject, foods high in potassium. Read each food item and use knowledge about nutrition and components of food. Recall that peas and cauliflower are high in magnesium.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? 1.Sustained tissue damage 2.Requires nasogastric suction 3.Has a history of Addison's disease 4.Uric acid level of 9.4 mg/dL (559 mmol/L)

2.Requires nasogastric suction Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia. Test-Taking Strategy: Note that the subject of the question is potassium deficit. First recall the normal uric acid levels and the causes of hypokalemia to assist in eliminating option 4. For the remaining options, note that the correct option is the only one that identifies a loss of body fluid.

The nurse has observed that an older client has episodes of extreme agitation. Which measure is most appropriate for the nurse to implement to avoid episodes of agitation? 1.Wait until the client's agitation has subsided before approaching the client. 2.Speak and move slowly toward the client while assessing the client's needs. 3.Speak to the client at the entrance of the room to avoid any episodes of agitation. 4.Walk up behind the client and gently put a hand on the client's shoulder while speaking.

2.Speak and move slowly toward the client while assessing the client's needs. Speaking and moving slowly toward the client will prevent the client from becoming further agitated. Any sudden moves or speaking too quickly may cause the client to become agitated and could trigger a violent episode. Remaining at the entrance of the room may make the client feel alienated. If the client's agitation is not addressed, it will only increase. Therefore, waiting for the agitation to subside is not an appropriate option. Walking up behind the client may cause the client to become startled and react violently.

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? 1.To examine the testicles while lying down 2.That the best time for the examination is after a shower 3.To gently feel the testicle with 1 finger to feel for a growth 4.That TSEs should be done at least every 6 months

2.That the best time for the examination is after a shower. The TSE is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with fingers under the scrotum and thumbs on top, the client should gently roll the testicles, feeling for any lumps.

The nurse is preparing to provide preoperative teaching to a Spanish-speaking client and the client's family. Which nursing action would be most effective for teaching the client? 1.The nurse asks one of the client's English-speaking relatives to interpret. 2.The nurse secures the assistance of a professional interpreter to communicate with the client. 3.The nurse obtains a Spanish-language dictionary for help in conducting the teaching session. 4.The nurse obtains a preoperative teaching Spanish-language brochure and gives it to the client.

2.The nurse secures the assistance of a professional interpreter to communicate with the client. Using the services of a professional interpreter is the most effective way to provide preoperative instructions. Asking a family member to interpret is not acceptable because that client may interpret different or erroneous meanings from the nurse's instructions. Non-Spanish-speaking nurses should never attempt to do the teaching themselves with only the help of a Spanish dictionary. A Spanish-language brochure may be given to the client as an adjunct to interpreted verbal instructions but would not be adequate by itself.

The nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. The nurse plans to implement which intervention to obtain the specimen? 1.Ask the client to obtain the specimen after breakfast. 2.Use a sterile plastic container for obtaining the specimen. 3.Provide tissues for expectoration and obtaining the specimen. 4.Ask the client to expectorate a small amount of sputum into the emesis basin.

2.Use a sterile plastic container for obtaining the specimen. Sputum specimens for culture and sensitivity testing need to be obtained using sterile technique because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, the specimen will be contaminated, and the results of the test will be invalid. A first-morning specimen is preferred because it contains overnight secretions from the tracheobronchial tree.

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1."I swim 3 times a week." 2."I have stopped smoking cigars." 3."I drink hot chocolate before bedtime." 4."I read for 40 minutes before bedtime."

3."I drink hot chocolate before bedtime." Many nonpharmacological sleep aids can be used to influence sleep. However, the client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client should exercise regularly because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride 3 times a week is helpful. The client should sleep on a bed with a firm mattress. Smoking and alcohol should be avoided. The client should avoid large meals; peanuts, beans, fruit, raw vegetables, and other foods that produce gas; and snacks that are high in fat because they are difficult to digest.

The nursing student is writing a plan of care for a child who presents with an acute head injury. The nursing instructor reviews the plan of care and praises the student for identifying which assessment as a priority? 1. Inspecting the scalp 2. Pupillary assessment 3. Airway and breathing 4. Palpating the child's head

3.Airway and breathing. The first step in the emergency treatment of child with head injury includes the ABCs-airway, breathing, and circulation-assessments. The other assessments are included when evaluating a head injury, but the priority is ABC.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1.Weight loss and dry skin 2.Flat neck and hand veins and decreased urinary output 3.An increase in blood pressure and increased respirations 4.Weakness and decreased central venous pressure (CVP)

3.An increase in blood pressure and increased respirations Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit. Test-Taking Strategy: Focus on the subject, fluid volume excess. Remember that when there is more than one part to an option, all parts need to be correct in order for the option to be correct. Think about the pathophysiology associated with a fluid volume excess to assist in directing you to the correct option. Also, note that the incorrect options are comparable or alike in that each includes manifestations that reflect a decrease.

The nurse is providing home care instructions to the parents of an infant who had a surgical repair of an inguinal hernia. What instruction should the nurse include to prevent infection at the surgical site? 1.Report a fever immediately. 2.Restrict the infant's physical activity. 3.Change the diapers as soon as they become damp. 4.Soak the infant in a tub bath twice a day for the next 5 days.

3.Change the diapers as soon as they become damp. Changing diapers as soon as they become damp helps prevent infection at the surgical site. Parents are instructed to change diapers more frequently than usual during the day and once or twice during the night. A fever may indicate the presence of an infection, but measuring the temperature does not prevent an infection. No restrictions on the infant's activity are needed. Parents are instructed to give the infant sponge baths instead of tub baths for 2 to 5 days.

Which is the best nursing intervention regarding complementary and alternative medicine? 1.Advising the client about "good" versus "bad" therapies 2.Discouraging the client from using any alternative therapies 3.Educating the client about therapies that he or she is using or is interested in using 4.Identifying herbal remedies that the client should request from the health care provider

3.Educating the client about therapies that he or she is using or is interested in using Rationale: Complementary and alternative therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse's role. Options 1, 2, and 4 are inappropriate actions for the nurse to take because they provide advice to the client. Test-Taking Strategy: Note the strategic word, best. Use therapeutic communication techniques. Eliminate options 1, 2, and 4 because they are nontherapeutic. Also note that they are comparable or alike in that they provide advice to the client. Recommending an herbal remedy or discouraging a client from doing something is not within the role practices of the nurse. In addition, it is nontherapeutic to advise a client to do something.

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action? 1.Advise the client to read the labels of herbal therapies closely. 2.Tell the client that herbal substances are not safe and should never be used. 3.Encourage the client to discuss the use of an herbal substance with the health care provider (HCP). 4.Tell the client that if he takes the herbal substance he will need to have his blood pressure checked frequently.

3.Encourage the client to discuss the use of an herbal substance with the health care provider (HCP). Rationale: Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be encouraged to avoid herbal substances because the combination may lead to an excessive reaction or to unknown interaction effects. The nurse should advise the client to discuss the use of the herbal substance with the HCP. Therefore, options 1, 2, and 4 are inappropriate nursing actions. Test-Taking Strategy: Eliminate option 2 first because of the closed-ended word never. Next, eliminate options 1 and 4 because they are comparable or alikeand indicate acceptance of using an herbal substance.

An Asian American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method? 1.Prayer 2.Magnetic therapy 3.Foods considered to be yin 4.Foods considered to be yang

3.Foods considered to be yin Rationale:In the Asian American culture, health is believed to be a state of physical and spiritual harmony with nature and a balance between positive and negative energy forces (yin and yang). Yin foods are cold and yang foods are hot. Cold foods are eaten when one has a hot illness (fever), and hot foods are eaten when one has a cold illness. Options 1 and 2 are not health practices specifically associated with the Asian American culture or the yin and yang theory. Test-Taking Strategy: Focus on the subject, an Asian American, and the client's diagnosis, fever. Remember that cold foods (yin foods) are eaten when one has a hot illness, and hot foods (yang foods) are eaten when one has a cold illness.Review:

The nurse is reviewing the laboratory test results for a client and notes that the differential white blood cell (WBC) count indicates a shift to the right. The nurse suspects that the client's diagnosis is most likely to be which one? 1.Sepsis 2.Pneumonia 3.Pernicious anemia 4.Coronary artery disease

3.Pernicious anemia A differential WBC count is the leukocyte count broken down (differentiated) according to the cell type. A right shift represents an increased number of mature neutrophils, which is seen with pernicious anemia and after tissue breakdown. The conditions in the remaining options are not associated with this finding.

A client is scheduled for a fiberoptic gastrointestinal procedure. The nurse instructs the client to remain on clear liquids the day before the test because a clear liquid diet supports which action? 1.Stimulating peristalsis 2.Promoting a laxative action 3.Providing little or no residue 4.Providing minimal calories and nutrients

3.Providing little or no residue Before a gastrointestinal (GI) procedure, the health care provider (HCP) generally desires that the GI tract be cleansed of substances. Because clear liquid diets have little or no residue, the GI tract will have an opportunity to empty itself of solid contents. This will enable the HCP to view the GI tract clearly. Clearing the GI tract via diet is safer than having enemas until clear because this process can disrupt fluid and electrolyte balance. All other options are inaccurate regarding a clear liquid diet.

A client is suspected of having systemic lupus erythematosus (SLE). On reviewing the client's record, the nurse should expect to note documentation of which characteristic sign of SLE? 1.Fever 2.Fatigue 3.Skin lesions 4.Elevated red blood cell count

3.Skin lesions. Systemic lupus erythematosus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. The major skin manifestation of SLE is a dry, scaly, raised rash on the face known as the butterfly rash. Fever and fatigue may occur before and during exacerbation, but these signs and symptoms are vague. Anemia is most likely to occur in SLE.

Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet? 1.Pork roast, rice, vegetables, mixed fruit, milk 2.Crab salad on a croissant, vegetables with dip, potato salad, milk 3.Sweet and sour chicken with rice and vegetables, mixed fruit, juice 4.Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea

3.Sweet and sour chicken with rice and vegetables, mixed fruit, juice Rationale: Members of Orthodox Judaism adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven hoofed, and ritually slaughtered. Test-Taking Strategy: Focus on the subject, dietary kosher laws, and recall that the dairy-meat combination is unacceptable in the Orthodox Judaism group. Eliminate option 1 because this option contains pork roast and milk. Next, eliminate options 2 and 4 because both options contain shellfish.Review: The dietary rules of members of the Orthodox Judaism religious group

A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse nextassesses the client to determine a history of which condition? 1. Pyelonephritis 2. Glomerulonephritis 3. Trauma to the bladder or abdomen 4. Renal cancer in the client's family

3.Trauma to the bladder or abdomenBladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client described in this question. Renal cancer would not cause pain that is felt in the low abdomen; rather, the pain would be in the flank area.

The nurse is caring for an older client with dysphagia who is at risk for aspiration. When preparing the client for eating, the nurse should place the client in which position to minimize the risk for aspiration? 1.Low Fowler's 2.On the left side 3.Upright in a chair 4.On the right side

3.Upright in a chair It is best to assist the client who is at risk for aspiration and is dysphagic to sit upright in a chair for meals. This position facilitates chewing and swallowing and prevents reflux of stomach contents. Options 1, 2, and 4 are not the best positions to prevent aspiration of food and fluids.

The nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action? 1.Sit upright when using the device. 2.Inhale slowly, maintaining a constant flow. 3.Place the lips completely over the mouthpiece. 4.After maximal inspiration, hold the breath for 10 seconds and then exhale.

4. After maximal inspiration, hold the breath for 10 seconds and then exhale. For optimal lung expansion with the incentive spirometer, the client should assume a semi Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 2 or 3 seconds and then exhale slowly.

The nurse is giving client instructions over the telephone about preparing for a mammography. The nurse should make which statement to the client? 1."Wear metal jewelry as desired." 2."Consume clear liquids only on the day of the test." 3."Avoid using underarm deodorant on the day of the test." 4."Use only lanolin-based skin lotions on the day of the test."

4. Avoid using underarm deodorant on the day of the test The client should avoid the use of lotions or underarm deodorant on the day of mammography because this can affect breast and axilla positioning and obtaining clear mammography pictures. Mammography is a type of radiographic procedure. Therefore, the client is advised not to wear jewelry or metal objects on the day of the test. No special dietary preparation is needed.

The nurse provides instructions to a client who is scheduled for an electroencephalogram. Which statement by the client indicates a need for further instruction? 1."The test will take between 45 minutes and 2 hours." 2."My hair should be washed the evening before the test." 3."Cola, tea, and coffee are restricted on the day of the test." 4."All medications need to be withheld on the day of the test."

4."All medications need to be withheld on the day of the test."The client is informed that the test will take 45 minutes to 2 hours and that medications usually are not withheld before the test unless specifically prescribed. Preprocedural instructions include informing the client that the procedure is painless. Cola, tea, and coffee are stimulants and need to be restricted on the morning of the test. The hair should be washed the evening before the test, and gels, hair sprays, and lotion should be avoided.

The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made? 1."I cannot have surgery." 2."I cannot have any medicine." 3."I believe the soul lives on after death." 4."I cannot have any food containing or prepared with blood."

4."I cannot have any food containing or prepared with blood." Rationale: Among Jehovah's Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden. For a Jehovah's Witness, administration of medication is an acceptable practice except if the medication is derived from blood products. This religious group believes that the soul cannot live after death. Jehovah's Witnesses avoid foods prepared with or containing blood. Test-Taking Strategy: Focus on the subject, beliefs of Jehovah's Witnesses. Remember that the administration of blood and any associated blood products is forbidden among Jehovah's Witnesses. Even foods prepared with blood or containing blood are avoided.

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? 1."I will not mix the medication with food." 2."I will take my child's pulse before administering the medication." 3."If more than 1 dose is missed, I will call the health care provider." 4."If my child vomits after medication administration, I will repeat the dose."

4."If my child vomits after medication administration, I will repeat the dose." Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. In addition, the parents should be instructed that if a dose is missed and is not identified until 4 hours later, the dose should not be administered.

The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories? 1."CAM includes biologically based practices." 2."Whole medical systems are a component of CAM." 3."Mind-body medicine is part of the CAM approach." 4."Magnetic therapy and massage therapy are a focus of CAM."

4."Magnetic therapy and massage therapy are a focus of CAM." Rationale: The 5 main categories of CAM include whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine. Magnetic therapy and massage therapy are therapies within specific categories of CAM. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect option. Also, focus on the subject of the question, the 5 main categories of CAM. Noting that the question asks about main categories, not specific therapies, will assist in directing you to the correct option.

The nurse is providing dietary instructions to a client about food items that are high in vitamin C. Which food item does the nurse recommend as being highest in vitamin C? 1.Milk 2.Eggs 3.Liver 4.Cabbage

4.Cabbage Cabbage, tomatoes, potatoes, and strawberries are some of the foods that are high in vitamin C. Milk contains vitamins A and D and some B vitamins. Eggs contain B vitamins. Liver contains vitamins B6 (pyridoxine), B9 (folic acid), and K.

The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness? 1.A full bladder 2.Emotional instability 3.Insufficient iron intake 4.Compression of the vena cava

4.Compression of the vena cava. Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome late in pregnancy. Having the woman turn onto her left side or elevating the left buttock during fundal height measurement will prevent or correct the problem. The remaining options are unrelated to this syndrome.

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body. Which finding suggests that an escharotomy may be necessary? 1.Pallor of all extremities 2.Pulse oximetry reading of 93% 3.Peripheral pulses are diminished 4.High pressure alarm keeps sounding on the ventilator

4.High pressure alarm keeps sounding on the ventilator. A client with a circumferential burn of the entire trunk likely will be on a ventilator because of the potential for breathing to be affected by this injury. The high pressure alarm will sound on the ventilator when there is any kind of obstruction. If the chest cannot expand due to restriction by eschar and increasing edema, this results in obstruction.

The nurse is planning care for a client who has just returned to the nursing unit after an oral cholecystogram. The nurse should expect to delete which prescription on the client's care plan? 1.Monitor hydration status. 2.Assess for nausea and vomiting. 3.Monitor for abdominal discomfort. 4.Maintain a clear liquid diet for 72 hours.

4.Maintain a clear liquid diet for 72 hours. The client should be able to resume the usual diet once the nurse is sure that the client's gastrointestinal (GI) function is normal. It is not necessary to keep the client on clear liquids for 72 hours after the procedure. The nurse would also assess hydration status as part of routine care for the client undergoing a GI diagnostic test. The nurse would monitor the client for complaints of GI discomfort and nausea and vomiting.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriateaction in the care of this client? 1.Obtain a court order for the surgery. 2.Have the charge nurse sign the informed consent immediately. 3.Send the client to surgery without the consent form being signed. 4.Obtain a telephone consent from a family member, following agency policy.

4.Obtain a telephone consent from a family member, following agency policy. Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.

The nurse is implementing the complementary therapy of therapeutic touch when caring for clients. The nurse should implement which action when performing therapeutic touch? 1.Apply heating pads to the back. 2.Vigorously massage bony prominences. 3.Position hands directly on the client's skin. 4.Position hands 2 to 4 inches (5 to 10 cm) from the body.

4.Position hands 2 to 4 inches (5 to 10 cm) from the body. During therapeutic touch, nurses use their hands to assess the client's energy field. Hands are positioned 2 to 4 inches (5 to 10 cm) from the body. The energy field is assessed for bilateral similarities or differences in the flow of energy. The next step is clearing and balancing the energy field. Nurses then redirect energy through their own intentionality. The session ends with a smoothing of the energy. Therefore, the remaining options are incorrect.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? 1.Metabolic acidosis with compensation 2.Respiratory acidosis with compensation 3.Metabolic acidosis without compensation 4.Respiratory acidosis without compensation

4.Respiratory acidosis without compensation The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm). In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate (HCO3-) level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

The health care provider (HCP) prescribes 1000 mL of normal saline to be infused over a period of 10 hours. The drop factor is 15 gtt/mL. The nurse adjusts the flow rate at how many drops per minute? Fill in the blank.

The prescribed 1000 mL is to be infused over 10 hours. Follow the formula, and multiply 1000 mL by 15 (drop factor). Then divide the result by 600 minutes (10 hours = 600 minutes). The infusion is to run at 25 gtt/min. Total volume × Drop factor -------------------------- = gtt/min Time in minutes

The nurse is reviewing the medication record and notes that a client is to receive heparin 6000 units subcutaneously. The medication label states heparin 10,000 units/mL. How much heparin will the nurse prepare to administer to the client? Fill in the blank. Record your answer using one decimal place.

Use the formula to calculate the correct dose. Desired --------- × Volume = mL/dose Available 6000 units ------------- × 1 mL = 0.6 mL 10,000 units