Ultimate NCLEX Questions and Rationales

The healthcare provider prescribes 3000mL of 5% dextrose (D5W) to run over a 24hr period. The drop factor is 10gtt/mL. There are 300mL remaining at 0900. What time should the PN anticipate the next bag of D5W solution to be hung? Fill in the blank... The next bag of D5W solution will be hung at _____________.

11:24AM 3000mL/24hr=125mL 300mL/125mL/hr=2.4 0.4x60= 24min + 2hrs= 2hrs and 24min from 9AM. - 11:24AM

The primary health care provider has prescribed an antibiotic for a child. The average adult dose is 500mg. The child has a body surface area of 0.63m2. What is the dose for the child? Fill In the Blank _____mg

182mg When calculating pediatric dosages that are specified for adults, calculate the child's dose using the formula that incorporates BSA values. Standard adult BSA value is 1.73m2, the child's BSA is 0.63m2. BSA of child (m2)/1.73m2 X Adult dose = Child's dose 0.63/1.73 X 500mg = 182.0mg

Sulfisoxazole 1g orally four times daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads, "250mg tablets." The nurse has determined that the prescribed dose is safe. How many tablets per dose should the nurse administer to the adolescent? Fill in the Blank

1g(1000mg/1g)(1 tablet/250mg) = 4 Tablets

The healthcare provider prescribes an infusion of antibiotic. The prescription is for 150 mL of antibiotic in NS in 3 hours by infusion pump. What is the flow rate in mL/hr? (If rounding is necessary, round to the whole number).

50 mL/hr 150mL/3 hrs = 50mL/hr

The primary health care provider has prescribed phenobarbital sodium, 25mg orally twice daily, for a child with febrile seizures. The medication label reads as follows: "Phenobarbital sodium, 20mg/5mL." The nurse has determined that the dose prescribed is a safe dose for the child. How many milliliters per dose should the nurse administer to the child? Fill In the Blank _______mL

6.25mL 25mg(5mL/20mg)= 6.25mL

The primary health care provider's prescription reads acetaminophen 240mg orally every 6 hours as needed for relief of pain, for a 5 year old child. The medication label reads "acetaminophen 160 mg per 5mL." How many mL per dose should the nurse administer to the child? Fill In the Blank _______mL

7.5 mL 240mg(5mL/160mg) = 7.5mL

Prior to discharge the PN is reinforcing teaching for a client diagnosed with type 2 diabetes who has been prescribed a heart-healthy diet, metformin 1000 mg orally bid, and increased physical activity to 10,000 steps per day. Which statements by the client would alert the PN that further instruction is needed? (Select all that apply...) A.) "I will stop taking my diabetes medications if I become bloated and nauseated." B.) "I will increase my fiber and water intake." C.) "My feet are always cold, so I'll use my heating pad on the low setting." D.) "I'll continue to walk every afternoon."

A&C.- Bloating and nausea are common side effects of antidiabetic medications, and clients should not stop these medications without consulting the HCP. Hot water bottles and heating pads should be avoided due to high risk for burn injury. The client should wear socks for warmth. B: Fluid intake and fiber are important to prevent dehydration and to help prevent constipation. D: Exercise may help normalize blood glucose levels.

The client with sqaumous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed? (Select all that apply.) A.) Chest X-ray B.) Echocardiography C.)Electrocardiography D.) Cervical Radiography E.) Pulmonary function studies

A&E. Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. During pulmonary fibrosis, the lung tissue becomes very scarred and hard. Pulmonary fibrosis is not reversible and the client is continuously short of breath. Pulmonary function studies and chest x-ray, along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and adventitious sounds, which could indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Cardiac studies such as an echocardiogram and electrocardiogram, and a cervical radiograph are unrelated to the specific use of this medication.

While obtaining the health history of a client and reviewing his medical records, which data will alert the PN that the client has an increased risk of developing peptic ulcer disease? (Select all that apply...) A.)Excess of gastric acid or a decrease in the natural ability of the GI mucosa to protect itself from acid and pepsin. B.)Invasion of the stomach and/or duodenum by H. Pylori. C.)Viral infection, allergies to certain foods, immunologic factors, and psychosomatic factors. D.) Taking certain drugs, including corticosteroids and anti-inflammatory medications. E.)Having allergies to foods that contain gluten.

A,B,&D -CORRECT!!! C&E: Viral infections and gluten allergies can cause gastritis, but not necessarily ulcers.

A client is receiving digoxin daily. The nurse suspects digoxin toxicity after noting which signs and symptoms? (Select all that apply...) A.) Visual disturbances B.) Nausea and vomiting C.) Apical pulse rate of 63 beats per minute D.) Serum digoxin level of 2.3 E.) Serum potassium level of 3.9mEq/L

A,B,&D. Signs and symptoms of digoxin toxicity include gastrointestianl signs, bradycardia, visual disturbances, and hypokalemia. A therapeutic serum digoxin level ranges from 0.8 to 2.0. The serum potassium level should be between 3.5 and 5.0 mEq/L. The apical pulse must be greater than or equal to 60 beats per minute.

The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? (Select all that apply...) A.) Insomnia B.) Weight Loss C.) Bradycardia D.) Constipation E.) Mild heat intolerance

A,B,&E. Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine sodium. Bradycardia and constipation are not side effects associated with this medication, but rather are associated with hypothyroidism, which is the disorder that this medication is prescribed to treat.

A histamine receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2-receptor antagonists? (Select all that apply...) A.) Nizatidine B.) Ranitidine C.) Famotidine D.) Cimetidine E.) Esomeprazole F.) Lansoprazole

A,B,C,&D. H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist with preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, pathological hypersecretory conditions. The other medications listed are proton pump inhibitors.

The home care nurse is visiting a client who was recently diagnosed with type II diabetes mellitus. The client, prescribed repaglinide and metformin, asks the nurse to explain these medications. The nurse should reinforce which instructions to the client? (Select all that apply...) A.) Diarrhea can occur secondary to metformin B.) The repaglinide is not taken if a meal is skipped. C.) The repaglinide is taken 30 minutes before eating. D.) Candy or another simple sugar is carried and used to treat mild hypoglycemia episodes. E.) Muscle pain is an expected side effect of metformin and may be treated with acetaminophen F.) Metformin increases hepatic glucose production to prevent hypoglycemia associated iwth repaglinide

A,B,C,&D. Repalinide is a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion that should be taken before meals and that should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide, and the client should always be prepared by carrying a simple sugar with her or him at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an affect from metformin, but it also might signify a more serious condition that warrants PHCP notification, not the use of acetaminophen.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse should monitor for which side/adverse effects of the medication? (Select all that apply...) A.) Signs of hepatitis B.) Flu-like syndrome C.) Low neutrophil count D.) Vitamin B6 Deficiency E.) Ocular pain or blurred vision F.) Tingling and numbness of the fingers

A,B,C,&E. Rifabutin may be prescribed for a client with active MAC disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side effects include rash, GI disturbances, neutropenia (low neutrophil count), red-orange body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flu-like syndrome. Vitamin B6 deficiency and numbness and tingling in the extremities are associatedwith the use of isoniazid. Ethambutol also causes peripheral neuritis.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? (Select all that apply...) A.) Communicate expected behaviors to the client. B.) Follow through about the consequences of behavior in a nonpunitive manner. C.) Ensure that the client knows that he or she is not in charge of the nursing unit. D.) Assist the client with developing a means of setting limits on personal behavior. E.) Enforce rules and inform the client that he or she will not be allowed to attend therapy groups. F.) Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

A,B,D,&F. Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences in a nonpunitive manner; and assisting the client with developing a means for setting limits on personal behaviors. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups are violations of a client's rights. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided.

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? (Select all that apply...) A.) Restating B.) Listening C.) Asking the client, "Why?" D.) Maintaining neutral responses E.) Giving advice, approval, or disapproval F.) Providing acknowledgement and feedback

A,B,D,&F. Some therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgement and feedback, giving information and presenting reality, encouraging formulation of a plan of action, providing non-verbal encouragement, and summarizing. Asking why, giving advice, and approving or disapproving are nontherapeutic.

The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which adverse effects are associated with this medication? (Select all that apply...) A.) Tinnitus B.) Ototoxicity C.) Hyperkalemia D.) Hypercalcemia E.) Nephrotoxicity F.) Hypomagensemia

A,B,E,&F. Cisplatin is an alkylating medication. Alkylating medications are cell cycle phase nonspecific and affect the synthesis of DNA by causing its cross-linking to inhibit cell reproduction. Cisplatin may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. Amifostine may be administered before cisplatin to reduce the potential for renal toxicity.

The PN has UAPs on the team. Which client task(s) could be assigned to the UAP? A.) Transporting a client scheduled for a STAT CT scan. B.) Bathing a client receiving IV vancomycin through a peripherally inserted central catheter (PICC) line. C.) Removing a Foley catheter, per the healthcare provider's prescription, and encouraging voiding in 8 hours. D.) Changing the IV tubing on a client recovering from pneumonia. E.) Clearing the alarm on the IV pump and restarting the pump.

A,C

Which assignment should the nurse delegate to a UAP in a long-term acute care setting? Select all that apply... A.) Checking the blood glucose level before meals for a client with an insulin order. B.) Giving PO medications left at the bedside for the client to take after eating. C.) Taking vital signs for an older client with left humerus and left tibial fractures. D.) Replacing an abdominal wound dressing that has been soiled by incontinence. E.) Obtaining a culture and sensitivity sample from a central line catheter site.

A,C

The licensed practical nurse is assisting the registered nurse to create a teaching plan for the client receiving an antineoplastic medication. The LPN expects which information to be included? (Select all that apply...) A.) Rinse mouth after meals and use a soft toothbrush B.) Notify the PHCP if the temperature is above 101F. C.) Maintain oral hygiene and inspect the mouth for sores daily. D.) A sore throat is expected so the client should suck on soothing throat lozenges. E.) Consult with primary health care provider before receiving immunizations

A,C,&E. Clients with cancer treated with antineoplastic medications must be aware of how to care for themselves and it is important that client teaching is included in the care plan. Because antineoplastic medications medications affect the bone marrow, clients are often anemic, have lower immunity, and may be at risk for bleeding. Oral hygiene is important and client should inspect their mouths daily, rinse after meals, and use a soft toothbrush. The client should check with the PHCP before receiving any immunizations. The client should notify the PHCP for a low grade temperature such as 99.5F and a sore throat. These are often associated with low white blood cell counts.

A 3 week old baby with pyloric stenosis has severe vomiting. Which sign(s) of dehydration should the PN anticipate the baby presenting? (Select all that apply...) A.) Sunken fontanel B.) Increased urine output C.) High serum hematocrit levle D.) Cracked lips E.) Thirst

A,C,D,&E.- All signs of dehydration in the infant.

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? (Select all that apply...) A.) Monitor vital signs B.) Maintain an NPO status C.) Provide a safe environment D.) Address hallucinations therapeutically E.) Provide stimulation in the environment F.) Provide reality orientation as appropriate

A,C,D,&F. When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would frequently reorient the client to reality and would address hallucinations therapeutically. Adequate nutritional and fluid intake must be maintained.

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? (Select all that apply...) A.) Flushing B.) Hypertension C.) Increased urine output D.) Depressed respirations E.) Extreme muscle weakness F.) Hyperactive deep tendon reflexes

A,D,&E. Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizure. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? (Select all that apply...) A.) Back B.) Axilla C.) Eyelids D.) Soles of the feet E.) Palms of the hands

A,D,&E. Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal? A.) The client gives away a DVD and a cherished autographed picture of the performer. B.) The client runs out of the therapy group swearing at the group leader and then runs to their room. C.) The client gets angry with her roommate when the roommate borrows their clothes without asking. D.) The client becomes angry while speaking on their cell phone and slams the phone down on her bed.

A. A depressed, suicidal client often gives away that which is of value as a way of saying "goodbye" and wanting to be remembered. Options B,C, and D identify acting-out behaviors.

A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "what is the name of my wife's disorder?" Which answer should the nurse give to the spouse? A.) Agoraphobia B.) Hematophobia C.) Claustrophobia D.) Hypochondriasis

A. Agoraphobia is a fear of being alone in open or public places where escape might be difficult. Agoraphobia includes experiencing fear or a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situations usually results in the reduction of social and professional interactions. Hematophobia is the fear of blood. Claustrophobia is a fear of closed-in places. Clients with somatic symptom disorder focus their anxiety on physical complaints and are preoccupied with their health data.

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement? A.) "I no longer feel that I deserve the beatings my husband inflicts on me." B.) "My attendance at the meetings has helped me to see that I provoke my husband's violence." C.) "I enjoy attending the meetings because they get me out of the house and away from my husband." D.) "I can tolerate my husband's destructive behaviors now that I know they are common for alcoholics."

A. Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain suggestions about successful behavioral changes. Option A is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. The nonalcoholic partner should not feel responsible when the spouse loses control, option B. Option C indicates that the group is being seen as an escape, not a place to work on issues. Option D indicates that the wife remains codependent.

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment? A.) Weight loss B.) Sleep pattern C.) Medication Compliance D.) Onset of the crying spells

A. All the options are possible issues to address; however, the weight loss is the first item that needs further data collection because ill-fitting clothing could indicate a problem with nutrition. The client has already told the nurse that the crying spells have been a problem. Medication or sleep patterns are not mentioned or addressed in the question.

The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if which is documented in the client's history? A.) Pancreatitis B.) Diabetes mellitus C.) Myocardial Infarction D.) Chronic obstructive pulmonary disease

A. Asparaginase is a antineoplastic enzyme that is contraindicated if hypersensitivity exists in the case of pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function, and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between the administration of doses. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The medication may be used for clients with a history of diabetes mellitus, myocardial infarction, or chronic obstructive pulmonary disease.

The home care nurse visits a client at home who has been prescribed prednisone 5mg orally daily. The nurse reinforces teaching for the client about the medication. Which statement made by the client indicates a need for further teaching? A.) "I can take aspirin or my antihistamine if I need it." B.) "I need to take the medication every day at the same time." C.) "I need to avoid coffee, tea, cola, and chocolate in my diet." D.) "If I gain more than 5lbs a week, I will call my doctor."

A. Aspirin and other over-the-counter medications should not be taken unless the client consults with the PHCP. The client needs to take the medication at the same time every day and should be instructed not to stop. A slight weight gain as a result of an improved appetite is expected, but after the dosage is stabilized, a weight gain of 5lb or more weekly should be reported to the PHCP. Caffeine-containing foods and fluids need to be avoided because they may contribute to steroid-ulcer development.

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated with the use of this medication? A.) Itching B.) Euphoria C.) Drowsiness D.) Frequent Urination

A. Azelaic acid is a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypopigmentation of the skin in clients with a dark complexion. The effects noted in the other options are not specifically associated with this medication.

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, " Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism? A.) Denial B.) Projection C.) Regression D.) Rationalization

A. Denial is the refusal to admit to a painful reality and is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other people, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying the unacceptable attributes about oneself.

Desmopressin acetate is prescribed for the treatment of diabetes insipidus. The nurse monitors the client after medication administration for which therapeutic response? A.) Decreased urinary output B.) Decreased blood pressure C.) Decreased peripheral edema D.) Decreased blood glucose level

A. Desmopressin promotes renal conservation of water. The hormone carries out this action by acting on the collecting ducts of the kidney to increase their permeability to water, which results in increased water reabsorption. The therapeutic effect of this medication would be manifested by a decreased urine output. Options B,C,&D are unrelated to the effects of this medication.

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication? A.) Hematocrit of 33% B.) Platelet count of 400,000 mm3. C.) White blood cell count of 6000mm3 D.) Blood Urea Nitrogen level of 15mg/dL

A. Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate red blood cell production in the bone marrow. It is used to treat anemia associated with chronic kidney disease. The normal hematocrit level is Male-42 to 52% and Female- 37 to 47%. Therapeutic effect is seen when the hematocrit reaches between 30 and 33%. The normal platelet count is 150,000 to 400,000. The normal blood urea nitrogen level is 10 to 20. The normal white blood cell count is 5,000 to 10,000. Platelet production, white blood cell production, and blood urea nitrogen do not respond to erythropoietin.

The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed? A.) "I will flush the eyes after instilling the ointment." B.) "I will clean the newborn's eyes before instilling ointment." C.) "I need to administer the eye ointment within 1 hour after delivery." D.) "I will instill the eye ointment into each of the newborn's conjunctival sacs."

A. Eye prophylaxis protects the newborn against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush would wash away the administered medication. Options B,C,and D are correct statements regarding the procedure for administering eye medication to the newborn.

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse expect to note? A.) The client presents a harm to self. B.) The client requested the admission. C.) The client consented to the admission D.) The client provided written application to the facility for admission.

A. Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care. Options B,C, and D describe the process of voluntary admission.

The nurse assists with preparing the client for ear irrigation as prescribed by the primary health care provider. Which action should the nurse plan to take? A.) Warm the irrigating solution to 98F. B.) Position the client with the affected side up after the irrigation. C.) Direct a slow, steady stream of irrigation solution toward the eardrum. D.) Assist the client with turning his or her head so that the ear to be irrigated is facing upward.

A. Irrigation solutions that are not close to the client's body temperature can be uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist with the removal of the ear wax and solution. After the irrigation, the client is to lie on the affected side to finish draining the irrigating solution. A slow, steady stream of solution should be directed toward the upper wall of the ear canal and not toward the eardrum. Too much force could cause the tympanic membrane to rupture.

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finiding indicates the occurrence of a systemic effect? A.) Hyperventilation B.) Elevated blood pressure C.) Local rash at the burn site D.) Local pain at the burn site

A. Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the med will probably be discontinued for 1-2 days. Options B and D describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

The nurse is assisting with planning the care of a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? A.) One-to-one suicide precautions B.) Suicide precautions, with 30-minute checks C.) Checking the whereabouts of the client every 15 minutes D.) Asking that the client to report suicidal thoughts immediately

A. One-to-one suicide precautions are required for the client who has attempted suicide. Options B and C are not appropriate, considering the situation. Option D may be an appropriate nursing intervention, but the priority is stated in Option A. The best option is constant supervision so that the nurse may intervene as needed if the client attempts to cause harm to him or herself.

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat? A.) Open-ended questions and silence. B.) Focusing on self-disclosure regarding food preferences. C.) Stating the reasons that the client may not want to eat. D.) Offering opinions about the necessity of adequate nutrition.

A. Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options C and D do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons, but should encourage the client to identify the reasons for their behavior. Option B is not a client-centered intervention.

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs? A.) Naloxone B.) Morphine Sulfate C.) Betamethasone D.) Meperidine Hydrochloride

A. Opioid analgesics may be prescribed to relieve moderate to severe pain associated with labor. Opioid toxicity can occur and cause respiratory depression. Naloxone is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Morphine sulfate and meperidine hydrochloride are opioid analgesics. Betamethasone is a corticosteroid administered to enhance fetal lung maturity.

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care? A.) Provide safety for the client and other clients on the unit. B.) Provide the clients on the unit with a sense of comfort and safety. C.) Assist the staff with caring for the client in a controlled environment. D.) Offer the client a less-stimulating area to calm down and gain control.

A. Safety of the client and other clients is the priority. Option A is the only option that addresses the client and other clients' safety needs. Option B addresses other clients' needs. Options C is not client centered. Option D addresses the client's needs.

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? A.) Tinnitus B.) Diarrhea C.) Constipation D.) Decreased Respirations

A. Salicylic acid is absorbed readily through the skin and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychologicla disturbances. Constipation and diarrhea are not associated with saicylism.

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention? A.) Escort the manic client to his or her room. B.) Orient the client to time, person, and place C.) Tell the client that the behavior is not appropriate D.) Tell the client that smoking privileges are revoked for 24 hours.

A. The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Option D may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate has already been attempted by the psychiatric nurse's aide.

A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention? A.) Feed, bathe, and dress the client as needed until the client can perform these activities independently. B.) Offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living. C.) Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for the activities of daily living. D.) Have the client's peers confront the client about how their noncompliance with addressing activities of daily living affects the milieu.

A. The client with depression may not have the energy or interest to complete activities of daily living. Often, severely depressed clients are unable to perform even the simplest activities of daily living. The nurse assumes this role and completes these tasks with the client. Options B and C are incorrect because the client lacks the energy and motivation to perform these tasks independently. Option D will increase the client's feelings of poor self-esteem and unworthiness.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action? A.) Call the nursing supervisor B.) Call security to block all exit areas C.) Tell the client that she cannot return to this hospital again if she leaves now D.) Restrain the client until the primary health care provider (PHCP) can be reached.

A. The nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Notifying the nurse supervisor is the correct option. Most health care facilities have documents that the client is asked to sign that relate to the client's responsibilities when he or she leaves against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the PHCP before leaving, but if the client refuses to do so, the nurse cannot hold the client against his or her will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care (Option C) and cannot be told otherwise.

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response? A.) "I cannot discuss any client situation with you." B.) "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!" C.) "You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand." D.) "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!"

A. The nurse is required to maintain confidentiality regarding clients and their care. Confidentiality is basic to the therapeutic relationship and is a client's right. Option C is correct in a sense, but it is a rather blunt statement. Both options B and D identify statements that do not maintain client confidentiality.

Glimepiride is prescribed for a client with diabetes mellitus. The nurse reinforces instructions for the client and tells the client to avoid which while taking this medication? A.) Alcohol B.) Organ meats C.) Whole-grain cereals D.) Carbonated beverages.

A. When alcohol is combined with glimepiride, a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. The items in options B,C,&D do not need to be avoided.

The nurse is reinforcing teaching for a client regarding how to mix regular insulin and NPH insulin in the same syringe. Which action performed by the client indicates the need for further teaching? A.) Withdraws the NPH insulin first B.) Withdraws the regular insulin first C.) Injects air into NPH insulin vial first D.) Injects an amount of air equal to the desired dose of insulin into the vial.

A. When preparing a mixture of regular insulin with another insulin preparation, the regular insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of regular insulin with insulin of another type. Options B,C, and D identify the correct actions for preparing NPH and regular insulin.

The nurse is caring for a client who is receiving an intravenous infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse should take which appropriate action? A.) Notify the registered nurse immediately B.) Administer pain medication to reduce the discomfort C.) Apply ice and maintain the infusion rate, as prescribed D.) Elevate the extremity of the IV site, and slow the infusion

A. When antineoplastic medications are administered via IV, great care must be taken to prevent extravasation, the condition in which the medication escapes into the tissues surrounding the injection site, because pain, tissue damage, and necrosis can result. The nurse monitors for signs of extravasation, such as redness or swelling at the insertion site. If extravasation occurs, the RN needs to be notified at once and the infusion will be stopped. The nurse will contact the PHCP. Depending on the specific medication, actions are taken to counteract the negative effects. The medication may be aspirated out, ice or warmth applied, and the area infiltrated with a neutralizing agent specific to the medication.

A postmenopausal woman with a BMI of 19 has come to the clinic for her annual well-woman examination. Which teaching plan topic is most important for the nurse to prepare for this high-risk client? A.) Osteoporosis B.) Obesity C.) Anorexia D.) Breast Cancer

A. - Osteoporosis

A client is admitted to the acute care unit with stable angina. At 0700 the client is pain free, has stable vital signs and is on 2L NC. At 1000, the client reports chest pain 6 on scale of 1 to 10, is slightly diaphoretic and pale, BP of 100/52, and a RR 24. Which prescription will the PN implement first? A.) Increase oxygen from 2L/min to 4L/min. B.) Monitor a rapid bolus of 0.9% saline via infusion pump. C.)Administer prescribed oral opioid for pain control. D.)Obtain a full set of vital signs including temperature.

A. - The client may be experiencing a myocardial infarction or the early stages of cardiogenic shock. The client requires oxygen (ABCs first). B: If the client is experiencing an MI, fluids should be administered cautiously to avoid pulmonary edema and increasing the workload of the heart. Fluids are administered cautiously, and the first priority is oxygen. C:Chest pain is likely caused by lack of oxygen to the heart tissues and the build-up of lactic acid. Pain will be addressed, but oxygen is the first priority. D:It is prudent to obtain a full set of vitals and reassess the client after the oxygen has been increased.

An elderly client is confused and was admitted to the hospital 4 days ago with a diagnosis of cellulitis. Current vital signs: 103F (39.6C), HR 109, RR 37, BP 86/42. The client requires intravenous antibiotics, oxygen, and an indwelling urinary catheter. The nurse assesses the client and develops a plan of care. Which disease does the PN expect to see on the plan of care? A.)Septic shock B.)Multiple organ failure C.)Acute respiratory distress syndrome D.)Acute myocardial infarction

A. - This client has certain risk factors: fever, the history of cellulitis, and the indwelling urinary catheter. The VS are indicative of shock. B:There is no information in the stem to determine MODS, but the client meets the criteria for septic shock. C&D: The client does not have the symptoms of ARDS or MI.

A client expresses anxiety to the PN about an upcoming surgery. Which response by the PN is likely to be most supportive of the client? A.) "Tell me what has been shared with you about the surgery" B.) "Let me review the postoperative care you'll receive after surgery" C.) "Don't worry. Your surgeon has the best record of success" D.) "I had surgery just like that, and I'm fine"

A.) "Tell me what has been shared with you about the surgery"

In the elevator the UAP overhears two nurses talking about a client who will lose her leg because of the negligence of the staff. What federal law has been violated? A.) Health Insurance Portability and Accountability Act (HIPPA) B.) Americans with Disabilities Act (ADA) C.) Nurse Practice Act (NPA) D.) Patient Self-Determination Act (PSDA)

A.) Health Insurance Portability and Accountability Act (HIPPA)

The PN is caring for a client who is 24 hours postoperative for a hemicolectomy with temporary colostomy placement. On assessment, the PN finds that the stoma is dry and dark red. Based on this finding, what action should the nurse take? A.) Notify the healthcare provider of the finding. B.)Document the finding in the client's record. C.)Replace the pouch system over the stoma. D.)Place petroleum gauze dressing on the stoma

A.) Notify the healthcare provider of the finding.

A 76 year old client reports that since she stopped hormone replacement therapy (HRT), she has had increased vaginal discomfort during intercourse. What action should the PN take? A.) Suggest that the client use a vaginal cream or lubricant. B.) Recommend that the client abstain from sexual intercourse. C.) Teach the client Kegal exercises to be performed daily. D.) Instruct the client to resume HRT.

A.) Suggest that the client use a vaginal cream or lubricant.

The UAP reports to the PN that a client, who had surgery 4 hours ago, has had a decrease in BP from 150/80 to 110/70 in the past hour. The PN advises the UAP to check the client's dressing for excess drainage and report findings to the charge nurse. Which factor is most to consider when assessing the legal ramifications of this situation? A.) The parameters of the state's nurse practice act. B.) The need to compare an adverse occurrence report. C.) Hospital protocols regarding the frequency of assessing VS. D.) The healthcare provider's prescription for changing the postoperative dressing.

A.) The parameters of the state's nurse practice act.

A pregnant client tells the PN that she smokes only a few cigarettes a day. What information should the nurse provide the client about the effects of smoking during pregnancy? A.) Smoking causes vasoconstriction and reduces placental perfusion. B.) Smoking reduces the lecithin-sphingomyelin (L:S) ration, contributing to lung immaturity. C.) Smoking causes vasodilation and fluid overload for the fetus. D.) Smoking during pregnancy places the fetus at risk for lung cancer.

A.- Cigarette smoking causes maternal vasoconstriction, which decreases blood flow to the placenta, resulting in less oxygen and nutrient flow to the fetus and contributing to IUGR. B: This statement is not accurate. Smoking does not affect fetal lung maturity, and the lecithin:sphingomyelin (L:S) ratio (which are precursors for surfactant) is a measure of lung maturity. C: Smoking does not cause vasodilation or fluid overload in the fetus. D: This is an incorrect statement. However, inhalation of second-hand smoke in children has been found to contribute to asthma and SIDS.

The nurse is evaluating blood results for a client with end-stage renal disease who has just undergone hemodialysis. Which value should the nurse verify with the laboratory? A.) Elevated serum potassium. B.) Increase in serum calcium. C.)Low hemoglobin. D.) Reduction in serum sodium

A.- Hyperkalemia should have been corrected by hemodialysis, and the nurse should verify the results with the lab. B: As serum phosphates are removed during hemodialysis, calcium levels should increase. C:Anemia is common in clients who require long-term hemodialysis. D:As fluid and electrolytes are removed by hemodialysis, serum sodium levels should fall.

A 12-year old child is admitted with sickle cell crisis. She is anemic and has painful joints and a fever of 101F. Which priority intervention should the PN include in the plan of care for this child? A.) Maintain oral fluids for hydration B.) Apply cold packs to painful joints C.) Administer aspirin daily for pain and fever. D.) Perform range of motion to decrease joint pain.

A.- In sickle cell crisis it is important to keep the client hydrated to prevent further crisis. B: Although this may be helpful, it is not the priority. C: This would not be therapeutic to manage fever or pain. D: During crisis rest is maintained.

The PN initiates neuro checks for a client at risk for neurological compromise. Which manifestation typically provides the first indication of altered neurological function? A.) Change in level of consciousness B.) Increasing muscular weakness C.) Changes in pupil size bilaterally D.) Progressive nuchal rigidity.

A.- Level of consciousness is the earliest and most sensitive indicator of the patient's neurologic status. B: This is not the first sign of neurological change. C: This is a late sign. D: This is a sign of meningitis.

A child with hydrocephalus is 1 day postoperative for revision of a ventriculoatrial shunt. Which finding is most important? A.) Increased blood pressure B.) Increased temperature C.) Increased serum glucose D.) Increased hematocrit

A.- On the first postoperative day the nurse should monitor for increased intracranial pressure due to shunt malfunction and recognize a widening pulse pressure (trends of Cushing's triad). B: This may indicate infection, but the priority assessment is ICP postoperatively. C: This is not related to shunt malfunction or increased ICP. D: This is more likely related to dehydration and not typically ICP.

The client at the assisted living facility is prescribed prednisone 10mg orally daily. The PN reinforces teaching for the client about the medication. Which statement by the client indicates that further teaching is necessary? A.) "I can take aspirin if I need it for pain." B.) "I need to take the medication at the same time daily." C.) "I need to check for bruising on my skin." D.) "If I gain more than 5lb a week, I will call my doctor."

A.- Steroids and aspirin can cause GI bleeding, and this combination is not recommended. B: Steroids are taken at same time to mimic the body's secretion of steroids. C: Ecchymosis is a side effect of steroids. D: Weight gain is a side effect, but a 5lb weight gain in a week is above average. Average is 1-2lbs.

A client who has reached 36 weeks' gestation is placed in the lithotomy position. She suddenly complains of feeling breathless and lightheaded, and she shows marked pallor. What action should the nurse take first? A.) Turn the client to a lateral position. B.) Place the client in the Trendelenburg position. C.) Obtain vital signs and a pulse oximetry reading. D.) Initiate distraction techniques

A.- Supine hypotension occurs when the gravid uterus compresses the vena cava. Turning the client to a lateral position will displace the uterus, which allows adequate blood return to the heart, increases cardiac output, and subsequently improves placental and renal perfusion. B: In this position, the client remains supine, and the gravid uterus still compresses the vena cava. C: While monitoring VS and pulse oximetry is important, it is most necessary to prevent compression of the vena cava, which is the priority. D: This may facilitate the examiner to complete the assessment, but the client's safety and physiologic integrity are the priority.

The PN reviews the medication record of a 2 month old and notes that the infant was given a scheduled dose of digoxin with a documented apical pulse of 76 beats/min. What action should the PN take first? A.) Assess the current apical heart rate. B.) Observe for the onset of diarrhea. C.) Complete an adverse occurrence report. D.) Determine the serum potassium level.

A.- The nurse should first verify the infant's current cardiac function. B: Diarrhea may occur if toxicity develops, but this is not the priority. C: This should be done, and the healthcare provider should be notified, but this is not the priority. D: This is valuable information but is of less priority than assessing the child.

A 52-year-old client who had an abdominal hysterectomy for cervical adenocarcinoma in situ is preparing for discharge. Which recommendation should the PN offer the client about women's health and screening exams? A.) "Continue your annual Pap smear, mammogram, clinical breast exam, and monthly breast self-exam (BSE)." B.) "A pap smear is no longer necessary, but continue your annual mammogram and clinical breast exam, plus monthly BSE." C.) "When the ovaries have been removed, only an annual mammogram and clinical breast exam are necessary." D.) "Annual mammograms are not necessary if biannual clinical breast exams and weekly BSE are done."

A.- This is the desired schedule that should be continued. B: Pap smears (cervical stump or vaginal vault) should be included as follow-up after hysterectomy, especially for Grade III (suspicious) results. C: This recommendation omits follow-up monitoring. D: This frequency is not necessary and omits in situ follow-up.

The PN on the subacute unit is assigned to care for the stable ventilator-dependent tracheostomy client. Which nursing actions are most essential in reducing the client's risk for ventilator-associated pneumonia (VAP)? Select all that apply... A.) Administer the influenza vaccine. B.) Perform chlorhexidine oral care every 2 hours. C.) Elevate the head of the bed to 45 degrees. D.) Perform suction with only 5mL saline. E.) Monitor SaO2 every 4 hours

B&C To reduce ventilator associated pneumonia (VAP) the PN can follow VAP. Bundle Recommendations- oral care and head of bed elevation. The flu vaccine is not part of the VAP Bundle. Suction with 5mL of saline is not a recommended practice because it may increase risk for infection. The client may require more frequent monitoring of SaO2.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted during assessment? (Select all that apply...) A.) Proteinuria of 3+ B.) Respirations of 10 breaths/minute C.) Presence of deep tendon reflexes D.) Urine output of 20mL in an hour E.) Serum magnesium level of 6mEq/L

B&D. Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Urine output should be at least 25mL to 30mL per hour. Therapeutic serum levels of magnesium are 4mEq/L to 7. Proteinuria of 3+ is an expected finding in a client with preeclampsia.

The PN is assigned a client with diabetes. Which findings should the PN report immediately? (Select all that apply...). A.) Finger stick blood sugar 247 mg/dL B.) Cold, clammy skin. C.) Crackles at the end of inspiration D.) Numbness in fingertips and toes E.) Unsteady gait, slurred speech.

B&E.- Both options are manifestations of hypoglycemia. A:Although elevated, this blood sugar is not considered a medical emergency. C: Crackles heard at the end of inspiration occur in small airway and may indicate atelectasis, which is not a medical emergency. D: In the client with diabetes, numbness is considered a common complication but not a medical emergency.

A client is in the oliguric phase of acute kidney injury. Which of the following findings would the nurse expect to assess on the client? (Select all that apply...) A.)450 mL urine output in 24 hours B.) Potassium of 6.2 mEq/L C.) Sodium (serum) 155 mEq/L D.) Metabolic alkalosis E.) Weight gain

B&E.- Hyperkalemia due to reduced potassium excretion is common in acute kidney injury and can be life threatening. Fluid gain is common in AKI and is an expected finding. A:Oliguria is defined as a urine output that is <400 mL daily in adults. It is one of the clinical hallmarks of renal failure. C: Hyponatremia usually occurs and correlates with a surplus of water. Not hypernatremia. D: Metabolic acidosis is common in AKI due to retention of hydrogen.

A 59 year old client diagnosed with a gastrointestinal bleed is found by the PN slumped in the chair. Place the PN's actions in order of priority for this client from first to last priority. A.) Activate the code team and obtain a defibrillator. B.) Determine unresponsiveness C.) Use the quick look paddles to determine rhythm. D.) Check for carotid pulse. E.) Open airway and give two rescue breaths by bagvalve mask. F.) Move the client to a flat position in bed. G.) Begin compressions

B,A,D,F,G,E,C The first action is to determine unresponsiveness. If there is no response call the code, then check for a carotid pulse. In order for the PN to perform CPR, the client must be on a flat, hard surface; the CPR board or CPR mode on the bed will need to be activated. After establishing no pulse or an ineffective pulse, start good quality CPR, hard and fast, at a rate of 100/minute, allowing full chest recoil. Once the circulation has been addressed, give 2 breaths over 1 second each, using a bag valve mask. By this time the AED or defibrillator has arrived; attach the "quick look" paddles and get a quick look for a shockable rhythm.

The PN suspects a postoperative thyroidectomy client may have had the inadvertent removal of the parathyroid gland when the client begins to experience which symptoms? (Select all that apply...) A.) Hematoma formation B.) Harsh, vibratory sounds on inspiration and expiration. C.) Tingling of lips, hands, and toes. D.) Positive Chvostek's sign E.) Sensation of fullness at the incision site.

B,C,&D.- Laryngeal stridor may be related to tetany when parathyroid glands are damaged or removed, leading to hypocalcemia. Tingling of toes, fingers, and lips along with muscular twitching are signs of tetany. A positive Chvostek's sign is noted with hypocalcemia. A: Bleeding and the formation of hematomas are postoperative complications of neck surgeries. Stable clients must be assessed every 2 hours for 24 hours for hemorrhage. E: Hemorrhage may result in sensations of fullness at the incision site, choking, and blood on the dressing.

The health education nurse provides instruction to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions should the nurse provide? (Select all that apply...) A.) Sunscreen should be applied every 8 hours. B.) Use sunscreen when participating in outdoor activities. C.) Wear a hat, opaque clothing, and sunglasses when in the sun D.) Avoid sun exposure in the late afternoon and early evening hours. E.) Examine your body monthly for any lesions that may be suspicious.

B,C,&E. The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10AM to 4PM. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

A client who is postoperative for a colectomy complains, "I just felt a popping right after I coughed." The PN notes a large amount of serosanguineous drainage and the intestines protruding slightly from the incision. The LPN should immediately implement which priority intervention (s)? Select all that apply... A.)Encourage the client to turn and breathe deeply while splinting the opening. B.) Cover the wound with a moist, sterile, normal saline dressing. C.) Document the appearance of loops of bowel through the wound. D.) Reinsert the organs and apply a firm pressure dressing. E.)Place the client in a low Fowler's position with the knees bent. F.) Contact the charge nurse and call the healthcare provider.

B,C,E,F The nurse notifies the charge nurse and HCP immediately. The patient is placed in a low Fowler's position, kept quiet, instructed not to cough, and provided emotional support. The nurse covers protruding viscera with a warm, sterile, saline dressing and does not attempt to reinsert the protruding organ or viscera.

The PN directs the unlicensed assistive personnel to play with a 4 year old child on bed rest. Which activity or activities should the PN recommend? (Select all that apply...) A.) Monopoly board game B.) Checkers C.) 50 piece puzzle D.) Hand puppets E.) Coloring book

B,D,&E: They are tactile learners, simple games are appropriate. Preschoolers enjoy activities that involve "make believe", such as hand puppets, which can be used while on bed rest. By 4 years old, the preschooler can hold a crayon and express his/her feelings through coloring. A: This game is too complex for a preschooler. C: Most preschoolers will be able to take apart and put together an 8-10 piece puzzle.

The primary health care provider prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse knows that which is the most appropriate intervention? A.) The medication is administered within 60 minutes before the morning and evening meal. B.) The medication is withheld and the PHCP is called to question the prescription for the client C.) The client is monitored for gastrointestinal side effects after administration of the medication. D.) The insulin is withdrawn from the Penlet into an insulin syringe to prepare for administration

B.

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, parethesia, and tingling in the extremities. The nurse interprets that the client is experiencing which problem? A.) Hypercalcemia B.) Peripheral neuritis C.) Small blood vessel spasm D.) Impaired peripheral circulation

B. A common adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and parethesias in the extremities. This adverse effect can be minimized by pyridoxine intake. Options A,C, and D are incorrect.

The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which event? A.) Witnessing a murder B.) The death of a loved one C.) A fire that destroyed the client's home D.) A recent rape episode experienced by the client

B. A situational crisis is associated with a life event. External situations that could precipitate a situational crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, and severe illness. Options A, C, and D identify adventitious crisis. An adventitious crisis relates to a crisis, disaster, or event that is not a part of everyday life, is unplanned, and is accidental.

The nurse is monitoring a client who is taking propranolol. Which data collection finding would indicate a potential serious complication associated with propranolol? A.) The development of complaints of insomnia B.) The development of audible expiratory wheezes C.) A baseline resting heart rate of 88 beats/min followed by a resting heart rate of 72 beats/min after two doses of the medication. D.) A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication.

B. Audible expiratory wheezes may indicate a serious adverse reaction: bronchospasm. Beta blockers may induce this reaction particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.

A client in preterm labor (31 weeks) who is dilated to 4cm has been started on magnesium sulfate and her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? A.) Nalbuphine B.) Betamethasone C.) Rh (D) immune globulin D.) Dinoprostone vaginal insert

B. Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if the labor can be inhibited for 48 hours. Nalbuphine is an opioid analgesic. Rho(D) immune globulin is given to Rh-negative clients to prevent sensitization. Dinoprostone vaginal insert is a prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions.

Bethanechol chloride is prescribed for a client with urinary retention. Which disorder should be a contraindication to the administration of this medication? A.) Gastric atony B.) Urinary strictures C.) Neurogenic atony D.) Gastroesophageal reflux

B. Bethanechol chloride can be harmful to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these conditions.

The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate? A.) Interrupt the client and weigh her immediately. B.) Interrupt the client and offer to take her for a walk. C.) Allow the client to complete her exercise program. D.) Tell the client that she is not allowed to exercise vigorously.

B. Clients with anorexia nervosa are frequently preoccupied with vigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise as well as place limits on vigorous activities. Options A,C, and D are inappropriate nursing actions.

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion? A.) The mother should restrict the daughter's socializing time with her friends. B.) The mother should restrict the amount of chocolate and caffeine products in the home. C.) The mother should keep her daughter out of school until she can adjust to the school environment. D.) The mother should consider taking time off of work to help her daughter readjust to the home environment.

B. Clients with anxiety disorder should abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Options A and C are unreasonable and are an unhealthy approach. It may not be realistic for a family member to take time away from work.

The nurse is caring for a client with severe depression. Which activity is appropriate for this client? A.) A puzzle B.) Drawing C.) Checkers D.) Paint by number

B. Concentration and memory are poor in a client with severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities that have no right or wrong choices or decisions minimize opportunities for the client to put down himself or herself. The nurse can also process the client's feelings by sitting with the client and talking or encouraging the client to write in a journal.

Cycloserine is added to the medication regimen for a client with tuberculosis. Which instructin should the nurse reinforce in the client-teaching plan regarding this medication? A.) To take the medication before meals B.) To return to the clinic weekly for serum drug level testing C.) It is not necessary to restrict alcohol intake with this medication. D.) It is not necessary to call the primary health care provider if a skin rash occurs.

B. Cycloserine is an antitubercular medication that requires weekly serum drug level determinations to monitor for the potential of neurotoxicity. Serum drug levels lower than 30mcg/mL reduce the incidence of neurotoxicity. The medication must be taken after meals to prevent GI irritation. The client must be instructed to notify the PHCP if a skin rash or signs of CNS toxicity are noted. Alcohol must be avoided because it increases the risk of seizure activity.

The nurse is reinforcing discharge instructions to a client receiving sulfadiazine. Which should be included in the list of instructions? A.) Restrict fluid intake B.) Maintain a high fluid intake C.) Decrease the dosage when symptoms are improving to prevent an allergic response. D.) If the urine turns dark brown, call the primary health care provider immediately.

B. Each dose of sulfadiazine should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfadiazine cause urine to turn dark brown or red. This does not indicate the need to notify the PHCP.

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states to report which occurrence immediately? A.) Impaired sense of hearing B.) Problems with visual acuity C.) Gastrointestinal side effects D.) Red-orange discoloration of body secretions

B. Ethambutol causes optic neuritis, which decreases visual acuity and the ability to descriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client is also taugh to take the medication with food if GI upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Red-orange discoloration of secretions occurs with rifampin.

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based o this type of admission, which would the nurse expect to note? A.) The client will be angry and will refuse care. B.) The client will participate in the treatment plan. C.) The client will be very resistant to treatment measures. D.) The client's family will be very resistant to treatment measures.

B. Generally, voluntary admission is sought by the client or client's guardian. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Options A and C are not likely for a client seeking voluntary admission. Option D is not centered on the individual client.f

A client has a prescription to take guaifenesin every 4 hours, as needed. The nurse determines that the client understands the most effective use of this medication if the client makes which statement? A.) "I will watch for irritability as a side effect." B.) "I will take the tablet with a full glass of water." C.) "I will take an extra dose if the cough is accompanied by fever." D.) "I will crush the sustained-release tablet if immediate relief is needed."

B. Guaifenesin is an expectorant. It should be taken with a full glass of water to decrease the viscosity of secretions. Sustained-release preparations should not be broken open, crushed, or chewed. The medication may occasionally cause dizziness, headache, or drowsiness. The client should contact the PHCP if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache.

A client is taking Humulin NPH insulin daily every morning. The nurse reinforces instructions to the client and should tell the client that which is the most likely time for a hypoglycemic reaction to occur? A.) 2 to 4 hours after administration. B.) 6 to 14 hours after administration C.) 16 to 18 hours after administration D.) 18 to 24 hours after administration

B. Humulin NPH is an intermediate-acting insulin. The onset of action is 1 to 2 hours, it peaks in 6 to 14 hours, and its duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.

Betaxolol hydrochloride eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication? A.) Monitoring temperature B.) Monitoring blood pressure C.) Checking peripheral pulses D.) Check the blood glucose level

B. Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options A,C, and D are not specifically associated with this medication.

The homecare nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should provide which information? A.) Freeze the insulin B.) Refrigerate the insulin C.) Store the insulin in a dark, dry place D.) Keep the insulin at room temperature.

B. Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen because freezing affects the chemical composition of the insulin. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Freezing insulin, storing insulin in a dark, dry place and keeping the insulin at room temperature are all incorrect actions.

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to provide which information to the client? A.) Drink alcohol in small amounts only. B.) Report yellow eyes or skin immediately C.) Increase intake of Swiss or aged cheeses. D.) Avoid vitamin supplements during therapy

B. Isoniazid is hepatotoxic, and therefore the client is taught to report signs/symptoms of hepatitis immediately (which include yellow skin and sclera). For the same reason, alcohol should be avoided during therapy. The client should avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or light-headedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine during the course of isoniazid therapy.

Isotretinoin is prescribed for a client with severe acne. Before administration of this medication, the nurse anticipates that which laboratory test will be prescribed? A.) Potassium level B.) Triglyceride level C.) Hemoglobin A1C D.) Total cholesterol level

B. Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on triglycerides has been evaluated. There is no indication that isotretinoin affects postassium, hemoglobin A1C, or total cholesterol levels.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action? A.) Move the client next to the nurse's station. B.) Use a night light and turn off the television. C.) Keep the television and a soft light on during the night. D.) Play soft music during the night and maintain a well-lit room.

B. It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial intervention.

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment? A.) Uterine tone B.) Blood pressure C.) Amount of lochia D.) Deep tendon reflexes

B. Methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority assessment before the administration of the medication is to check the blood pressure. The HCP should be notified if hypertension is present. Although options A,C,and D may be components of the postpartum assessment, the correct option, blood pressure, is related specifically to the administration of this medication.

The client has been taking omeprazole for 4 weeks. The nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom? A.) Diarrhea B.) Heartburn C.) Flatulence D.) Constipation

B. Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called "heartburn" by clients. Omeprazole is not used to treat the conditions identified in options A,C, and D.

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond with which question or statement? A.) "The technician is not going to hurt you but is going to help." B.) "Are you fearful and think that others may want to hurt you?" C.) "What makes you think that the technician wants to hurt you?" D.) "The technician will leave and come back later for your blood."

B. Option B is the only option that recognizes the client's need. This response helps the client focus on the emotion underlying the delusion but does not argue with it. If the nurse attempts to change the client's mind, the delusion may, in fact, be even more strongly held. Options A,C, and D do not focus on the client's feelings.

A client with diabetes mellitus visits a healthcare clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 mg/dL to 200 mg/dL. Which medication, added to the client's regimen, may have contributed to the hyperglycemia? A.) Atenolol B.) Prednisone C.) Phenelzine D.) Allopurinol

B. Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option A, a beta-blocker and option C, a monoamine oxidase inhibitor, have their own intrinsic hypoglycemic activity. Option D decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral agents, which can lead to hypoglycemia.

The nurse is preparing to administer beractatn to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route? A.) Intradermal B.) Intratracheal C.) Subcutaneous D.) Intramuscular

B. Respiratory distress syndrome is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. It is common in premature infants and may occur as a result of lung immaturity caused by surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, whcih is administered by the intratracheal route. Options A,C,and D are not routes of administration for this medication.

A sulfonamide is prescribed for a client with a urinary tract infection. During review of the client's record, the nurse notes that the client is taking warfarin sodium daily. Which prescription should the nurse antcipate for this client? A.) Discontinuation of warfarin sodium. B.) A decrease in the warfarin sodium dosage C.) An increase in the warfarin sodium dosage D.) A decrease in the usual dose of the sulfonamide

B. Sulfonamides can potentiate the effects of warfarin sodium, phenytoin, and orally administered hypoglycemics such as tolbutamide. When an oral anticoagulant is combined with a sulfonamide, a decrease in the anticoagulant dosage may be needed.

The client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication? A.) Glucose level B.) Calcium level C.) Potassium level D.) Prothrombin time

B. Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium levels should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain. Tamoxifen does not increase glucose or potassium levels, or increase the prothrombin time.

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate? A.) A client with pneumonia B.) A client receiving diagnostic tests C.) A client who thrives on managing others D.) A client who could benefit from the client's assistance at mealtimes.

B. The client receiving diagnostic tests is an appropriate roommate. The client with anorexia is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client would place the client with anorexia nervosa at risk for infection. The client anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which he or she can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of his or her own hunger.

The client who frequently uses nonsteroidal antiinflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that this medication is having the intended therapeutic effect if which is noted? A.) Resolved diarrhea B.) Relief of epigastric pain C.) Decreased platelet count D.) Decreased white blood cell count

B. The client who frequently uses nonsteroidal antiinflammatory drugs is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence. Diarrhea can be a side effect of the medication, but it is not an intended effect. Options C and D are incorrect.

The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action? A.) Administer an antianxiety agent B.) Examine and treat the wound sites C.) Secure and record a detailed history D.) Encourage and assist the client with venting their feelings

B. The initial nursing action is to examine and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions may follow after the client has been treated medically.

The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response? A.) "No, I won't tell anyone." B.) "I cannot promise to keep a secret." C.) "If you tell me the secret, I will tell it to your doctor." D.) "If you tell me the secret, I will need to document it in your record."

B. The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret.

A client with Crohn's disease is scheduled to receive an infusion of infliximab. The nurse asssisting with caring for the client should take which action to monitor the effectiveness of treatment? A.) Monitoring the leukocyte count for 2 days after the infusion. B.) Checking the frequency and consistency of bowel movements C.) Checking serum liver enzyme levels before and after the infusion. D.) Carrying out a Hematest on gastric fluids after the infusion is completed.

B. The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options A,C,& D are unrelated to this medication.

The nurse is planning to administer hydrochlorothiazide to a client. Which are concerns related to the administration of this medication? A.) Hypouricemia, hyperkalemia B.) Hypokalemia, hyperglycemia, sulfa allergy C.) Hypokalemia, increased risk of osteoporosis D.) Hyperkalemia, hypoglycemia, penicillin allergy

B. Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse? A.) "Why did you get started on these drugs?" B.) "How much do you use and what effect does it have on you?" C.) "How long did you think you could take these drugs without someone finding out?" D.) "The nurse does not ask any questions because of fear that the client is in denial and will throw the nurse out of the room."

B. Whenever the nurse collects data from a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option A is incorrect because it is judgmental, off focus, and reflects the nurse's bias. Option C is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option D is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

The client with acute myelocytic leukemiais being treated with busulfan. Which laboratory value should the nurse specifically monitor during treatment with this medication? A.) Clotting time B.) Uric acid level C.)Potassium level D.) Blood glucose level

B. Busulfan can cause an increase in the uric acid level because of massive cell death of malignant cells. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Clotting time, potassium, and glucose blood levels are not specifically related to this medication.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids? A.) Dilated pupils, tachycardia, and diaphoresis B.) Yawning, irritability, diaphoresis, cramps, and diarrhea C.) Tachycardia, hypertension, sweating, and marked tremors D.) Depressed feelings, high drug craving, fatigue, and agitation

B. Opiods are central nervous system depressants. Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, nausea, and vomiting, muscle aches, chills, fever, lacrimation, and diarrhea. Withdrawal is treated by methadone tapering or medication detoxification. Option B identifies the clinical manifestations associated with withdrawal from opioids. Option A describes intoxication from hallucinogens. Option C describes withdrawal from alcohol. Option D describes withdrawal from cocaine.

The PN is caring for an elderly client in a nursing home setting who has a recent diagnosis of delirium. Which action has the highest priority in the care for this client? A.)Assist the client with dressing and hygiene. B.)Maintain the bed in lowest position. C.)Encourage participation in social activities. D.)Talk to the patient in quiet tones.

B. - Ensuring a safe environment for the client is always a high priority. Clients with delirium are especially prone to falls partly because of the neurological effects of delirium. A: These are important self-care activities; however, keeping the client safe within the environment is a higher priority. C:The client with delirium should be provided with a low-stimulation environment, so singing and group environments may provide too much sensory stimulation. D:This is appropriate, but the priority is safety.

The PN is administering 0900 medications to three clients on a telemetry unit when the unlicensed assistive personnel (UAP) reports that another client is complaining of a sudden substernal discomfort. What action should the PN take? A.) Ask the UAP to obtain the client's vital signs. B.)Assess the client's discomfort. C.)Advise the client to rest in bed. D.) Observe the client's ECG pattern.

B. - It is critical to assess the client immediately. The nurse should delegate medication administration or complete it after the client is assessed. A: The nurse should not delegate this assessment for a client who is experiencing a potentially life-threatening symptom. C: This leaves the client in a potentially physiologically unstable condition. D: ECG patterns may not provide immediate waveform changes, and the nurse should go to the bedside and assess the client.

The PN is caring for a 2 year old child suspected of having croup. What early signs of respiratory distress require immediate reporting? A.) Cyanosis B.) Restlessness C.) Crying D.) Barking cough

B. - Restlessness is considered an early sign of hypoxia, and the HCP should be contacted immediately. A: Cyanosis is considered a late sign of respiratory distress. C: Although crying is distressful, it is not considered an early sign of respiratory distress. D: Barking cough is an expected sign of respiratory distress.

The PN observes an elderly client with glaucoma administer eye drops by tilting his head back, instilling each drop close to the inner canthus, and keeping his eye closed for 15 seconds. What action should the PN take first? A.) Ask the client whether another family member is available to administer the drops. B.) Review the correct steps of the procedure with the client. C.) Administer the eye drops correctly in the other eye to demonstrate the technique. D.) Discuss the importance of correct eye drop administration for individuals with glaucoma.

B. - Review the correct steps of the procedure with the client.

A client who is 1 day postoperative after a left pneumonectomy is lying on his right side with the head of the bed elevated 10 degrees. The PN assesses his respiratory rate at 32 breaths/min. What action should the nurse take first? A.) Elevate the head of the bed. B.) Assist the client into the supine position. C.) Measure the O2 saturation. D.) Administer PRN morphine IV

B. - To facilitate full lung expansion, the nurse should first reposition the client. A: This is more effective when the client is supine and will improve diaphragmatic excursion and relieve tachypnea. C: This action will provide the nurse with objective data that evaluates the effectiveness of the initial measures taken to relieve tachypnea. D: Tachypnea can be related to pain and anxiety, and the nurse should determine if analgesia is indicated and then administer morphine after first repositioning the client.

A 72 year old client returned from surgery 6 hours ago. The client received hydromorphone 2 milligrams IV 30 minutes ago for a pain rating of 8/10. The family member requests that her father be checked immediately. On arrival to the room you find the client difficult to arouse with a respiratory rate of 6. What is the priority nursing action? A.) Elevate the head of bed and turn client to side. B.) Assist with the administration of naloxone 0.4 mg IV. C.) Assess breath sounds and neurological status. D.) Check vital signs and pulse oximetry.

B.) Assist with the administration of naloxone 0.4 mg IV

A client who is receiving chemotherapy has these CBC results: hemoglobin, 8.5 g/dL; hematocrit, 32%; and WBC count, 6500 cells/mm3. Which meal is the best choice for this client? A.) Grilled chicken, rice, fresh fruit, salad, and milk. B.) Broiled steak, whole wheat rolls, spinach salad, and coffee. C.) Smoked ham, mashed potatoes, applesauce, and iced tea. D.) Tuna noodle casserole, garden salad, and lemonade.

B.) Broiled steak, whole wheat rolls, spinach salad, and coffee. Rationales: A,C,D these choices do not fully address client's deficiencies. B: Eating foods high in iron (such as red meats, enriched breads) or folic acid (such as enriched breads and spinach) help moderate anemia.

The PN is making assignments for 5 clients at the nursing home. The nursing team includes a LVN and 2 UAPs. Which client task(s) would be assigned to the UAPs? Select all that apply... A.) Administering an injection of enoxaparin sodium (Lovenox) to a client who requires anticoagulant therapy. B.) Repositioning a client with a stage 3 pressure ulcer who needs a bath. C.) Checking the residual for a client with an enteral feeding absorbing at 30mL/hr. D.) Changing the IV tubing on a client recovering from pneumonia. E.) Performing a straight catheterization on a client prescribed intermittent catheterization.

B.) Repositioning a client with a stage 3 pressure ulcer who needs a bath.

A client is admitted with gastric ulcer disease and GI bleeding. Which risk factor should the practical nurse identify in the client's history? A.)Eats heavily seasoned foods B.) Uses NSAIDs daily C.)Consumes alcohol every day. D.) Follows an acid-ash diet.

B.- A side effect of frequent use of NSAIDs is gastric irritation and potential ulceration. A: Heavily seasoned foods may irritate the gastric mucosa but are not a risk factor causing gastric ulcer disease. C: Alcoholic beverages act as an irritation to gastric ulcer disease rather than the cause. D: An acid-ash diet encourages meats, eggs, and cheese and discourages milk products, fruits and vegetables, which is used to acidify urine and is not a risk factor for gastric ulcer disease.

A client with Parkinson's disease is prescribed carbidopa-levodopa. Which observation by the PN indicates that the desired effect of the medication is being achieved? A.) Decreased blood pressure B.) Steady gait C.) Increased salivation D.) Increased attention span

B.- Carbidopa-levodopa (Sinemet) has a dramatic effect on controlling the symptoms of unsteady or ataxic gait. A: Hypotension is an undesired effect of carbidopa-levodopa. C: The drug does not alter salivation D: The drug does not impact attention span.

While receiving IV antibiotics for sepsis, a 2-month-old infant is crying inconsolably, despite the mother's presence. The PN recognizes that the infant is exhibiting symptoms related to which likely condition? A.) Allergic reaction to antibiotics. B.) Pain related to IV infiltration C.) Separation anxiety from mother. D.) Hunger and thirst

B.- Crying inconsolably is typically due to pain. Observations are especially important when using IV drugs such as antibiotics, which can cause serious tissue damage and pain. A: Allergic reactions to antibiotics are systemic. C: Despite the mother's presence, the child is too young to suffer from separation anxiety. D: This is unlikely given the circumstances.

A client who has gestational diabetes asks the PN to explain why her baby is at risk for macrosomia. Which explanation should the nurse offer? A.) The placenta receives decreased maternal blood flow during pregnancy because of vascular constriction. B.) The fetus secretes insulin in response to maternal hyperglycemia, causing weight gain and growth. C.) Infants of diabetic mothers are postmature, which allows the fetus extra time to grow. D.) Rapid fetal growth contributes to congenital anomalies, which are more common in infants of diabetic mothers.

B.- Maternal glucose crosses the placenta, but insulin (either the mother's own or synthetic) does not. As the fetus gets too much glucose, fetal insulin secretion follows and acts as a growth hormone, thus causing the macrosomia. A: A decreased blood flow to the placenta will cause IUGR (growth restriction), not macrosomia. C: This is inaccurate. In post-maturity, the placenta ages and degenerates, resulting in fetal nutritional compromise. D: Fetal growth is not the etiology of congenital anomalies, although diabetes may increase the risk for defects.

A client who had a vaginal hysterectomy the previous day is saturating perineal pads with blood and requires frequent changes during the night. What priority action should the nurse take? A.) Provide iron-rich foods on each dietary tray. B.) Monitor the client's vital signs every 2 hours. C.) Administer IV fluids at the prescribed rate. D.) Encourage postoperative leg exercises.

B.- The client has experienced excessive bleeding, and the nurse should monitor the client's vital signs more closely (every 2 hours) and notify the HCP. A: This is an important action since the client has lost blood and may be anemic but is not the priority. C: This should be continued until the healthcare provider gives further prescriptions or the client's vital signs indicate hypovolemia. D: This is a standard of care postop, but the priority is evaluating the client for the physiological impact of the excessive bleeding following hysterectomy.

A client who is 72 hours post cesarean section is preparing to go home. She complains to the PN that she can't get the baby's diaper on right. Which action should the nurse take? A.) Demonstrate how to diaper the baby correctly. B.) Observe the client diapering the baby while offering praise and hints. C.) Call the social worker for long-term follow-up. D.) Reassure the client that she knows how to take care of her baby.

B.- This client is in the taking-hold phase. While she may still feel inadequate in her mothering skills, the nurse should observe her diapering technique, which will reinforce her confidence when the nurse offers praise and teaching hints. A: According to Reva Rubin, the taking-in phase lasts for 24-48hrs postpartum, during which dependency and help-seeking behaviors are common. This client is preparing for discharge, and demonstrating diapering technique will not increase her confidence. C: This client is responding normally and shows no indication of the need for a social work referral. D: This dismisses the client's worries and contributes to her feelings of inadequacy and guilt.

The PN is caring for a client hospitalized with Guillain-Barre syndrome. Which information would be most important for the PN to report to the RN? A.) Ascending numbness from feet to knees. B.) Decrease in cognitive status. C.) Blurred vision and sensation changes. D.) Persistent unilateral headache.

B.- This is the most concerning sign because it indicates decreased oxygenation of the brain, which occurs as the respiratory muscles are affected with ascending paralysis. A: This is an indication that the paralysis is ascending; however it is not immediately catastrophic. C: Although paresthesia is a common manifestation and visual changes are found with this syndrome, they are not as worrisome as respiratory failure. D: Headache is not a common symptom of this syndrome.

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? (Select all that apply..) A.) Fatigue B.) Drowsiness C.) Uterine hyperstimulation D.) Late decelerations of the fetal heart rate E.) Early decelerations of the fetal heart rate

C&D. Oxytocin stimulates uterine contractions and is a common pharmacological method to induce labor. High-dose protocols have been associated with more uterine hyperstimulation and more cesarean births related to fetal stress. Late decelerations, a non-reassuring fetal heart rate pattern, is an ominous sign indicating fetal distress. Some PHCPs prescribe the administration of oxytocin in 10-minute pulsed infusion rather than as a continuous infusion. This pulsed method, which is more like endogenous secretion of oxytocin, is reported to be effective for labor induction and requires significantly less oxytocin use. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.

A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Which appropriate actions should the nurse take? (Select all that apply...) A.) Call a code blue B.) Contact the client's family C.) Check the client's pain level D.) Check the client's blood pressure E.) Administer a second nitroglycerin, 0.4mg, sublingually

C,D,&E. The usual guideline for administering nitroglycerin tablets for a hospitalized client with chest pain is to administer one tablet every 5 minutes PRN for chest pain for a total dose of three tablets. The registered nurse is notified immediately if a client complains of chest pain. In this situation, because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would check the client's pain level and the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a code blue. In addition, it is not necessary to contact the client's family unless the client has requested this.

The PN is reviewing the electronic medical records of the assigned clients. Which client(s) is/are at high risk for a potassium deficit? Select all that apply... A.) The client with hyperthyroidism B.) The client with metabolic acidosis. C.) The client with intestinal obstruction. D.) The client with nasogastric suction. E.) The client with watery diarrhea

C,D,E Rationales: A: Hypokalemia is NOT a usual finding with hyperthyroidism. B: Hypokalemia is related to shift of potassium into the cells, causing alkalosis. C:Hypokalemia is common in the client with intestinal obstruction. Electrolytes leak into the peritoneal cavity. D:Loss of potassium due to suctioning. E: Loss of potassium may be related to diarrhea.

The PN receives the change of shift report about a client who is 6 hours postoperative from abdominal surgery. At the beginning of the shift vital signs were BP, 106/74; temp 98.6F; pulse 78 bpm; respirations, 14 breaths/min. The urine output for the previous 8-hour shift was 300 mL. Three hours into the shift, the PN suspects that the client is developing shock. What signs indicate the development of hypovolemic shock? Select all that apply... A.) Lethargy B.) Temp 99.0F C.)Anxiousness D.) Respiratory rate 25 breaths/min E.) Apical pulse 92 bpm F.) Urine output is 75 mL 3 hours into shift.

C,D,E,F A pulse that increases- coupled with a declining blood pressure, changes in level of consciousness, anxiousness, and decreased urine output may signal hypovolemic shock. Hypovolemic shock in the postoperative period is frequently caused by internal hemorrhage, a life-threatening emergency.

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? (Select all that apply...) A.) Discourage reminiscing B.) Make the decisions for the family C.) Encourage expression of feelings, concerns, and fears D.) Explain everything that is happening to all family members E.) Extend touch, and hold the client or family member's hand if appropriate. F.) Be honest and truthful, and let the client and family know that you will not abandon them.

C,E,&F. The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears, as well as reminiscing. The nurse needs to be honest and truthful and let the client and family know that they will not be abandoned. It is important to extend touch and to hold the client or family member's hand if appropriate.

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis? A.) Psychosis B.) Repression C.) Conversion Disorder D.) Dissociative disorder

C. A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's capacity to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

An older client has recently been taking cimetidine. The nurse should monitor the client for which most frequent central nervous system side effect of this medication? A.) Tremors B.) Dizziness C.) Confusion D.) Hallucinations

C. Cimetidine is a histamine 2 receptor antagonist. Older clients are especially susceptible to the central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.

The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective? A.) "I need to continue to avoid eating spinach and kale." B.) "I probably will have some weakness in my legs when I take this medicine." C.) "I should avoid taking aspirin while receiving this medication." D.) "I will have to get blood drawn routinely to check my clotting levels."

C. Clients prescribed rivaroxaban should be educated to avoid taking OTC meds or supplements that increase bleeding risk, such as NSAIDs(aspirin), garlic, and ginger. The combined effects of rivaroxaban and other anticoagulants may greatly increase the risk of uncontrolled bleeding and hemorrhage. Unlike Warfarin, factor Xa inhibitors are not affected by vitamin K, which is found in many green and leafy veggies (spinach, kale). Anticoagulants, particularly factor Xa inhibitors, increase the risk for spontaneous intracranial bleeding or formation of epidural hematomas. Clients taking factor Xa inhibitos should be instructed to immediately contact their health care provider for symptoms of neurological impairment (extremity weakness, altered sensation, numbness). Routine monitoring of clotting time is unnecessary for clients prescribed factor Xa inhibitors.

The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? A.) Engaging in immoral acts B.) Always reinforcing self-approval C.) Observing rigid rules and regulations D.) Having the need to always make the right decision

C. Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety. Options A,B, and D are incorrect.

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention? A.) Ask direct questions to encourage talking. B.) Leave the client alone and intermittently check on them. C.) Sit beside the client in silence and verbalize occasional open-ended questions. D.) Take the client into the dayroom with other clients so they can help watch him.

C. Clients with catatonic stupor may be immobile and mute and may require consistent, repeated approaches. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The nurse would not leave the client alone. Fortunately, with pharmacotherapy and improved individual management, severe catatonic symptoms rarely occur. Option D relies on other clients to care for this one, which is an inappropriate expectation. Asking direct questions of this client is not therapeutic. Option C is the best action because it provides for client supervision and communication as appropriate

Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication? A.) Hemoglobin level of 14.0 g/dL. B.) Creatinine level of 0.6 mg/dL. C.) Blood urea nitrogen level of 25mg/dL D.) Fasting blood glucose level of 99mg/dL

C. Cyclosporine is an immunosuppressant. Nephrotoxicity can occur from the use of cyclosporine. Nephrotoxicity is evaluated by monitorin for elevated blood urea nitrogen and serum creatinine levels. The normal blood urea nitrogen level is 10 to 20 mg/dL. The normal creatinine level for a male is 0.6 to 1.2 mg/dL and for a female 0.5 to 1.1 mg/dL. Cyclosporine can lower complete blood cell count levels. A normal hemoglobin is not an adverse effect. Cyclosporine does affect the glucose level. The normal fasting glucose is 70 to 110 mg/dL.

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates that he or she has learned positive coping skills? A.) "I will be more careful to make sure that my father's needs are met." B.) "Now that my father is moving into my home, I will need to change my ways." C.) "I feel better able to care for my father now that I know where to obtain assistance." D.) "I am so sorry and embarrassed that the abusive event occurred. It won't happen again."

C. Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or financially depleted. Knowing where in the community to turn for assistance with caring for aging family members can bring much-needed relief. Taking advantage of these alternatives is a positive alternative coping strategy, which many families use.

The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder? A.) Monitor intake and output B.) Monitor electrolyte levels C.) Observe for excessive exercise D.) Monitor for the use of laxatives and diuretics

C. Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Monitoring for both dehydration and electrolyte imbalance is an important nursing action. Option C is the only option that is not associated with care of the client with bulimia.

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse? A.) "When children are hurt the way you hurt them, people want you isolated." B.) "You're lucky it doesn't escalate into something pretty scary after your crime." C.) "You understand that people fear for their children, but you're feeling unfairly treated?" D.) "You seem angry, but you have committed serious crimes against several children, so your neighbors are frightened."

C. Focusing and verbalizing the implied concern is the therapeutic response because it assists the client to clarify thinking and to reexamine what the client is really saying. Option C is the only option that reflects the use of this therapeutic communication technique. Option A is insensitive and anxiety-provoking. Option B gives advice and does not facilitate the client's expression of feelings. Option D does not facilitate the client's expression of feelings.

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse and expects that the RN will take which action? A.) Call the client's family. B.) Persuade the client to stay a few more days C.) Contact the primary health care provider D.) Tell the client that discharge is not possible at this time.

C. Generally, voluntary admission is sought by the client or client's guardian. Voluntary clients have the right to demand and obtain release. The best nursing action is to contact the PHCP. Option A violates client confidentiality. Option B is not therapeutic or appropriate. Option D does not apply to a voluntary admission status.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety? A.) Request that a peer remain with the client at all times B.) Remove the client's clothing and place the client in a hospital gown. C.) Assign a staff member to the client who will remain with him or her at all times. D.) Admit the client to a seclusion room where all potentially dangerous articles are removed.

C. Hanging is a serious suicide attempt. The plan of care must reflect action that will promote the client's safety. Constant observation status (one-on-one) with a staff member who is never less than an arm's length away is the safest intervention.

A client with tuberculosis is being started on antituberculosis therapy with isoniazid Before giving the client the first dose, the nurse ensures that which baseline study has been completed? A.) Electrolyte levels B.) Coagulation times C.) Liver enzyme levels D.) Serum creatinine level

C. Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is greater than age 50 or abuses alcohol.

Isosorbide mononitrate is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. Which action should the nurse suggest to the client? A.) Cut the dose in half. B.) Discontinue the medication C.) Take the medication with food D.) Contact the primary health care provider

C. Isosorbide mononitrate is an antianginal medication. Headache is a frequent side effect of isosorbide mononitrate and usually disappears during continued therapy. If a headache occurs during therapy, the client should be instructed to take the medication with food or meals. It is not necessary to contact the PHCP unless the headaches persist with therapy. It is not appropriate to instruct the client to discontinue therapy or adjust dosages.

A client with severe acne is seen in the clinic and the primary health care provider prescribes isotretinoin. The nurse reviews the client's medication record and would contact the PHCP if the client is also taking which medication? A.) Digoxin B.) Phenytoin C.) Vitamin A D.) Furosemide

C. Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindication associated with digoxin, phenytoin, or furosemide.

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? A.) "I know you feel 'they are out to get you,' but it's not true." B.) "I can hear the voice, and she wants you to come to dinner." C.) "Sometimes people hear things or voices others can't hear." D.) "I talked to the voices you're hearing and they won't hurt you now."

C. It is important for the nurse to reinforce reality with the client. Options A,B, and D do not reinforce reality but reinforce the hallucination that the voices are real.

The client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication? A.) Constipation B.) Abdominal pain C.) An episode of diarrhea D.) Hematest-positive nasogastric tube drainage

C. Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options A,B,&D.

The client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? A.) Weight loss B.) Relief of heartburn C.) Reduction of steatorrhea D.) Absence of abdominal pain

C. Pancrelipase is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion.

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client? A.) "Have you shared your feelings with your family?" B.) "I think we should talk more about your anger with your family." C.) "You're feeling angry that your family continues to hope for you to be 'cured'?" D.) "Well it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia."

C. Reflection is the therapeutic communication technique that redirects the client's feelings back to validate what the client is saying. In option B, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option D, the nurse makes a judgment and is nontherapeutic in the one-on-one relationship. In option A, the nurse is attempting to assess the client's ability to openly discuss feelings with family members. Although this may be appropriate, the timing is somewhat premature and closes off facilitation of the client's feelings.

A client has been started on long-term therapy with rifampin. Which information about this medication should the nurse provide to the client? A.) Should always be taken with food or antacids B.) Should be double-dosed if one dose is forgotten C.) Causes red-orange discoloration of sweat, tears, urine, and feces. D.) May be discontinued independently if symptoms are gone in 3 months.

C. Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a PHCP. The medication should be administered on an empty stomach unless it causes GI upset, and then it may be taken with food. Antacids, if prescribed should be taken at least 1 hour before the medication. Rifampin causes red-orange discoloration of body secretions and will permanently stain soft contact lenses.

An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention? A.) Watch the behavior escalate before intervening B.) Attempt to talk with the client to de-escalate the behavior. C.) Offer to take the client to an examination room until he or she can be treated. D.) Inform the client that he or she will be asked to leave if the behavior continues.

C. Safety of the client, other clients, and staff is of prime concern. Option C is in effect an isolation technique that allows for separation from others and provides for a less stimulating environment where the client can maintain dignity. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option D would only further aggravate an already agitated individual.

Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? A.) "The medication is an antibacterial." B.) "The medication will help heal the burn." C.) "The medication is likely to cause stinging initially." D.) "The medication should be applied directly to the wound."

C. Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? A.) Plan short-term goals B.) Identify expected outcomes. C.) Assist with making appropriate referrals D.) Assist with developing realistic solutions

C. Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options A,B, and D identify the tasks of the working phase of the relationship.

The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client? A.) "You need to stop that behavior now!" B.) "You will need to be placed in seclusion!" C.) "What is causing you to become agitated?" D.) "You will need to be restrained if you do not change your behavior."

C. The best statement is to ask the client what is causing the agitation. This will assist the nurse with planning appropriate interventions for the client. Option A is demanding behavior, which could cause increased agitation in the client. Options B and D are threats to the client and are inappropriate.

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis? A.) Identifying the client's ability to function B.) Identifying the client's potential for self-harm. C.) Inquiring about the client's feelings that may affect coping. D.) Inquiring about the client's perception of the cause of the neighbor's death.

C. The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option C pertains directly to the client's feelings. Options A,B, and D do not directly address the client's feelings.

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern? A.) The client's report of not eating or sleeping. B.) The presence of bruises on the client's body. C.) The client's report of self-destructive thoughts D.) The family member is disapproving of the treatment.

C. The client's thoughts are extremely important when verbalized. Self-destructive thoughts are the highest priority. Options A,B, and D will all affect the treatment of the client but are not greatest importance at this time.

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement? A.) "Why don't you tell your husband about this?" B.) "This is not the best time to make that decision." C.) "What do you find difficult about this situation?" D.) "I agree with you. You should get out of this situation."

C. The most helpful response is the one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can also foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations.

The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask? A.) "With whom do you live?" B.) "Who is available to help you?" C.) "What leads you to seek help now?" D.) "What do you usually do to feel better?"

C. The nurse's initial task when gathering data from a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option C will assist with determining data related to the precipitating event that led to the crisis. Options A and B identify situational supports. Option D identifies personal coping skills.

The nurse who is administering bethanechol chloride is monitoring for acute toxicity associated with the medication. The nurse should check the client for which sign of toxicity? A.) Dry skin B.) Dry mouth C.) Bradycardia D.) Signs of dehydration

C. Toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously.

A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is reinforcing teaching for the client aobut the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen? A.) "My ulcer will heal because these medications will kill the bacteria." B.) "These medications are only taken when I have pain from my ulcer." C.) "The medications will kill the bacteria and stop the acid production." D.) "These medications will coat the ulcer and decrease the acid production in my stomach."

C. Triple therapy for Helicobacter pylori infection usually includes two antibacterial drugs and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.

Morphine sulfate, 2.5mg, is prescribed for a child. The safe pediatric dose is 0.05mg/kg/dose to 0.1mg/kg/dose. The child weighs 50kg. Which statement accurately describes the prescribed dosage for this child? A.) The dose is too low B.) The dose is too high. C.) The dose is within the safe dosage range. D.) There is not enough information to determine the safe dosage range.

C. Use formulas and substitute 50kg (child's weight) in for the kg part of the formulas to calculate a safe dosage range. 0.05mg x 50kg = 2.5mg 0.1mg x 50kg = 5mg Thus, the safe dosage range is 2.5mg to 5mg. The prescribed dosage is within a safe range, C.

A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? A.) Monitor for kidney failure B.) Monitor for psychosocial status C.) Monitor for signs of bleeding D.) Have heparin sodium available

C. Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin is given after thrombolytic therapy, but the question is not asking about follow-up medications.

The husband of a 94 year old woman tells the clinic PN that his wife has become increasingly confused over the past few days and has developed a cough. Which action should the nurse perform first? A.) Measure jugular vein distention B.) Check skin turgor C.) Obtain oxygen saturation D.) Check pupillary response to light

C. - Confusion due to lack of oxygen is often the first sign of pneumonia or other respiratory compromise. This is the priority assessment. A: Positive JVD may impact cardiac output, but O2 saturation is a higher priority. B: This may provide data about fluid deficit, but it is not the priority. D: This may provide useful data about neurological status, but O2 saturation is a priority.

The PN is caring for a client who suddenly loses consciousness. Which intervention will the PN implement first? A.) Quickly go to the nurses' station and ask the charge nurse to call a code. B.)Obtain a defibrillator from an adjacent nursing unit. C.)Call for help and initiate cardiopulmonary resuscitation (CPR). D.)Start oxygen by cannula at 10L/min and raise the head of the bed.

C. - Initiating immediate CPR and calling for help may preserve the life of the client. A&B: Do not leave the client in distress. D: Follow the CPR recommendations when a client loses consciousness.

The PN is assisting with a class on stroke prevention for clients with hypertension. What information is most important to provide the clients in the class? A.) Salt restriction diet B.) Weight reduction C.) Medication compliance D.) Risk for stroke

C. - Medication Compliance

A client complains of a severe headache after receiving nitroglycerin 0.4 mg SL for angina. What prescription should the PN administer? A.) A second dose of nitroglycerin. B.) A scheduled dose of low-dose aspirin. C.) A PRN dose of acetaminophen PO. D.) A PRN dose of morphine sulfate IM.

C. - One of the most common side effects of nitroglycerin is headache, and acetaminophen is typically prescribed to relieve the headache. A: Nitroglycerin is a drug of choice for angina. B: Aspirin at low dose is prescribed for its anticoagulant effects and not for pain relief. D: Morphine is not prescribed for headaches related to the side effect of nitroglycerin, and an IM would interfere with enzyme results.

A PN is caring for a child who had a tonsillectomy 2 hours ago. Which should alert the nurse that the child is bleeding? A.) Decrease in pulse B.) Increase in blood pressure C.) Frequent swallowing D.) Nasal congestion

C. - Postoperative hemorrhage may occur, and it is prudent to inspect the throat directly for evidence of bleeding. Other signs are frequent swallowing and vomiting of bright red blood. A: An increase in pulse occurs in clients who are bleeding. B: A decrease in BP occurs in clients who are bleeding. Normal VS for a child between 5-12 range from: HR 80-120/min; BP 90-120/60-70 (NIH). D: The child may have nasal congestion from dried old blood.

A client recovering from ARDS is transferred to the acute care unit. Awake and alert, the client has residual fatigue with generalized weakness. Current vital signs: HR 83, BP 104/64, RR 18, SpO2 on room air is 94%. Which intervention does the PN recognize as having the highest priority in the care of this client? A.)Ensure a diet high in protein and fruits B.)Perform passive range of motion every 4 hours. C.)Encourage frequent coughing and deep breathing. D.)Explain the importance of using rest appropriately.

C. - The most important interventions are related to lung status due to the sequela of ARDS. Using ABC strategy, these are the highest priority. A,B,D are all important interventions for the client but not the highest priority.

The nurse is preparing to administer a Mantoux (PPD) for a client entering nursing school. Which action is of highest priority? A.) Prepare 0.1 solution per tuberculin syringe. B.) Assess the skin condition on the forearm. C.) Inquire about BCG vaccine history. D.) Explain implications of positive findings.

C. Inquire about BCG vaccine history. The highest priority is assessing for a history of BCG vaccine because administering a PPD to a client who has received the vaccine will be positive and result in a large reaction at the site. Those clients will need to have a chest x-ray and avoid PPD screening for at least 10 years after administration. The other options are appropriate but not highest priority.

A 20 year old client has been receiving chemotherapy for acute lymphocytic leukemia. Which statement by the client indicates understanding of the nurse's discharge teaching about leukopenia? A.) "I'm relieved that I don't have any activity restrictions." B.) "I'd better wash my hands carefully, because my son can catch leukopenia." C.) "I should avoid close contact with people who might give me an infection" D.) "I need to be careful not to cut myself when shaving, because I may not be able to stop the bleeding"

C.) "I should avoid close contact with people who might give me an infection"

A client in a skilled nursing facility reports to the PN that he has not had a bowel movement in 2 days. Which intervention should the PN implement first? A.) Instruct the UAP to offer a glass of warm prune juice at mealtimes. B.) Ask the charge nurse to request a prescription for a stool softener. C.) Assess the client's medical record to determine his normal bowel pattern. D.) Instruct a family member to offer the client fluids, up to five 8-oz glasses a day.

C.) Assess the client's medical record to determine his normal bowel pattern. Prior to an intervention, the first step is to determine the usual pattern of elimination.

What nursing action has the highest priority when admitting a client to a psychiatric unit on an involuntary basis? A.) Reassure the client that admission is only for a limited time. B.) Offer the client and family the opportunity to share their feelings about the admission. C.) Determine the behaviors that resulted in the need for admission. D.) Advise the client about the legal rights of all hospitalized clients.

C.) Determine the behaviors that resulted in the need for admission.

A PN is preparing for change of shift. Which action by the nurse is characteristic of ineffective hand-off communication? A.) The PN tells the nurse coming on duty that a client is anxious about his pain and needs information about the use of incentive spirometer reinforced. B.) The nurse refers to the electronic medical record (EMR) to review the client's medication administration record. C.) During rounds the nurse talks about the problem the UAP created by not performing a finger stick blood glucose test on the client. D.) Before giving the report, the nurse performs rounds on her assigned clients so that there is less likelihood of interruption during handoff.

C.) During rounds the nurse talks about the problem the UAP created by not performing a finger stick blood glucose test on the client.

In completing a client's preoperative routine, the PN finds that the operative permit has not been signed. The client begins to ask more questions about the surgical procedure. What action should the PN take next? A.) Witness the client's signature on the permit. B.) Answer the client's questions about the surgery. C.) Inform the charge nurse that the client has questions about the surgery. D.) Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

C.) Inform the charge nurse that the client has questions about the surgery.

A client who has COPD is resting in a semi-Fowler's position with oxygen at 2L/min per nasal cannula. The client develops dyspnea. What actions should the PN implement first? A.) Call the healthcare provider B.) Obtain a bedside oximeter C.) Raise the head of the bed farther. D.) Assess the client's VS

C.) Raise the head of the bed.

The PN is reinforcing teaching for a school-age child and the child's parent regarding the administration of inhaled betamethasone dipropionate and albuterol for the treatment of asthma. Which statement by the parent indicates that teaching has been effective? A.) "I'll keep the inhalers in the refrigerator." B.) "We only need to use the inhalers when the peak flow numbers are in the red." C.) "We will take the bronchodilator first and then the corticosteroid." D.) "I will take the corticosteroid first, wait a few minutes, and then take the bronchodilator."

C.- A bronchodilator (Proventil & albuterol) is used to open up and relax constricted airways, making it easier to breathe. After the airways have been opened up and are more relaxed, the corticosteroid can be used. A: The parent should be storing inhalers at room temp. B: Maintenance asthma medications are prescribed for green zone peak flow numbers, and rescue medications are given during yellow and red zone. D: This is ineffective, and the parent needs to be retaught.

The PN is caring for a 16 year old with Down syndrome in a group home. The teenager has a functional age of 5. Which priority nursing action should be included in the plan of care? A.) Monitoring for hearing loss B.) Monitoring intake and output (I&O) C.) Providing a dependable routine D.) Providing a quiet environment

C.- A suitable, well-established, predictable schedule will help reduce anxiety. A,B,& D: This may be important but it is not the priority.

An adult client with a fracture of the femur is being discharged from the fast-track clinic after application of a plaster cast. The PN should reinforce with the client the need to use which method to dry the cast over the next 24 hours? A.) Place plastic wrap on the bottom of the cast to prevent sticking. B.) Support the cast on a firm surface during the night. C.) Keep the cast's surfaces exposed to circulating air. D.) Use a blow dryer set at low for 10 minutes every hour for four hours.

C.- Exposing the cast to air as much as possible aids in drying of the cast. A: Plastic wrap will not promote drying. B: Casts are supported on pillows to avoid indentations that will cause pressure on underlying skin. D: This will not effectively dry the cast.

Which action by the unlicensed assistive personnel requires immediate follow-up by the nurse? A.) Positions a client who is 12 hours postop above the knee amputation with the residual limb elevated on a pillow. B.) Assists a client with ambulation while the client uses a cane on the unaffected side. C.) Accompanies a client who has lupus erythematosus to sit outside in the sun during a break. D.) Helps a client with rheumatoid arthritis to the bathroom after the client takes Celebrex.

C.- Sunlight may trigger lupus and should be avoided. The nurse needs to instruct both the client and the UAP. A: This is correct positioning at 12 hours postop. B: This is correct use of the cane. D: Celebrex is an NSAID, with no contraindication for ambulation after administration.

The PN is reinforcing education to a client for coping with anxiety when the client is seen washing hands compulsively. What action should the PN take next? A.) Discuss alternatives to handwashing while the client continues washing hands. B.) Ask client to stop washing hands immediately. C.) Allow client to finish washing hands before teaching. D.) Ask client what triggered the handwashing.

C.- The best time for learning will be at the end of the impulsive behavior when the client's anxiety is lowest. A: Learning is impaired during compulsive acts that are used to alleviate anxiety, and interrupting the handwashing will only heighten the anxiety. B: Interrupting the client's behavior will increase his anxiety, which interferes with learning. D: Compulsions are uncontrollable acts used to deal with anxiety, a subjective feeling of unknown origin, and this will not help the nurse initiate a teaching plan.

The PN is reinforcing discharge teaching for parents of a 4-year-old with cystic fibrosis. Which statement by the parents demonstrates understanding of the teaching presented? A.) "We will discourage the child from playing outdoors." B.) "We will use pancreatic enzymes only if needed." C.) "We will thoroughly wash his hands when toileting." D.) "We will schedule a physical therapist evaluation."

C.- The child is at high risk for infection, and handwashing is the number one activity that can prevent contamination. A: Encouraging physical activity is important socially and physically for the child with CF. It can stimulate mucous excretion. B: Pancreatic enzymes are used regularly to replace the deficit caused by CF. D: ?

The PN and mental health technician are assigned a group of mental health clients to lead in bingo, a social activity. During the game, a client begins to complain of shortness of breath and dizziness. Which intervention should the nurse provide first? A.) Ask a technician to escort the client back to the unit. B.) Ask the client to describe current feelings. C.) Lead the client to a quiet area. D.) Request an additional staff member

C.- The nurse should take an anxious client to a location where there is reduced environmental stimuli away from the crowd. A: Sending the client to the unit will not enable the client to learn ways to cope with anxious feelings. B: The client may not be able to describe his feelings because increased autonomic hyperactivity impairs concentration and communication. D: Although this would be helpful, the priority is removing the client from the area causing the anxiety.

The charge nurse assigns the PN clients on the acute care unit. Which client should the PN assess first? A.) A client receiving oxygen per nasal cannula who is dyspneic with mild exertion and has a hemoglobin of 7g/dL. B.) A client receiving IV aminoglycosides per CVC who complains of nausea and has a trough level below therapeutic levels. C.) The client with heart failure with sudden onset of shortness of breath and a BNP level of 800pg/mL D.) A client receiving chemotherapy who has a temperature of 98.9F and a WBC count of 2500/mm3.

C.- These manifestations indicate worsening heart failure and this client is the priority and calls for an immediate assessment. A: This is an expected finding and does not require immediate follow-up by the nurse. B&D: Although these clients should be assessed, these are not the priority clients.

A client who has type 1 diabetes returns to the clinic for follow-up after dietary counseling. The client states that he has been managing his diabetes closely. Which laboratory result indicates the client is maintaining tight control over the disease? A.) FBS changes from 135 to 110 mg/dL B.) SMBG (serum monitor for blood glucose) at bedtime changes from 45 to 90 mg/dL. C.) Glycosylated hemoglobin (hemoglobin A1c) changes from 9% to 6%. D.) Urine ketones change from 0 to 3

C.- This is the best indicator of long-term diabetic control, and values less than 7% indicate tight diabetic control over the past 3 months. A: The fasting blood sugar is an improved value that reflects current serum glucose levels, but it is not the best indicator of long-term control. B: The serum monitor for blood glucose is also an improved value, since 45 is too low, but this is not the best indicator of disease control. D: This indicates fat mobilization related to hyperglycemia, which needs further assessment of glucose levels.

A client's suspected pregnancy is confirmed. The client tells the PN that she has had previous pregnancies: She delivered a single child at 39 weeks, twins at 34 weeks, and a single child at 35 weeks. Using the GTPAL notation system, how should the PN record the client's gravidity and parity? A.) 3-0-3-0-3 B.) 3-1-1-1-3 C.) 4-1-2-0-4 D.) 4-2-1-0-3

C.- This reflects the total number of times the woman has been pregnant; she is pregnant for the 4th time. T indicates the number of pregnancies carried to term, not the number of deliveries at term; she has had only one pregnancy result in a fetus at term. P is the number of pregnancies that resulted in a preterm birth; she has had 2 pregnancies where she delivered preterm. A signifies if the woman has had any abortions or miscarriages prior to the period of viability; she did not. L signifies the number of children born that are currently living; she has 4 children. 4th pregnancy, 1 term pregnancy, 2 preterm pregnancies, 0 abortions, 4 living children; 4-1-2-0-4.

A client with an obstruction of the common bile duct caused by cholelithiasis passes clay-colored stools containing streaks of fat. What action should the PN take? A.) Auscultate for diminished bowel sounds. B.)Send a stool specimen to the laboratory. C.) Document the assessment in the chart. D.)Notify the healthcare provider.

C.-This is an expected finding and should be documented as part of the nursing assessment. A:Diminished bowel sounds, inability to pass gas, and/or nausea and vomiting may indicate bowel obstruction, not obstruction of the common bile duct. B:This type of stool is not unusual in obstruction of the common bile duct, so it is not necessary to send stool to the lab. D:This is not a deviation from the normal course of the disease, so it is not necessary to notify the healthcare provider.

The charge nurse is assigning rooms for four new clients. Only one private room is available on the oncology unit. Which client should the PN expect to be placed in the private room? A.)The client with ovarian cancer who is receiving chemotherapy. B.) The client with breast cancer who is receiving external beam radiation. C.) The client with prostate cancer who has just had a transurethral resection D.) The client with cervical cancer who is receiving intracavitary radiation.

D - Clients with intracavity radiation need a private room to assure protection from radiation for other clients and staff.

The PN checks a client's abdominal surgical incision for signs of infection. Which sign or symptom would indicate an infection? Select all that apply... A.) The client refuses to cough and breathe deeply as directed. B.) The client complains of pain level of 7 on a scale of 1 to 10. C.) A moderate amount of serosanguineous drainage is present of the gauze dressing. D.) The client complains of chills and tremors. E.) The client's vital signs are: temperature, 100.4F(38C); Pulse, 106bpm; respirations, 20 breaths per min.

D,E - These are signs of infection A: This behavior increases the likelihood of atelectasis. B: Pain is expected related to the surgical incision. C:Drainage is expected.

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristics of which thoughts? A.) The false belief that one is a very powerful person. B.) The false belief that one is a very important person C.) The false belief that one's partner is being unfaithful D.) The false belief that one is being singled out for harm by others

D. A delusion is a false belief held to be true even when there is evidence to the contrary. A delusion of persecution is the thought that one is being singled out for harm by others. A delusion of grandeur is the false belief that he or she is a very powerful and important person. A delusion of jealousy is the false belief that one's partner is being unfaithful.

The client with small cell lung cancer is being treated with etoposide and the nurse is assisting with caring for the client during administration. The client gets up to use the bathroom and is dizzy and very weak. The nurse understands these symptoms are likely as a result of which side/adverse effect that is specifically associated with this medication? A.) Alopecia B.) Chest Pain C.) Pulmonary fibrosis D.) Orthostatic Hypotension

D. A side effect specific to etoposide is orthostatic hypotension. The client's blood pressure is monitored during the infusion. Hair loss occurs with nearly all antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication.

A client is receiving acetylcysteine, 20% solution diluted in 0.9% normal saline by nebulizer. The nurse should have which item available for a possible adverse event after giving this medication? A.) Ambu bag B.) Intubation tray C.) Nasogastric tube D.) Suction equipment

D. Acetylcysteine can be given orally or by nasogastric tube to treat acetaminopen overdose, or it may be given by inhalation for use as a mucolytic. The nurse administering this medication as a mucolytic should have suction equipment available in case the client cannot manage to clear the increased volume of liquefied secretions.

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group? A.) Al-Anon B.) Fresh start C.) Families Anonymous D.) Alcoholics Anonymous

D. Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option A is a group for families of alcoholics. Option B is for nicotine addicts. Option C is for parents of children who abuse substances.

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding? A.) Normal B.) Regressive C.) Indicative of the client's ambivalence D.) Evidence of the client's altered and distorted body image

D. Altered or distorted body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and present with regressed behavior, the client's coping pattern relates to the basic issue of distorted body image. The client's behavior is not normal.

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response? A.) A crisis state indicates that the individual is suffering from a mental illness. B.) A crisis state indicates that the individual is suffering from an emotional illness. C.) Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis. D.) A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

D. Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person because each is a unique individual. Being in a crisis state does not mean that the client is suffering from an emotional or mental illness.

The nurse reinforced discharge instructions to a postoperative client who is taking warfarin sodium. Which statement made by the client reflects the need for further teaching? A.) "I will take my pills every day at the same time." B.) "I will be certain to avoid alcohol consumption." C.) "I have already called my family to pick up a MedicAlert bracelet." D.) "I will take enteric-coated aspirin for my headaches because it is coated."

D. Aspirin-containing products should be avoided while taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The MedicAlert bracelet provides health care personnel with emergency information.

Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it developed during the course of this medication therapy? A.) Nausea B.) Diarrhea C.) Headache D.) Sore Throat

D. Clients taking trimethoprim-sulfamethoxazole should be informed about early signs of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the PHCP if these symptoms occur. The other options do not require PHCP notification.

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client? A.) "Have you talked to your family about this?" B.) "Everyone feels this way when they are depressed." C.) "You will feel better once your medication begins to work." D.) "You sound very upset. Are you thinking of hurting yourself?"

D. Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The client should be directly asked if a plan for self-harm exists. Options A,B, and C are not therapeutic responses.

The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student indicates a need to further research the disorder? A.) Dental erosion B.) Electrolyte imbalances C.) Enlarged parotid glands D.) Body weight well below ideal range

D. Clients with bulimia nervosa may not initially appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. During further inspection, the client demonstrates enlargement of the parotid glands with dental erosion and caries if he or she has been inducing vomiting. Electrolyte imbalances are present.

The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse should give which reply? A.) "In 7 days" B.) "In 14 days" C.) "In 21 days" D.) "Within a few hours"

D. Early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peak after 24 to 48 hours.

The client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determine that the client should be questioned about the use of which class of medications? A.) Diuretics B.) Antibiotics C.) Antitussives D.) Decongestants

D. Episodes of urinary retention can be triggered by certain medications such as decongestants , anticholingergics, and antidepressants. Diuretics, antibiotics, and antitussives generally do not trigger urinary retention. Retention also can be precipitated by other factors such as alcoholic beverages, infection, bed rest, and becoming chilled.

A client is taking nicotinic acid for hyperlipidemia, and the nurse reinforces instruction to the client about the medication. Which statement by the client indicates an understanding of the instructions? A.) "It is not necessary to avoid the use of alcohol." B.) "The medication should be taken with meals to decrease flushing." C.) "Clay-colored stools are a common side effect and should not be of concern." D.) "Ibuprofen taken 30 minutes before the nicotinic acid should decrease the flushing."

D. Flushing is a side effect of this medication. Aspirin or a nonsteroidal antiinflammatory drug can be taken 30 minutes before taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals; this will decrease gastrointestinal upset. Taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the PHCP.

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation? A.) Poor dietary choices B.) Lack of exercise and poor diet C.) Inadequate dietary intake and dehydration D.) Psychomotor retardation and side effects of medication

D. In this situation, urinary retention is most likely caused by medications. Option D is the only option that addresses both constipation and urinary retention. Constipation can be related to inadequate food intake, lack of exercise, and poor diet.

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse contacts the primary health care provider who prescribed the medication if which condition is documented in the client's medical history? A.) Hypotension B.) Hypothyroidism C.) Diabetes Mellitus D.) Peripheral vascular disease

D. Methylergonovine is an ergot alkloid used to trat postpartum hemorrhage. Ergot alkaloids are contraindicated in clients with significant cardiovascualr disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options A,B,and C are not contraindications related to the use of ergot alkaloids.

The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine. Which statement made by the client indicates the need for further teaching? A.) "Constipation and bloating might be a problem." B.) "I'll continue to watch my diet and reduce my fats." C.) "Walking a mile each day will help the whole process." D.) "I'll continue my nicotinic acid from the health food store."

D. Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalitis. All lipid -lowering medications can also cause liver abnormalities so a combination of nicotinic acid and cholestyramine resin is to avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.

The client has an as needed prescription for ondansetron. For which condition should the nurse administer this medication? A.) Paralytic Ileus B.) Incisional pain C.) Urinary retention D.) Nausea and vomiting

D. Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. The other options are incorrect

Rh(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? A.) Having Rh-positive blood B.) Developing a rubella infection C.) Developing physiological jaundice D.) Being affected by Rh incompatibility

D. Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the fetus's Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurse? A.) Glucose level of 99mg/dL (5.5mmol/L) B.) Platelet level of 300,000 mm3 (300 x 10/L) C.) Magnesium level of 1.5 mEq/L (0.75 mmol/L) D.) White blood cell count of 3000mm3 (3.0 x 10/L)

D. Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-screen or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the PHCP is notified and the med is usually discontinued. The white blood cell count noted in option D is indicative of leukopenia. The other laboratory values are not specific to this med, and are also within normal limits.

The client with a gastric ulcer has a prescription for sucralfate 1g by mouth four times dialy. The nurse should schedule the medication to be administered at which times? A.) With meals and at bedtime B.) Every 6 hours around the clock. C.) One hour after meals and at bedtime D.) One hour before meals and at bedtime

D. Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect.

Tamoxifen is prescribed for the client with metastatic breast carcinoma. The nurse understands that which is the primary action of this medication? A.) Increase DNA and RNA synthesis B.) Promote the biosynthesis of nucleic acids. C.) Increase estrogen concentration and estrogen response D.) Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors

D. Tamoxifen is an antineoplastic medication that competes with estradiol for binding estrogen in tissues containing high concentrations of receptors. Tamoxifen reduces DNA synthesis and estrogen response.

Heparin sodium is prescribed for the client. Which laboratory result indicates that the heparin is prescribed at a therapeutic level? A.) Thrombocyte count of 100,000 mm3. B.) Prothrombin time (PT) of 21 seconds C.) International normalized ratio (INR) of 2.3 D.) Activated partial thromboplastin time (aPTT) of 55 seconds

D. The aPTT will assess the therapeutic effect of heparin sodium. The normal aPTT is 30 to 40 seconds. To maintain a therapeutic level, the aPTT should be 1.5 to 2.5 times the normal value. The PT and INR will assess for the therapeutic effect of warfarin sodium. A decreased thrombocyte count can cause bleeding.

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? A.) "Right! Why not just 'pack it in'? B.) "That seems rather unlikely to me." C.) "I don't believe that, and neither do you." D.) "You must be feeling all alone at this point."

D. The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. In option A, the nurse uses sarcasm, which gives advice and is nontherapeutic as a nursing response. In option B, the nurse is voicing doubt, which is often used when a client verbalizes delusional ideas. In option C, the nurse is disagreeing with the client, which implies that the nurse has passed judgment on the client's ideas or opinions.

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care? A.) Facing the client when providing care. B.) Ensuring that a security officer is within the immediate area C.) Keeping the door to the client's room open when with the client D.) Assigning the client to a room at the end of the hall to prevent disturbing the other clients.

D. The client should be placed in a room near the nurses' station and not at the end of a long, relatively unprotected corridor. The nurse should not isolate himself or herself with a potentially violent client. The door to the client's room should be kept open, and the nurse should never turn away from the client. A security officer or male aide should be within immediate call in case the possibility of violence is suspected.

A client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response? A.) "It sounds as though you need to speak to the psychiatrist." B.) "Perhaps you'd like to see the ECT room and speak to the staff." C.) "Your child has decided to have this treatment. You should be supportive of the decision." D.) "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

D. The nurse needs to encourage the family and client to verbalize their fears and concerns. Option D is the only option that encourages verbalization. Options A,B, and C avoid dealing with the client or family concerns.

Phenazopyridine hydrochloride is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. Which should the nurse reinforce to the client? A.) Take the medication at bedtime B.) Take the medication before meals C.) Discontinue the medication if a headache occurs. D.) A reddish-orange discoloration of the urine may occur.

D. The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of GI upset. A headache is an occasional side effect of the med and does not warrant discontinuation of the medication.

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which symptoms? A.) Hypotension, ataxia, vomiting B.) Stupor, agitation, muscular rigidity C.) Hypotension, bradycardia, agitation D.) Hypertension, disorientation, hallucinations

D. The symptoms associated with alcohol withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions.

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement? A.) "My medications won't make me anxious." B.) "I'll go to a support group and talk so that I won't hurt anyone." C.) "I won't get anxious or hear things if I get enough sleep and eat well." D.) "I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."

D. There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination. Option D is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior.

Oxybutynin chloride is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication? A.) Pallor B.) Drowsiness C.) Bradycardia D.) Restlessness

D. Toxicity (overdose) of this medication produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdose.

The client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which adverse effect is specific to this medication? A.) Diarrhea B.) Hair loss C.) Chest pain D.) Extremity numbness

D. Vincristine is a vinca alkaloid antineoplastic (miotic inhibitor) medication that has an adverse effect, specifically peripheral neuropathy. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation, rather than diarrhea, is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all the antineoplastic medications. Chest pain is unrelated to this medication.

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? A.) Call the client's family B.) Place the client in seclusion immediately C.) Inform the client that seclusion has not been prescribed. D.) Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent.

D. A client may request to be secluded or restrained. Federal laws require the consent of the client unless an emergency situation exists in which an immediate risk to the client or others can be documented. The use of seclusion and restraint is permitted only with the written prescription of the PHCP, which must be reviewed and renewed every 24 hours, depending on state law requirements. It must also specify the type of restraint to be used.

The camp nurse asks the children preparing to swim in the lake if they ahve applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? A.) Immediately before swimming B.) 5 minutes before exposure to the sun C.) Immediately before exposure to the sun D.) At least 30 minutes before exposure to the sun

D. Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

An elderly client with a percutaneous gastrostomy feeding tube is admitted from a nursing home to the hospital. The client has altered mental status, dehydration, and fever. In caring for this client, the nurse should be alert to which priority condition? A.) Cardiogenic shock B.) Acute renal failure C.) Glomerulonephritis D.) Urinary tract infection

D. - Change in cognitive state, dehydration, and fever support the diagnosis of UTI. A: Client is at risk for SEPTIC shock B: The manifestations the client is exhibiting do not reflect acute renal failure. C: Generalized body edema, hypertension, oliguria, hematuria with a smoky or rusty appearance, and proteinuria occur in glomerulonephritis.

During the evaluation, which assessments indicate a late sign of increased ICP for a client newly diagnosed with a head injury? Select all that apply... A.) Alteration in the ability to respond to questions B.) Alteration in the ability to swallow liquids C.) Consensual response of pupils D.) Heart rate, 50; BP, 192/60 E.) Drooping of the mouth on one side

D. - This is considered a late sign. Wide pulse pressure, bradycardic. A&B: This sign is an early sign of increased ICP. C: This is a normal response E: Facial weakness may occur as a sign of stroke.

Which situation warrants a variance (incident) report by the PN? A.) Refusal by a client to take prescribed medication. B.) Improved status before completion of the course of medication. C.) An allergic reaction to a prescribed medication. D.) A client received medication prescribed for another client.

D.) A client received medication prescribed for another client.

A client who has hyperparathyroidism is scheduled to receive a prescribed dose of oral phosphate. The PN notes that the client's serum calcium level is 12.5 mg/dL. What action should the PN implement? A.) Hold phosphate and notify the healthcare provider B.) Review client's serum parathyroid hormone level. C.) Give a PRN dose of IV calcium per protocol. D.) Administer the dose of oral phosphate.

D.) Administer the dose of oral phosphate.

A client at 15 weeks' gestation is admitted for an inevitable abortion. Thirty minutes after her return from surgery, her vital signs are stable. Which nursing intervention has the highest priority? A.) Ask the client whether she would like to talk about losing her baby. B.) Place cold cabbage leaves on the client's breasts to reduce breast engorgement. C.) Send a referral to the grief counselor for at-home follow-up. D.) Confirm the client's Rh and Coombs status and administer RhoGAM if indicated.

D.) Confirm the client's Rh and Coombs status and administer RhoGAM if indicated.

Which nursing action has the highest priority for an infant immediately after birth? A.) Place the infant's head in the sniffing position and give oxygen via face mask. B.) Perform a bedside glucose test and feed the infant glucose water as needed. C.) Assess the heart rate and perform chest compressions if the rate is below 60 bpm D.) Dry the infant and place him or her under a radiant warmer or skin to skin with the mother.

D.) Dry the infant and place him or her under a radiant warmer or skin to skin with the mother.

A family member of a client who is in a Posey vest restraint (SRD) asks why the restraint was applied. How should the practical nurse respond? A.)The restraint was prescribed by the healthcare provider. B.) There are not enough staff members to keep the client safe all the time. C.) The other clients are upset when another client wanders. D.) The client's actions place her at high risk for harming herself.

D.) The client's actions place her at high risk for harming herself.

The healthcare provider prescribes the anticonvulsant phenytoin for an adolescent with a seizure disorder. The nurse should instruct the client to notify the healthcare provider if which condition develops? A.) Dry mouth B.) Dizziness C.) Sore throat D.) Gingival hyperplasia

D.- Clients taking phenytoin are especially prone to the development of gingival hyperplasia. A,B,&C: These are not side effects of phenytoin.

A 2-year-old child's blood work is evaluated by the PN. Considering that the child is prescribed furosemide, captopril, and Lanoxin for congestive heart failure, which value should the PN verify with the laboratory? A.) Hypocalcemia B.) Hypernatremia C.) Low hemoglobin D.) Hypokalemia

D.- Furosemide and digoxin in combination can deplete potassium stores and place the client at risk for digoxin toxicity. A: This is an expected outcome. B: Hyponatremia is expected, but this is a possibility if too much Lasix. Potassium is the greater concern. C: This combination does not affect hemoglobin.

A client who has acute renal failure is admitted to the hospital. The client's potassium level is 6.4 mEq/L. Which snack should the practical nurse offer? A.) An orange B.) A milkshake C.) Dried fruit and nuts D.) A gelatin dessert

D.- Gelatin contains little or no potassium. This is the best choice for this client. A: Oranges are a primary source of potassium, and should not be offered to the client with hyperkalemia. B: Milk products contained in a milkshake will further elevate the serum potassium (normal range 3.5-5.5 mEq/L). C: Dried fruit and nuts are a quick and portable source of potassium, but this client does not need added potassium.

A school-age child with nephrotic syndrome is seen at the clinic 2 days after discharge from the hospital. Which assessment is most important after discharge? A.) Pain B.) Capillary refill C.) Urine ketones D.) Daily weights

D.- Obtaining weight would inform the nurse about fluid balance. A: Although the client may complain of pain with insertion of the catheter or needle, this assessment is not a priority. B: Not a priority assessment. C: Hypoproteinemia stimulates protein synthesis in the liver, resulting in production of lipoproteins which spill over in the urine.

The PN walks into a hospital room and observes a teenage client experiencing a tonic-clonic seizure. Which intervention should the nurse provide first? A.) Restrain the client to protect against injury. B.) Flex the neck to ensure stabilization C.) Use a tongue blade to open the airway D.) Turn the client on side to aid ventilation

D.- The most important intervention is to turn the client to the side to maintain the airway. A: Restraining the client may cause injury during the seizure. B: Flexing the neck may block the airway. C: No objects should be placed in the client's mouth.

A female client who has just learned that she has breast cancer tells her family that the biopsy result was negative. What action should the nurse take? A.) Remind the client that the result was positive. B.) Ask the client to restate what the healthcare provider told her. C.) Talk to the family about the client's need for family support. D.) Encourages the client to talk to the nurse about her fears.

D.- The nurse can provide the client with a safe place to share her concerns and obtain support until she is ready to abandon denial as a defense mechanism. A: This does not allow the client to use denial as a defense mechanism, which she apparently needs at this time. B: This is argumentative. C: This approach may provide information that the client is not ready to share and lead to a violation of HIPPA.

Which client should the practical nurse collect data from first? A.) The client with hyperthyroidism who has exopthalmos. B.) The client with diabetes type 1 who has an inflamed foot ulcer. C.) The client with Cushing's syndrome who has moon facies. D.) The client with Addison's disease who has tremors and diaphoresis.

D.- The nurse should assess this client first because hypoglycemia is seen with Addison's and can be life-threatening. A: This is a nonreversible manifestation. B: This is a serious problem warranting action but is not immediately life threatening. C: This is not a life-threatening manifestation

Which change in the status of a client being treated for increased ICP warrants immediate action by the PN? A.) Urinary output increases from 20 to 50 mL/hr. B.) Arterial Po2 increases from 80 to 90 mm Hg. C.) Glasgow Coma Scale score changes from 5 to 7. D.) Pulse drops from 88 to 68 beats/min.

D.- This is a negative finding, and a component of Cushing's triad, which may indicate increasing ICP. A: This is a positive outcome, probably secondary to diuretic administration. B: This is a positive outcome, probably secondary to mechanical ventilation. C: This is a positive outcome, indicating an improvement in neuro status.

An adult client is admitted to the inpatient mental health unit for severe depression. Although the client has agreed to electroconvulsive therapy (ECT), the client's partner states, "I've heard that ECT destroys neurons and that memory loss is significant." Which response by the practical nurse is most helpful? A.) I'll contact the nursing supervisor for you. B.) Talking with the ECT staff may help you feel more comfortable. C.) I think you should show support for your partner. D.) Perhaps you and I can discuss your concerns about ECT.

D.- This response recognizes the partner's distress and offers the partner an opportunity to express it in a nonthreatening manner. A: The PN is capable of listening to the partner without escalation to the supervisor. B: This may be helpful at a later time but may provoke more anxiety at this time. C: This is judgmental and a nontherapeutic response.

A 4 year old is brought to the clinic with a fever of 103F, a sore throat, and moderate respiratory distress caused by a suspected bacterial infection. Which medical diagnosis is contraindicated to obtaining a throat culture in the child? A.) Tonsillitis B.) Streptococcal infection C.) Bronchoiolitis D.) Epiglottitis

D.- To avoid airway compromise, do not culture the child's throat. A: A throat culture is performed to rule out group A hemolytic streptococci. B: Throat cultures are commonly performed to differentiate between GABHS infection, which warrant antibiotic therapy and a viral infection where no antibiotic treatment is required. C: Although throat cultures are not commonly performed in broniolitis, they are not contraindicated.

A postoperative client has received a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse should check the client for which sign/symptom? A.) Pupillary changes B.) Scattered lung sounds C.) Sudden increase in pain D.) Sudden episodes of diarrhea

Naloxone hydrochloride is an antidote to opioids and may also be given to the postoperative client to treat respiratory depression. When given to the postoperative client for respiratory depression, it may also reverse the effects of analgestics. Therefore, the nurse must check the client for a sudden increase in the level of pain experienced. Options A,B, and D are not associated with this medication.