NCLEX LIPPINCOTT FINAL
A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet? A-Lean Beef B-Air Pop Corn
C-Hot Chocolate D-Raw Vegetables Correct: C
Reason: With GERD, eating substances that decrease lower esophageal sphincter pressure causes heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be acceptable.
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
a) Sit with the client for a few minutes.
b) Administer an analgesic.
c) Inform the nurse manager.
d) Call the physician immediately.
CORRECT ANSWER d) Call the physician immediately. Reason: The nurse should notify the physician immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
a) Endotracheal suctioning b) Encouragement of coughing c) Use of a cooling blanket d) Incentive spirometry Check my Answer
CORRECT ANSWER a) Endotracheal suctioning Reason: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should understand that acupuncture in the Asian culture is based on the theory that it:
a) Purges evil spirits. b) Promotes tranquility. c) Restores the balance of energy. d) Blocks nerve pathways to the brain.
CORRECT ANSWER c) Restores the balance of energy. Reason: Acupuncture, like acumassage and acupressure, is performed in certain Asian cultures to restore the energy balance within the body. Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance. Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many researchers think that the gate-control theory of pain may explain the success of acupuncture, acumassage, and acupressure.
A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved?
a) The entry should include clearer descriptions of the client's mood and behavior. b) The entry should avoid mentioning cognitive or psychosocial issues. c) The entry should list the specific reasons that the client was upset. d) The entry should specify the subsequent interventions that were performed.
a) The entry should include clearer descriptions of the client's mood and behavior. Reason: Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.
A nurse facilitated a mandated group therapy for clients who have sexually abused children. Children who are victims of sexual abuse are typically?
a) from any segment of the population b) of low socioeconomic background. c) strangers to the abuser.
d) willing to engage in sexual acts with adults.
CORRECT ANSWER a) from any segment of the population. Reason: Victims of childhood sexual abuse come from all segments of the population and from all socioeconomic backgrounds. Most victims know their abuser. Children rarely willingly engage in sexual acts with adults because they don't have full decision-making capacities.
A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. Which of the following should the nurse do upon the client's arrival?
a) Position the client in a supine position. b) Auscultate breath sounds every 4 hours. c) Monitor the vital signs every 4 hours. d) Admit the client to a quiet, darkened room.
a) Position the client in a supine position. b) Auscultate breath sounds every 4 hours. c) Monitor the vital signs every 4 hours. d) Admit the client to a quiet, darkened room.
CORRECT ANSWER d) Admit the client to a quiet, darkened room. Reason: Because of her age and report of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the absence of any underlying cause. Although the actual cause is unknown, adolescents and women older than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible.
Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema, breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least every hour.
Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?
a) The client will be maintained on bed rest for several days. b) Ambulation is restricted by the presence of drainage tubes. c) The operative incision is near the diaphragm. d) The presence of a nasogastric tube inhibits
CORRECT ANSWER c) The operative incision is near the diaphragm. Reason: The incisions made for upper abdominal surgeries, such as cholecystectomies, are near the diaphragm and make deep breathing painful. Incentive spirometry, which encourages deep breathing, is essential to prevent atelectasis after surgery. The client is not maintained on bed rest for several days. The client is encouraged to ambulate by the first postoperative day, even with drainage tubes in place. Nasogastric tubes do not inhibit deep breathing and coughing.
A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?
a) Diaphragmatic breathing
b) Use of accessory muscle
c) Pursed-lip breathing
d) Controlled breathing
CORRECT ANSWER
b) Use of accessory muscles Reason: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?
a) Trendelenburg's b) 30-degree head elevation c) Flat d) Side-lying
CORRECT ANSWER b) 30-degree head elevation Reason: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP
A nurse is developing a nursing diagnosis for a client. Which information should
a) Actions to achieve goals b) Expected outcomes c) Factors influencing the client's problem d) Nursing history
CORRECT ANSWER
c) Factors influencing the client's problem Reason: A nursing diagnosis is a written statement describing a client's actual or potential health problem. It includes a specified diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the evaluation step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process.
The nurse meets with the client and his wife to discuss depression and the client's medication. Which of the following comments by the wife would indicate that the nurse's teaching about disease process and medications has been effective?
a) "His depression is almost cured." b) "He's intelligent and won't need to depend on a pill much longer.
c) Ut's important for him to take his medication so that the depression will not return or get worse.d) "It's important to watch for physical dependency on Zoloft."
CORRECT ANSWER c) "It's important for him to take his medication so that the depression will not return or get worse." Reason: Improved balance of neurotransmitters is achieved with medication. Clients with endogenous depression must take antidepressants to prevent a return or worsening of depressive symptoms. Depression is a chronic disease characterized by periods of remission; however, it is not cured. Depression is not dependent on the client's intelligence to will the illness away. Zoloft is not physically addictive.
A nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to:
a) start using insulin. b) start taking an oral antidiabetic drug. c) monitor her urine for glucose. d) be taught about diet.
CORRECT ANSWER d) be taught about diet. Reason: The client will need to watch her overall diet intake to control her blood glucose level. The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. Oral antidiabetic drugs aren't used in pregnant clients. Urine glucose levels aren't an accurate indication of blood glucose levels.
A nurse preceptor is working with a student nurse who is administering medications. Which statement by the student indicates an understanding of the action of an antacid:
a) "The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity." b) "The action occurs in the small intestine, where the drug coats the lining and prevents further ulceration." c) "The action occurs in the esophagus by increasing peristalsis and improving movement of food into the stomach." d) "The action occurs in the large intestine by increasing electrolyte absorption into the system that decreases pepsin absorption."
CORRECT ANSWER a) "The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity." Reason: The action of an antacid occurs in the stomach. The anions of an antacid combine with the acidic hydrogen cations secreted by the stomach to form water, thereby increasing the pH of the stomach contents. Increasing the pH and decreasing the pepsin activity provide symptomatic relief from peptic ulcer disease. Antacids don't work in the large or small intestine or in the esopha
Which of the following statements would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?
a) Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks. b) Activity level is determined by the client's tolerance; she can be as active as she wishes. c) Activity level will be restricted for several months, so she should plan on being sedentary. d) Activity level can return to normal and may include regular aerobic exercises.
CORRECT ANSWER a) Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks. Reason: The scarring of the retinal tear needs time to heal completely. Therefore, resumption of activity should be gradual; the client may resume her usual activities in 5 to 6 weeks. Successful healing should allow the client to return to her previous level of functioning.
A parent brings a 5-year-old child to a vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. To determine the current evidence for best practices for scheduling missed vaccinations the nurse should:
a) Ask the primary care provider. b) Check the website at the Center for Disease Control and Prevention (CDC). c) Read the vaccine manufacturer's insert. d) Contact the pharmacist.
CORRECT ANSWER b) Check the website at the Center for Disease Control and Prevention (CDC). Reason: The CDC is the federal body that is ultimately responsible for vaccination recommendations for adults and children. A division of the CDC, the Advisory Committee on Immunization Practices, reviews vaccination evidence and updates recommendation on a yearly basis. The CDC publishes current vaccination catch-up schedules that are readily available on their website. The lack of vaccinations is a strong indicator that the child probably does not have a primary care provider. If consulted, the pharmacist would most likely have to review the CDC guidelines that are equally available to the nurse. Reading the manufacturer's inserts for multiple vaccines would be time consuming and synthesis of the information could possibly lead to errors.
A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem?
a) Abruptio placentae. b) Placenta previa. c) Disseminated intravascular coagulation. d) Threatened abortion.
CORRECT ANSWER c) Disseminated intravascular coagulation. Reason: A fetus that has died and is retained in utero places the mother at risk for disseminated intravascular coagulation (DIC) because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. The longer the fetus is retained in utero, the greater the risk of DIC. This client has no risk factors, history, or signs and symptoms that put her at risk for either abruptio placentae or placenta previa, such as sharp pain and "woody," firm consistency of the abdomen (abruption) or painless bright red vaginal bleeding (previa). There is no evidence that she is threatening to abort as she has no complaints of cramping or vaginal bleeding.
Which of the following client statements indicates that the client with hepatitis B understands discharge teaching?
a) "I will not drink alcohol for at least 1 year." b) "I must avoid sexual intercourse." c) "I should be able to resume normal activity in a week or two. d) "Because hepatitis B is a chronic disease, I know I will always be jaundiced."
CORRECT ANSWER a) "I will not drink alcohol for at least 1 year." Reason: It is important that the client understand that alcohol should be avoided for at least 1 year after an episode of hepatitis. Sexual intercourse does not need to be avoided, but the client should be instructed to use condoms until the hepatitis B surface antigen measurement is negative. The client will need to restrict activity until liver function test results are normal; this will not occur within 1 to 2 weeks. Jaundice will subside as the client recovers; it is not a permanent condition.
During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients take an active role in their health care?
a) Ask clients to complete a questionnaire.
b) Provide clients with written instructions.
c) Ask clients for their description of events and for their views concerning past medical care.
d) Ask clients if they have any questions.
CORRECT ANSWER c) Ask clients for their description of events and for their views concerning past medical care. Reason: One of the best strategies to help clients feel in control is to ask them their view of situations, and to respond to what they say. This technique acknowledges that clients' opinions have value and relevance to the interview. It also promotes an active role for clients in the process. Use of a questionnaire or written instructions is a means of obtaining information but promotes a passive client role. Asking whether clients have questions encourages participation, but alone it does not acknowledge their views.
The nurse has discussed sexuality issues during the prenatal period with a primigravida who is at 32 weeks' gestation. She has had one episode of preterm labor. The nurse determines that the client understands the instructions when she says:
a) "I can resume sexual intercourse when the bleeding stops. b) I should not get sexually aroused or have any nipple stimulation. c) "I can resume sexual intercourse in 1 to 2 weeks." d) "I should not have sexual intercourse until my next prenatal visit."
CORRECT ANSWER b) "I should not get sexually aroused or have any nipple stimulation." Reason: This client has already had one episode of preterm labor at 32 weeks' gestation. Sexual intercourse, arousal, and nipple stimulation may result in the release of oxytocin which can contribute to continued preterm labor and early delivery. The client should be advised to refrain from these activities until closer to term, which is 6 to 8 weeks later. Telling the client that intercourse is acceptable after the bleeding stops is incorrect and may lead to early delivery of a preterm neonate. The client should not have intercourse for at least 6 weeks because of the danger of inducing labor. There is no indication when the client's next prenatal visit is scheduled.
Category: Gastrointestinal DisordersWhich of the following interventions would be most appropriate for the nurse to recommend to a client to decrease discomfort from hemorrhoids?
a) Decrease fiber in the diet.
b) Take laxatives to promote bowel movements.
c) Use warm sitz baths.
d) Decrease physical activity.
CORRECT ANSWER c) Use warm sitz baths. Reason: Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids. Fiber in the diet should be increased to promote regular bowel movements. Laxatives are irritating and should be avoided. Decreasing physical activity will not decrease discomfort.
The nurse is serving on the hospital ethics committee which is considering the ethics of a proposal for the nursing staff to search the room of a client diagnosed with substance abuse while he is off the unit and without his knowledge. Which of the following should be considered concerning the relationship of ethical and legal standards of behavior?
a)Ethical standards are generally higher than those required by law.b)Ethical standards are equal to those required by law.c)Ethical standards bear no relationship to legal standards for behavior.d)Ethical standards are irrelevant when the health of a client is at risk.
CORRECT ANSWER a) Ethical standards are generally higher than those required by law. Reason: Some behavior that is legally allowed might not be considered ethically appropriate. Legal and ethical standards are often linked, such as in the commandment "Thou shalt not kill." Ethical standards are never irrelevant, though a client's safety or the safety of others may pose an ethical dilemma for health care personnel. Searching a client's room when they are not there is a violation of their privacy. Room searches can be done with a primary health care provider's order and generally are done with the client present.
A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching?
a) "I'll increase my intake of protein during exacerbations. b) "I should increase my intake of fresh fruits and vegetables during remissions." c) "I'll snack on nuts, olives, and popcorn during flare-ups." d) "I'll incorporate foods rich in omega-3 fatty acids into my diet."
" CORRECT ANSWER b) "I should increase my intake of fresh fruits and vegetables during remissions." Reason: A client with diverticulitis needs to modify fiber intake to effectively manage the disease. During episodes of diverticulitis, he should follow a low-fiber diet to help minimize bulk in the stools. A client with diverticulosis should follow a high-fiber diet. Clients with diverticular disease don't need to modify their intake of protein and omega-3 fatty acids.
The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect which of the following:
a) Increased forced expiratory volume.
b) Normal breath sounds.
c) Inspiratory and expiratory wheezing.
d) Morning headaches.
CORRECT ANSWER c) Inspiratory and expiratory wheezing. Reason: The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations, there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume [forced expiratory flow (FEF) is the flow (or speed) of air coming out of the lung during the middle portion of a forced expiration] due to bronchial constriction. Morning headaches are found with more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia.
Which of the following laboratory findings are expected when a client has diverticulitis?
a) Elevated red blood cell count.
b) Decreased platelet count.
c) Elevated white blood cell count.
d) Elevated serum blood urea nitrogen concentration.
CORRECT ANSWER c) Elevated white blood cell count. Reason: Because of the inflammatory nature of diverticulitis, the nurse would anticipate an elevated white blood cell count. The remaining laboratory findings are not associated with diverticulitis. Elevated red blood cell counts occur in clients with polycythemia vera or fluid volume deficit. Decreased platelet counts can occur as a result of aplastic anemias or malignant blood disorders, as an adverse effect of some drugs, and as a result of some heritable conditions. Elevated serum blood urea nitrogen concentration is usually associated with renal conditions.
When developing a care plan for a client with a do-not-resuscitate (DNR) order, a nurse should:
a) withhold food and fluids.
b) discontinue pain medications.
c) ensure access to spiritual care providers upon the client's request.
d) always make the DNR client the last in prioritization of clients.
CORRECT ANSWER c) ensure access to spiritual care providers upon the client's request. Reason: Ensuring access to spiritual care, if requested by the client, is an appropriate nursing action. A nurse should continue to administer appropriate doses of pain medication as needed to promote the client's comfort. A health care provider may not withhold food and fluids unless the client has a living will that specifies this action. A DNR order does not mean that the client does not require nursing care.
A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent?
a) Protects the client's right to self-determination in health care decision making.
b) Helps the client refuse treatment that he or she does not wish to undergo.
c) Helps the client to make a living will regarding future health care required.
d) Provides the client with in-depth knowledge about the treatment options available.
CORRECT ANSWER a) Protects the client's right to self-determination in health care decision making. Reason: Informed consent protects the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.
A worried mother confides in the nurse that she wants to change physicians because her infant is not getting better. The best response by the nurse is which of the following?
a) "This doctor has been on our staff for 20 years."
b) "I know you are worried, but the doctor has an excellent reputation."
c) "You always have an option to change. Tell me about your concerns."
d) "I take my own children to this doctor."
CORRECT ANSWER c) "You always have an option to change. Tell me about your concerns." Reason: Asking the mother to talk about her concerns acknowledges the mother's rights and encourages open discussion. The other responses negate the parent's concerns.
A client is scheduled for an excretory urography at 10 a.m. An order directs the nurse to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at:
a) 7:30 a.m.
b) 8:30 a.m.
c) 9 a.m.
d) 9:30 a.m.
CORRECT ANSWER a) 7:30 a.m. Reason: It takes up to 2 hours for lidocaine-prilocaine cream (EMLA cream) to anesthetize an insertion site. Therefore, if the insertion is scheduled for 9:30 a.m., EMLA cream should be applied at 7:30 a.m. The local anesthetic wouldn't be effective if the nurse administered it at the later times.
When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include:
a) increased coronary artery blood flow.
b) decreased posterior thoracic curve.
c) decreased peripheral resistance.
d) delayed gastric emptying.
CORRECT ANSWER d) delayed gastric emptying. Reason: Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.
Category: The Nursing ProcessA nurse is caring for a client with a diagnosis of Impaired gas exchange. Based upon this nursing diagnosis, which outcome is most appropriate?
a) The client maintains a reduced cough effort to lessen fatigue.
b) The client restricts fluid intake to prevent overhydration.
c) The client reduces daily activities to a minimum.
d) The client has normal breath sounds in all lung fields
CORRECT ANSWER d) The client has normal breath sounds in all lung fields. Reason: If the interventions are effective, the client's breath sounds should return to normal. The client should be able to cough effectively and should be encouraged to increase activity, as tolerated. Fluids should help thin secretions, so fluid intake should be encouraged.
determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea?
a) Moist mucous membranes.
b) Passage of a soft, formed stool.
c) Absence of diarrhea for a 4-hour period.
d) Ability to tolerate intravenous fluids well.
CORRECT ANSWER a) Moist mucous membranes. Reason: The outcome of moist mucous membranes indicates adequate hydration and fluid balance, showing that the problem of fluid volume deficit has been corrected. Although a normal bowel movement, ability to tolerate intravenous fluids, and an increasing time interval between bowel movements are all positive signs, they do not specifically address the problem of deficient fluid volume.
A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test?
a) Total iron-binding capacity
b) Hemoglobin (Hb)
c) Total protein
d) Sweat test
CORRECT ANSWER c) Total protein Reason: The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake. Measuring total iron- binding capacity and Hb levels would help detect iron deficiency anemia, not a negative nitrogen balance. The sweat test helps diagnose cystic fibrosis, not a negative nitrogen balance.
After discussing asthma as a chronic condition, which of the following statements by the father of a child with asthma best reflects the family's positive adjustment to this aspect of the child's disease?
a) "We try to keep him happy at all costs; otherwise, he has an asthma attack."
b) "We keep our child away from other children to help cut down on infections."
c) "Although our child's disease is serious, we try not to let it be the focus of our family."
d) "I'm afraid that when my child gets older, he won't be able to care for himself like I do."
CORRECT ANSWER c) "Although our child's disease is serious, we try not to let it be the focus of our family." Reason: Positive adjustment to a chronic condition requires placing the child's illness in its proper perspective. Children with asthma need to be treated as normally as possible within the scope of the limitations imposed by the illness. They also need to learn how to manage exacerbations and then resume as normal a life as possible. Trying to keep the child happy at all costs is inappropriate and can lead to the child's never learning how to accept responsibility for behavior and get along with others.
Although minimizing the child's risk for exposure to infections is important, the child needs to be with his or her peers to ensure appropriate growth and development. Children with a chronic illness need to be involved in their care so that they can learn to manage it. Some parents tend to overprotect their child with a chronic illness. This overprotectiveness may cause a child to have an exaggerated feeling of importance or later, as an adolescent, to rebel against the overprotectiveness and the parents.
ChildA 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately:
a) Put the client to bed.
b) Obtain the child's blood pressure.
c) Notify the physician.
d) Administer acetaminophen (Tylenol).
CORRECT ANSWER b) Obtain the child's blood pressure. Reason: Hypertension occurs with acute glomerulonephritis. The symptoms of headache and blurred vision may indicate an elevated blood pressure. Hypertension in acute glomerulonephritis occurs due to the inability of the kidneys to remove fluid and sodium; the fluid is reabsorbed, causing fluid volume excess. The nurse must verify that these symptoms are due to hypertension. Calling the physician before confirming the cause of the symptoms would not assist the physician in his treatment. Putting the client to bed may help treat an elevated blood pressure, but first the nurse must establish that high blood pressure is the cause of the symptoms. Administering Tylenol for high
A nurse is performing a psychosocial assessment on a 14-year-old adolescent. Which emotional response is typical during early adolescence?
a) Frequent anger
b) Cooperativeness
c) Moodiness
d) Combativeness
CORRECT ANSWER c) Moodiness Reason: Moodiness may occur often during early adolescence. Frequent anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence.
Based on a client's history of violence toward others and her inability to cope with anger, which of the following should the nurse use as the most important indicator of goal achievement before discharge?
a) Acknowledgment of her angry feelings.
b) Ability to describe situations that provoke angry feelings.
c) Development of a list of how she has handled her anger in the past.
d) Verbalization of her feelings in an appropriate
CORRECT ANSWER d) Verbalization of her feelings in an appropriate manner. Reason: Verbalizing feelings, especially feelings of anger, in an appropriate manner is an adaptive method of coping that reduces the chance that the client will act out these feelings toward others. The client's ability to verbalize her feelings indicates a change in behavior, a crucial indicator of goal achievement. Although acknowledging feelings of anger and describing situations that precipitate angry feelings are important in helping the client reach her goal, they are not appropriate indicators that she has changed her behavior. Asking the client to list how she has handled anger in the past is helpful if the nurse discusses coping methods with the client. However, based on this client's history, this would not be helpful because the nurse and client are already aware of the client's aggression toward others.
Disorders
A 16-year-old academically gifted boy is about to graduate from high school early, because he has completed all courses needed to earn a diploma. Within the last 3 months, he has experienced panic attacks that have forced him to leave classes early and occasionally miss a day of school. He is concerned that these attacks may hinder his ability to pursue a college degree. What would be the best response by the school nurse who has been helping him deal with his panic attacks?
a) "It is natural to be worried about going into a new environment. I am sure with your abilities you will do well once you get settled."
b) "You are putting too much pressure on yourself. You just need to relax more and things will be alright."
c) "It might be best for you to postpone going to college. You need to get these panic attacks controlled first."
d) "It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment."
CORRECT ANSWER d) "It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment." Reason: The client's concerns are real and serious enough to warrant assessment by a physician rather than being dismissed as trivial. Though he is
very intelligent, his intelligence cannot overcome his anxiety. In fact, his anxiety is likely to interfere with his ability to perform in college if no assessment and treatment are received. Just postponing college is likely to increase rather than lower the client's anxiety, because it does not address the panic he is experiencing.
A client was hospitalized for 1 week with major depression with suicidal ideation. He is taking venlafaxine (Effexor), 75 mg three times a day, and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse should make which judgment about the client?
a) The client is decompensating and in need of being readmitted to the hospital.
b) The client needs an adjustment or increase in his dose of antidepressant.
c) The depression is improving and the suicidal ideation is lessening.
d) The presence of suicidal ideation warrants a telephone call to the client's primary care provider.
CORRECT ANSWER c) The depression is improving and the suicidal ideation is lessening. Reason: The client's statements about being in control of his behavior and his or her plans to return to work indicate an improvement in depression and that suicidal ideation, although present, is decreasing. Nothing in his comments or behavior indicate he is decompensating. There is no evidence to support an increase or adjustment in the dose of Effexor or a call to the primary care provider. Typically, the cognitive components of depression are the last symptoms eliminated. For the client to be experiencing some suicidal ideation in the second week of psychopharmacologic treatment is not unusual.
Category: Psychotic DisordersA client with chronic undifferentiated schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking to himself. This behavior is characteristic of:
a) delusion.
b) looseness of association.
c) illusion.
d) hallucination
CORRECT ANSWER d) hallucination. Reason: Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Clients with schizophrenia may exhibit looseness of association, a pattern of thinking and communicating in which ideas aren't clearly linked to one another. Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia. Give me more questions of the day
Which of the following is a priority during the first 24 hours of hospitalization for a comatose client with suspected drug overdose?
a) Educate regarding drug abuse.
b) Minimize pain.
c) Maintain intact skin.
d) Increase caloric intake.
CORRECT ANSWER c) Maintain intact skin. Reason: Maintaining intact skin is a priority for the unconscious client. Unconscious clients need to be turned every hour to prevent complications of immobility, which include pressure ulcers and stasis pneumonia. The unconscious client cannot be educated at this time. Pain is not a concern. During the first 24 hours, the unconscious client will mostly likely be on nothing-by-mouth status.
A nurse is assessing the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect?
a) Absent pedal pulses
b) Bilateral dependent edema
c) Sluggish capillary refill
d) Unilateral calf enlargement
CORRECT ANSWER b) Bilateral dependent edema Reason: As the uterus grows heavier during pregnancy, femoral venous pressure rises, leading to bilateral dependent edema. Factors interfering with venous return, such as sitting or standing for long periods, contribute to edema. Absence of pedal pulses and sluggish capillary refill signal inadequate circulation to the legs — an unexpected finding during pregnancy. Unilateral calf enlargement, also an abnormal finding, may indicate thrombosis.
Which nursing action is required before a client in labor receives epidural anesthesia?
a) Give a fluid bolus of 500 ml.
b) Check for maternal pupil dilation.
c) Assess maternal reflexes.
d) Assess maternal gait.
CORRECT ANSWER a) Give a fluid bolus of 500 ml. Reason: One of the major adverse effects of epidural administration is hypotension. Therefore, a 500-ml fluid bolus is usually administered to prevent
hypotension in the client who wishes to receive an epidural for pain relief. Assessing maternal reflexes, pupil response, and gait isn't necessary.
On the second postpartum day a gravida 6, para 5 complains of intermittent abdominal cramping. The nurse should assess for:
a) endometritis.
b) postpartum hemorrhage.
c) subinvolution.
d) afterpains.
CORRECT ANSWER d) afterpains. Reason: In a multiparous client, decreased uterine muscle tone causes alternating relaxation and contraction during uterine involution, which leads to afterpains. The client's symptoms don't suggest endometritis, hemorrhage, or subinvolution.
During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. Which of the following should the nurse do first?
a) Start mouth-to-mouth resuscitation.
b) Contact the neonatal resuscitation team.
c) Raise the neonate's head and pat the back gently.
d) Clear the neonate's airway with suction or gravity.
CORRECT ANSWER d) Clear the neonate's airway with suction or gravity. Reason: If a neonate gags on mucus and becomes cyanotic during the first feeding, the airway is most likely closed. The nurse should clear the airway by gravity (by lowering the infant's head) or suction. Starting mouth-to-mouth resuscitation is not indicated unless the neonate remains cyanotic and lowering his head or suctioning doesn't clear his airway. Contacting the neonatal resuscitation team is not warranted unless the infant remains cyanotic even after measures to clear the airway. Raising the neonate's head and patting the back are not appropriate actions for removing mucus. Doing so allows the mucus to remain lodged causing further breathing difficulties.
A client with chronic heart failure is receiving digoxin (Lanoxin), 0.25 mg by mouth daily, and furosemide (Lasix), 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause:
a) visual disturbances.
b) taste and smell alterations.
c) dry mouth and urine retention.
d) nocturia and sleep disturbances.
CORRECT ANSWER a) visual disturbances. Reason: Digoxin toxicity may cause visual disturbances (such as, flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (such as headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (abnormal heart rate and arrhythmias). Digoxin toxicity doesn't cause taste and smell alterations. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night.
A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client?
a) Wear sterile gloves.
b) Place incontinence pads in the regular trash container.
c) Wear personal protective equipment when handling blood, body fluids, and feces.
d) Provide a urinal or bedpan to decrease the likelihood of soiling linens.
CORRECT ANSWER c) Wear personal protective equipment when handling blood, body fluids, and feces. Reason: Chemotherapy drugs are present in the waste and body fluids of clients for 48 hours after administration. The nurse should wear personal protective equipment when handling blood, body fluids, or feces. Gloves offer minimal protection against exposure. The nurse should wear a face shield, gown, and gloves when exposure to blood or body fluid is likely. Placing incontinence pads in the regular trash container and providing a urinal or bedpan don't protect the nurse caring for the client.
Prochlorperazine (Compazine) is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which of the following?
a) Nausea.
b) Dizziness.
c) Abdominal spasms.
d) Abdominal distention.
CORRECT ANSWER a) Nausea. Reason: Prochlorperazine is administered postoperatively to control nausea and vomiting. Prochlorperazine is also used in psychotherapy because of its effects on mood and behavior. It is not used to treat dizziness, abdominal spasms, or abdominal distention.
Category: Integumentary DisordersA nurse is performing a baseline assessment of a client's skin integrity. What is the priority assessment parameter?
a) Family history of pressure ulcers
b) Presence of pressure ulcers on the client
c) Potential areas of pressure ulcer development
d) Overall risk of developing pressure ulcers
CORRECT ANSWER d) Overall risk of developing pressure ulcers Reason: When assessing skin integrity, the overall risk potential of developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.
A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. Which is the nurse's best response?
a) "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid."
b) "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor."
c) "The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction."
d) "The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."
CORRECT ANSWER b) "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." Reason: Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of red blood cells in this condition.
A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:
a) 10 g of carbohydrates.
b) 15 g of carbohydrates.
c) 20 g of carbohydrates.
d) 25 g of carbohydrates
CORRECT ANSWER b) 15 g of carbohydrates. Reason: The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates.
A client has been diagnosed with degenerative joint disease (osteoarthritis) of the left hip. Which of the following factors in the client's history would most likely increase the joint symptoms of osteoarthritis?
a) A long history of smoking.
b) Excessive alcohol use.
c) Obesity.
d) Emotional stress.
CORRECT ANSWER c) Obesity. Reason: Osteoarthritis most commonly results from "wear and tear"--- excessive and prolonged mechanical stress on the joints. Increased weight increases stress on weight- bearing joints. Therefore, an obese client with osteoarthritis should be encouraged to lose weight.
Smoking does not cause osteoarthritis. Excessive alcohol use does not cause osteoarthritis. Emotional stress does not cause osteoarthritis.
Category: Neurosensory Disorders
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
a) Decreased level of consciousness (LOC)
b) Elevated blood pressure
c) Increased urine output
d) Decreased heart rate
CORRECT ANSWER c) Increased urine output Reason: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
Category: Respiratory DisordersWhich of the following alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago?
a) Increased blood pressure and decreased pulse and respiratory rates.
b) Sanguineous drainage from the chest tube at a rate of 50 ml/hour during the past 3 hours.
c) Restlessness and shortness of breath.
d) Urine output of 180 ml during the past 3 hours.
CORRECT ANSWER c) Restlessness and shortness of breath. Reason: Restlessness indicates cerebral hypoxia due to decreased circulating volume. Shortness of breath occurs because blood collecting in the pleural space faster than suction can remove it prevents the lung from reexpanding. Increased blood pressure and decreased pulse and respiratory rates are classic late signs of increased intracranial pressure. Decreasing blood pressure and increasing pulse and respiratory rates occur with hypovolemic shock. Sanguineous drainage that changes to serosanguineous drainage at a rate less than 100 ml/hour is normal in the early postoperative period. Urine output of 180 ml over the past 3 hours indicates normal kidney perfusion.
Category: Genitourinary Disorders
Of the following findings in the client's history, which would be the least likely to have predisposed the client to renal calculi?
a) Having had several urinary tract infections in the past 2 years.
b) Having taken large doses of vitamin C over the past several years.
c) Drinking less than the recommended amount of milk.
d) Having been on prolonged bed rest after an accident the previous year.
CORRECT ANSWER c) Drinking less than the recommended amount of milk. Reason: A high, rather than low, milk intake predisposes to renal calculi formation, owing to the calcium in milk. Recurrent urinary tract infections are implicated in stone formation as certain bacteria promote stone formation. High daily doses of vitamins C are a risk factor because they can increase the citric acid level. Prolonged immobility is a risk factor for renal calculi because it causes calcium to be released into the bloodstream.
Category: Basic Physical Care
The nurse-manager of a home health facility includes which item in the capital budget?
a) Salaries and benefits for her staff
b) A $1,200 computer upgrade
c) Office supplies
d) Client-education materials costing $300
CORRECT ANSWER b) A $1,200 computer upgrade Reason: Capital budgets generally include items valued at more than $500. Salaries and benefits are part of the personnel budget. Office supplies and client education materials are part of the operating budget.
Category: Basic Psychosocial NeedsBefore preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary purpose of preoperative teaching?
a) To determine whether the client is psychologically ready for surgery
b) To express concerns to the client about the surgery
c) To reduce the risk of postoperative complications
d) To explain the risks associated with the surgery and obtain informed consent
CORRECT ANSWER c) To reduce the risk of postoperative complications Reason: Preoperative teaching helps reduce the risk of postoperative complications by telling the client what to expect and providing a chance for him to practice, before surgery, any required postoperative activities, such as breathing and leg exercises. The physician — not the nurse — is responsible for determining the client's psychological readiness for surgery. It's inappropriate for the nurse to express personal concerns about surgery to a client. The physician should describe alternative treatments and explain the risks to the client when obtaining informed consent.
Category: Medication and I.V. AdministrationA health care provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames?
a) 5 minutes.
b) 10 minutes.
c) 20 minutes.
d) 30 minutes
CORRECT ANSWER c) 20 minutes. Reason: A dose of 0.5 mg of protamine sulfate reverses a 100-unit dose of heparin within 20 minutes. The nurse should administer protamine sulfate by I.V. push slowly to avoid adverse effects, such as hypotension, dyspnea, bradycardia, and anaphylaxis.
Category: Basic Physical AssessmentA nurse is assessing a client's pulse. Which pulse feature should the nurse document?
a) Timing in the cycle
b) Amplitude
c) Pitch
d) Intensity
CORRECT ANSWER b) Amplitude Reason: The nurse should document the rate, rhythm, and amplitude, such as weak or bounding, of a client's pulse. Pitch, timing, and intensity aren't associated with pulse assessment.
The nurse is assigning tasks to unlicensed assistive personnel (UAP) for a client with an abdominal hysterectomy on the first postoperative day. Which of the following can NOT be delegated to the UAP?
a) Taking vital signs.
b) Recording intake and output.
c) Giving perineal care.
d) Assessing the incision site.
CORRECT ANSWER d) Assessing the incision site. Reason: The registered nurse is responsible for monitoring the surgical site for condition of the dressing, status of the incision, and signs and symptoms of complications. Unlicensed assistive personnel who have been trained to report abnormalities to the registered nurse supervising the care may take vital signs, record intake and output, and give perineal care.
Category: Infant
Before placement of a ventriculoperitoneal shunt for hydrocephalus, an infant is irritable, lethargic, and difficult to feed. To maintain the infant's nutritional status, which of the following actions would be most appropriate?
a) Feeding the infant just before doing any procedures.
b) Giving the infant small, frequent feedings.
c) Feeding the infant in a horizontal position.
d) Scheduling the feedings for every 6 hours.
CORRECT ANSWER b) Giving the infant small, frequent feedings. Reason: An infant with hydrocephalus is difficult to feed because of poor sucking, lethargy, and vomiting, which are associated with increased intracranial pressure. Small, frequent feedings given at times when the infant is relaxed and calm are tolerated best. Feeding an infant before any procedure is inappropriate because the stress of the
procedure may lead to vomiting. Ideally, the infant should be held in a slightly vertical position when feeding to prevent backflow of formula into the eustachian tubes and subsequent development of ear infections. Most infants are fed on demand every 3 to 4 hours.
Category: ToddlerAfter teaching the parents of an 18-month-old who was treated for a foreign body obstruction about the three cardinal signs indicative of choking, the nurse determines that the teaching has been successful when the parents state that a child is choking when he or she cannot speak, turns blue, and does which of the following?
a) Vomits.
b) Gasps.
c) Gags.
d) Collapses.
CORRECT ANSWER d) Collapses. Reason: The three cardinal signs indicating that a child is truly choking and requires immediate life-saving interventions include inability to speak, blue color (cyanosis), and collapse. Vomiting does not occur while a child is unable to breathe. Once the object is dislodged, however, vomiting may occur. Gasping, a sudden intake of air, indicates that the child is still able to inhale. When a child is choking, air is not being exchanged, so gagging will not occur.
A dehydrated 3 year old has vomited three times in the last hour and continues to have frequent diarrhea. The child was admitted 2 days ago with gastroenteritis caused by rotavirus. The child weighs 22 kg, has a normal saline lock in the right hand, and has had 30 ml of urine output in the last 4 hours.
Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary healthcare provider with a recommendation for:
a) Giving a dose of loperaminde (Immodium).
b) Starting a fluid bolus of normal saline.
c) Beginning an intravenous (IV) antibiotic.
d) Establishing a Foley catheter.
CORRECT ANSWER b) Starting a fluid bolus of normal saline. Reason: The child is dehydrated, cannot retain oral fluids, and continues to have diarrhea. A normal saline bolus should be given followed by maintenance IV fluids. Anti-diarrheal medications are not recommended for children and will prolong the illness. The child has gastroenteritis caused by a viral illness. IV antibiotics are not indicated for viral illnesses.
Category: School-age Child
A parent asks the nurse about head lice (pediculosis capitis) infestation during a visit to the clinic. Which of the following symptoms should the nurse tell the parent is most common in a child infected with head lice?
a) Itching of the scalp.
b) Scaling of the scalp.
c) Serous weeping on the scalp surface.
d) Pinpoint hemorrhagic spots on the scalp surface.
CORRECT ANSWER a) Itching of the scalp. Reason: The most common characteristic of head lice infestation (pediculosis capitis) is severe itching. The head is the most common site of lice infestation. If the child scratches, scaling may occur. Itching also occurs when lice infest other parts of the body.
Scratch marks are almost always found when lice are present. Weeping on the scalp surface may be an indication of an infection or other dermatologic condition. Hemorrhagic spots are not a symptom of head lice, but may be caused by scratch marks.
Category: AdolescentA nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother?
a) "What do you think about having your mother leave the room now?"
b) "Mother, do you think your daughter is sexually active?"
c) "Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter."
d) "The two of you seem like you share everything. I am going to ask questions about sexual history now."
CORRECT ANSWER c) "Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter." Reason: Confidentiality and privacy are critical developmental needs for the adolescent. These needs are important to enable the nurse to establish a relationship of trust with the adolescent. A sexual history should be conducted with a teen without parents. Therefore, the nurse should not ask the mother to provide information or put the daughter in a position of having to make a decision about her mother remaining in the room. Inform the adolescent that this information is confidential, and will not be shared with the parent. Inform the adolescent that issues of abuse or life-threatening issues are required by law to be disclosed to the authorities, and all other information is private.
Category: Foundations of Psychiatric NursingA client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which technique?
a) Presenting reality
b) Making observations
c) Restating
d) Exploring
CORRECT ANSWER d) Exploring Reason: The nurse is using the technique of exploring because she's willing to delve further into the client's concern. She isn't presenting reality or making observations or simply restating. The nurse is encouraging the client to explore his feelings.
Category: Anxiety DisordersA client with obsessive-compulsive disorder may use reaction formation as a defense mechanism to cope with anxiety and stress. What typically occurs in reaction formation?
a) The client assumes an attitude that contradicts an impulse he harbors.
b) The client believes his thoughts can control other people and events.
c) The client persistently thinks and talks about a particular idea or subject.
d) The client uses a specific act to negate a previous act.
CORRECT ANSWER a) The client assumes an attitude that contradicts an impulse he harbors. Reason: Reaction formation is a defense mechanism in which a person assumes an attitude that contradicts an impulse or a wish that he harbors. The belief that one's thoughts can control other people and events is
called "magical thinking." Persistent thoughts and discussion of a particular idea or subject are called "rumination." Use of an act to negate a previous act is called "undoing."
A nurse is evaluating a client's electrocardiogram (ECG). Which ECG change can result from amitriptyline (Elavil) therapy?
a) Presence of U waves
b) Depressed ST segment
c) Widening QT interval
d) Prolonged PR interval
CORRECT ANSWER c) Widening QT interval Reason: Amitriptyline therapy may cause a conduction delay, demonstrated by a widening QT interval on the ECG. U waves, a depressed ST segment, and a prolonged PR interval aren't typically induced by amitriptyline therapy.
Category: Psychotic DisordersA newly admitted client diagnosed with paranoid schizophrenia is pacing rapidly and wringing his hands. He states that another client is out to get him. Then he says, "Protect me, select me, reject me." The nurse should next:
a) Administer his oral PRN lorazepam (Ativan) and haloperidol (Haldol).
b) Place the client in temporary seclusion before he has a chance to hurt others.
c) Call the primary health care provider for a prescription for restraints.
d) Ask the other clients to leave the immediate area
CORRECT ANSWER a) Administer his oral PRN lorazepam (Ativan) and haloperidol (Haldol). Reason: The client's anxiety as reflected in rapid pacing and clang associations is rising as a result of his paranoid delusions. Administering the Ativan and Haldol will help the anxiety and delusions. He is not threatening others at this point, so seclusion, restraints, and asking clients to leave the area is not necessary.
Category: Substance Abuse, Eating Disorders, Impulse Control DisordersAfter a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium (Nembutal) at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective in the client does not develop:
a) Psychosis.
b) Seizures.
c) Hypotension.
d) Hypothermia
CORRECT ANSWER b) Seizures. Reason: Generalized seizures may occur on the second or third day of withdrawal from barbiturates. Without treatment, the seizures may be fatal. Psychosis is a possibility but is not fatal and will not be prevented by the pentobarbital sodium regimen. Orthostatic hypotension is possible but is unlikely to be fatal; it is also not treatable by the pentobarbital sodium regimen.
Hyperthermia, rather than hypothermia, occurs during withdrawal.
Category: Antepartum PeriodThe primary health care provider orders intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside?
a) Diazepam (Valium).
b) Hydralazine (Apresoline).
c) Calcium gluconate.
d) Phenytoin (Dilantin).
CORRECT ANSWER c) Calcium gluconate. Reason: The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The antidote for magnesium sulfate toxicity is calcium gluconate, which should be readily available at the client's bedside. Diazepam (Valium), used to treat anxiety, usually is not given to pregnant women. Hydralazine (Apresoline) would be used to treat hypertension, and phenytoin (Dilantin) would be used to treat seizures.
Which finding indicates placental detachment?
a) An abrupt lengthening of the cord
b) A decrease in the number of contractions
c) Relaxation of the uterus
d) Decreased vaginal bleeding
CORRECT ANSWER a) An abrupt lengthening of the cord Reason: An abrupt lengthening of the cord, an increase (not a decrease) in the number of contractions, and an increase (not a decrease) in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus. Relaxation of the uterus isn't an indication for detachment of the placenta.
A primiparous client at 4 hours after a vaginal delivery and manual removal of the placenta voids for the first time. The nurse palpates the fundus, noting it to be 1 cm above the umbilicus, slightly firm, and deviated to the left side, and notes a moderate amount of lochia rubra. The nurse notifies the physician based on the interpretation that the assessment indicates which of the following?
a) Perineal lacerations.
b) Retained placental fragments.
c) Cervical lacerations.
d) Urine retention.
CORRECT ANSWER b) Retained placental fragments. Reason: At 4 hours postpartum, the fundus should be midline and at the level of the umbilicus. Whenever the placenta is manually removed after delivery, there is a possibility that all of the placenta has not been removed. Sometimes small pieces of the placenta are retained, a common cause of late postpartum hemorrhage. The client is exhibiting signs and symptoms associated with retained placental fragments. The client will continue to bleed until the fragments are expelled. Perineal and cervical lacerations are characterized by bright red bleeding and a firmly contracted fundus at the level that is expected. Urine retention is characterized by a full bladder, which can be observed by a bulge or fullness just above the symphysis pubis. Also, the client's fundus would be deviated to one side and boggy to the touch.
Category: The NeonateA neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result?
a) Bradycardia.
b) Rapid eye movement.
c) Seizures.
d) Tachycardia
CORRECT ANSWER a) Bradycardia. Reason: As a result of vigorous suctioning the nurse must watch for bradycardia due to potential vagus nerve stimulation. Rapid eye movement is not associated with vagus nerve stimulation. Vagal stimulation will not cause seizures or tachycardia.
A nurse should monitor a client receiving lidocaine (Xylocaine) for toxicity. Which signs or symptoms in a client suggest lidocaine toxicity?
a) Nausea and vomiting
b) Pupillary changes
c) Confusion and restlessness
d) Hypertension
CORRECT ANSWER c) Confusion and restlessness Reason: Confusion and restlessness are signs of lidocaine toxicity. Nausea and vomiting may occur with oral administration of mexiletine (Mexitil) or tocainide (Tonocard) — other class IB drugs. Pupillary changes and hypertension aren't signs of lidocaine toxicity, although visual changes and hypotension may occur as adverse reactions to class IB drugs.
A 45-year-old single mother of three teenaged boys has metastatic breast cancer. Her parents live 750 miles away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the client to consider high-dose chemotherapy. She is concerned about her children's welfare during the treatment. When assessing the client's present support systems, the nurse will be most concerned about the potential problems with:
a) Denial as a primary coping mechanism.
b) Support systems and coping strategies.
c) Decision-making abilities.
d) Transportation and money for the boys
CORRECT ANSWER b) Support systems and coping strategies. Reason: The client's resources for coping with the emotional and practical needs of herself and her family need to be assessed because usual coping strategies and support systems are often inadequate in especially stressful situations. The nurse may be concerned with the client's use of denial, decision-making abilities, and ability to pay for transportation; however, the client's support systems will be of more importance in this situation.
A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision?
a) Autonomy
b) Fidelity
c) Nonmaleficence
d) Veracity
CORRECT ANSWER a) Autonomy Reason: Autonomy refers to an individual's right to make his own decisions. Fidelity is equated with faithfulness. Nonmaleficence is the duty to "do no harm." Veracity refers to telling the truth.
Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that suggests necrotizing fasciitis is:
a) erythema.
b) leukocytosis.
c) pressurelike pain.
d) swelling
CORRECT ANSWER c) pressurelike pain. Reason: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
a) Administer acetaminophen.
b) Take the client's blood pressure.
c) Discontinue the transfusion.
d) Check the infusion rate of the blood.
CORRECT ANSWER c) Discontinue the transfusion. Reason: Chills and headache are signs of a febrile, nonhemolytic blood transfusion reaction and the nurse's first action should be to discontinue the transfusion as soon as possible and then notify the physician. Antipyretics and antihistamines may be ordered. The nurse would not administer acetaminophen without an order from the physician. The client's blood pressure should be taken after the transfusion is stopped. Checking the infusion rate of the blood is not a pertinent action; the infusion needs to be stopped regardless of the rate.
A 75-year-old client is newly diagnosed with diabetes. The nurse is instructing him about blood glucose testing. After the session, the client states, "I can't be expected to remember all this stuff." The nurse should recognize this response as most likely related to which of the following?
a) Moderate to severe anxiety.
b) Disinterest in the illness.
c) Early-onset dementia.
d) Normal reaction to learning a new skill.
CORRECT ANSWER a) Moderate to severe anxiety. Reason: Anxiety, especially at higher levels, interferes with learning and memory retention. After the client's anxiety lessens, it will be easier for him to learn the steps of the blood glucose monitoring. Because the client's illness is a chronic, lifelong illness that severely changes his lifestyle, it is unlikely that he is uninterested in the illness or how to treat it. It is also unlikely that dementia would be the cause of the client's frustration and lack of memory. The client's response indicates anxiety. Client responses that would indicate lessening anxiety would be questions to the nurse or requests to repeat part of the instructio
The nurse is evaluating the pin insertion site of a client's skeletal traction. Which of the following indicate a complication?
a) Presence of crusts around the pin insertion site.
b) Serous drainage on the dressing.
c) Pin moves slightly at insertion site.
d) Client does not feel pain at insertion site.
CORRECT ANSWER c) Pin moves slightly at insertion site. Reason: Skeletal pins should not be loose and able to move. Any pin loosening should be reported immediately. Slight serous drainage is normal and may crust around the insertion site or be present on the dressing. The pin insertion site should be cleaned with aseptic technique according to facility policy. Pin insertion sites are typically not painful; pain may be indicative of
An Arab client with pneumonia has been admitted to the health care facility. What should the nurse avoid while conducting the interview of the client?
a) Giving a light handshake.
b) Maintaining eye contact.
c) Asking about the client's symptoms.
d) Asking about the client's medical history.
CORRECT ANSWER b) Maintaining eye contact. Reason: While interviewing an Arab client, the nurse should avoid maintaining eye contact. In Arab culture, maintaining eye contact is sexually suggestive; if the nurse does so during the interview, it may give the wrong message to the client. However, the nurse may give a light handshake or ask about the client's personal life and medical history during the interview.
The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?
a) Minimal leaking.
b) No swelling.
c) Tissue pallor.
d) Evidence of a bleb or wheal.
CORRECT ANSWER d) Evidence of a bleb or wheal. Reason: A properly administered intradermal injection shows evidence of a bleb or wheal at the injection site. There should be no leaking of medication from the bleb; it needs to be absorbed into the tissue. Lack of swelling at the injection site means that the injection was given too deeply. The presence of tissue pallor does not indicate that the injection was given correctly.
The nurse is assessing a client's testes. Which of the following findings indicate the testes are normal?
a) Soft.
b) Egg-shaped.
c) Spongy.
d) Lumpy.
CORRECT ANSWER b) Egg-shaped. Reason: Normal testes feel smooth, egg-shaped, and firm to the touch, without lumps. The surface should feel smooth and rubbery. The testes should not be soft or spongy to the touch. Testicular malignancies are usually nontender, nonpainful hard lumps. Lumps, swelling, nodules, or signs of inflammation should be reported to the physician.
An 18-year-old high school senior wishes to obtain birth control through her parents' insurance but does not want the information disclosed. The nurse tells the client that under the Health Information Portability and Accountability Act (HIPAA) parents:
a) Have the right to review a minor's medical records until high school graduation.
b) Have the right to review a minor's medical record if they are responsible for the payment.
c) May not view the medical record, but may learn of the visit through the insurance bill.
d) May not view the minor's medical record or the insurance bill.
CORRECT ANSWER c) May not view the medical record, but may learn of the visit through the insurance bill. Reason: Under HIPAA, 18-year-olds have the right to medical privacy and their medical records may not be disclosed to their parents without their permission. However, the adolescent must be made aware of the fact that information is sent to third party payers for the purpose of reimbursement. Those payers send the primary insurer, in this case the parent, a statement of benefits. HIPAA protects the right to medical privacy of all 18-year-olds regardless of their educational status. Even if parents are responsible for payment, they may not view the patient's chart without the consent of the adolescent.
During assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations, and a temperature of 103.2° F (39.6° C). The infant's fontanel is more tense than at the last assessment. What should the nurse do first?
a) Ask another nurse to verify the findings.
b) Notify the primary care provider of the findings.
c) Raise the head of the bed.
d) Administer an antipyretic.
CORRECT ANSWER c) Raise the head of the bed. Reason: Signs such as a decrease in the level of consciousness, bradycardia, hypertension, irregular respirations, and a tense fontanel strongly suggest increased intracranial pressure. The first action should be to attempt to lower the pressure by raising the head of the bed, which should improve venous return and decrease the pressure. Asking another nurse to verify the findings is unnecessary because temperature, pulse, and respirations are fairly objective data and not subject to interpretation. Additionally, asking for verification would waste valuable time.
After elevating the infant's head by raising the bed, the nurse can notify the primary care provider and administer the antipyretic.
A 4-year-old boy presents to the emergency department. His father tearfully reports that he was in the driveway and had his son on his shoulders when the child began to fall. The father grabbed him by the
leg, swinging him toward the grass to avoid landing on the pavement. As the father swung his son, the child hit his head on the driveway and twisted his right leg. After a complete examination, it is determined that the child has a skull fracture and a spiral fracture of the femur. Which of the following actions should the nurse take?
a) Restrict the father's visitation.
b) Notify the police immediately.
c) Refer the father for parenting classes.
d) Record the father's story in the chart.
CORRECT ANSWER d) Record the father's story in the chart. Reason: The father's story is consistent with the injuries incurred by the child; therefore, the nurse should document the cause of injury. There is no need to restrict the father's visitation, because the injuries sustained by the child are consistent with the explanation given. The police need to be notified only if there is suspicion of child abuse. The injuries incurred by this child appear accidental. There is no need to refer the father for parenting classes. The father seems upset about the accident and will not likely repeat such reckless behavior. The nurse should educate the father, however, regarding child safety.
hool-age Child
Which of the following measures should the nurse include in the care plan for a child who is receiving high-dose methotrexate (amethopterin) therapy?
a) Keeping the child in a fasting state.
b) Obtaining a white blood cell (WBC) count.
c) Preparing for radiography of the spinal canal.
d) Collecting a specimen for urinalysis
CORRECT ANSWER b) Obtaining a white blood cell (WBC) count. Reason: Methotrexate is not highly toxic in low doses but may cause severe leukopenia at higher doses. It is customary and recommended for blood tests to be done before therapy to provide a baseline from which to study the effects of the drug on WBC count. Maintaining a fasting state, radiography of the spinal canal, and urinalysis are not necessary when this drug is administered.
A 17-year-old client who has been taking an antidepressant for six weeks has returned to the clinic for a medication check. When the nurse talks with the client and her mother, the mother reports that she has to remind the client to take her antidepressant every day. The client says, "Yeah, I'm pretty bad about remembering to take my meds, but I never miss a dose because Mom always bugs me about taking it." Which of the following responses would be effective for the nurse to make to the client?
a) "It's a good thing your mom takes care of you by reminding you to take your meds."
b) "It seems there are some difficulties with being responsible for your medications that we need to address".
c) "You'll never be able to handle your medication administration at college next year if you're so dependent on her."
d) "I'm surprised your mother allows you to be so irresponsible."
CORRECT ANSWER b) "It seems there are some difficulties with being responsible for your medications that we need to address". Reason: The client and mother need to address the issue of responsibility for medication administration and only Option 2 opens that subject to discussion. Option 1 reinforces the mother's over-involvement in medication taking. Options 3 and 4 make negative comments about the client and mother that are unlikely to engage them in problem-solving about the matter.
The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes?
a) Coordinate documentation of the incident.
b) Resolve negative feelings and attitudes.
c) Improve the use of restraint procedures.
d) Calm down before returning to the other clients
CORRECT ANSWER c) Improve the use of restraint procedures. Reason: Although coordinating documentation, resolving negative feelings, and calming down are goals of debriefing after a restraint, the ultimate outcome is to improve restraint procedures.
A client who recently developed paralysis of the arms is diagnosed with conversion disorder after tests fail to uncover a physical cause for the paralysis. Which intervention should the nurse include in the care plan for this client?
a) Exercising the client's arms regularly
b) Insisting that the client eat without assistance
c) Working with the client rather than with the family
d) Teaching the client how to use nonpharmacologic pain-control methods
CORRECT ANSWER a) Exercising the client's arms regularly Reason: To maintain the integrity of the affected areas and prevent muscle wasting and contractures, the nurse should help the client perform regular passive range-of-motion exercises with his arms. The nurse shouldn't insist that the client use his arms to perform such functions as eating without assistance, because he can't consciously control his symptoms and move his arms; such insistence may anger the client and endanger the therapeutic relationship. The nurse should include family members in the client's care because they may be
contributing to the client's stress or conflict and are essential to helping him regain function of his arms. The client isn't experiencing pain and, therefore, doesn't need education regarding pain management.
A client with major depression sleeps 18 to 20 hours per day, shows no interest in activities he previously enjoyed and reports a 17-lb (7.7-kg) weight loss over the past month. Because this is the client's first hospitalization, the physician is most likely to order:
a) phenelzine (Nardil).
b) thiothixene (Navane).
c) nortriptyline (Pamelor).
d) trifluoperazine (Stelazine).
CORRECT ANSWER c) nortriptyline (Pamelor). Reason: Nortriptyline, a tricyclic antidepressant, is used in first-time drug therapy because it causes few anticholinergic and sedative adverse effects. Phenelzine isn't ordered initially because it may cause many adverse effects and necessitates dietary restrictions.
Thiothixene and trifluoperazine are antipsychotic agents and, therefore, inappropriate for clients with uncomplicated depression.
Which condition or characteristic is related to the cluster of symptoms associated with disorganized schizophrenia?
a) Odd beliefs
b) Flat affect
c) Waxy flexibility
d) Systematized delusions
CORRECT ANSWER b) Flat affect Reason: Flat affect (the lack of facial or behavioral manifestations of emotion) is related to disorganized schizophrenia. Other characteristics of disorganized schizophrenia include incoherence, loose associations, and disorganized behavior. Paranoid residual type schizophrenia is characterized by odd beliefs, unusual perceptions, and systematized delusions. Waxy flexibility, or maintaining the position the client is placed in, is seen in catatonic schizophrenia.
A client with alcohol dependency is prescribed a B-complex vitamin. The client states, "Why do I need a vitamin? My appetite is just fine." Which of the following responses by the nurse is most appropriate?
a) "Your doctor wants you to take it for at least 4 months."
b) "You've been drinking alcohol and eating very little."
c) "The vitamin is a nutritional supplement important to your health."
d) "The amount of vitamins in the alcohol you drink is very low."
CORRECT ANSWER c) "The vitamin is a nutritional supplement important to your health." Reason: Stating that the vitamin is a nutritional supplement important to the client's health is the best response. The client is nutritionally depleted, and the B-complex vitamins produce a calming effect on the irritated central nervous system and prevent anemia, peripheral neuropathy, and Wernicke's encephalopathy.
Although the statements about drinking alcohol and eating very little and that there is a low amount of vitamins in the alcohol consumed may be true, they fail to address the client's concerns directly and fail to provide the necessary information, as does telling the client that the doctor wants the client to take the vitamin for 4 months.
A potential concern when caring for an older adult who has diminished hearing and vision is the client's:
a) Feelings of disorientation.
b) Cognitive impairment.
c) Sensory overload.
d) Social isolation.
CORRECT ANSWER d) Social isolation. Reason: Social isolation is a concern for an older adult who has diminished hearing and vision. Feeling disoriented may be related to cognitive problems rather than diminished hearing and vision. Diminished hearing and vision is related to the aging process and does not result in impairment of the older adult's thought processes. The client with impaired hearing and vision is unlikely to experience sensory overload.
A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine (Mucomyst). Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it:
a) is a respiratory depressant.
b) is a respiratory stimulant.
c) may induce bronchospasm.
d) inhibits the cough reflex
CORRECT ANSWER c) may induce bronchospasm. Reason: Acetylcysteine must be used cautiously in a client with asthma because it may induce bronchospasm. The drug isn't a respiratory depressant or stimulant. It's a mucolytic agent that decreases the viscosity of respiratory secretions by altering the molecular composition of mucus. Acetylcysteine doesn't inhibit the cough reflex.
A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for:
a) nausea and vomiting.
b) dyspnea and cyanosis.
c) fatigue and weakness.
d) thrush and circumoral pallor.
CORRECT ANSWER c) fatigue and weakness. Reason: RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Nausea and vomiting may occur in CRF but don't result from faulty RBC production. Dyspnea and cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor, which reflects decreased oxygenation, aren't signs of CRF.
A physician has ordered penicillin G potassium (Pfizerpen), I.V., for a client with a severe streptococcal infection. A nurse determines that the client may be allergic to penicillin. When considering best practice, what should the nurse's priority intervention be?
a) Holding the penicillin G potassium and charting that it was held because the client is allergic
b) Administering the penicillin G potassium and staying alert for any reaction
c) Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin
d) Administering the penicillin G potassium but notifying the pharmacist that the client might experience an allergic reaction
CORRECT ANSWER c) Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin Reason: The nurse should hold the penicillin G potassium, even if the client isn't sure he's allergic to penicillin, and notify the physician so he may order a different antibiotic. Many clients can't act as their own advocates; they rely on nurses to protect their rights. An allergy to penicillin G potassium is suspected, but not comfirmed. Administering penicillin G potassium could cause a life- threatening reaction. Administering the medication, then watching for a reaction or notifying the pharmacist that a reaction might occur, isn't best practice. If a client is allergic to penicillin, a nurse should alert the pharmacist and label the client's chart appropriately.
Which medication is considered safe during pregnancy?
a) Aspirin
b) Magnesium hydroxide
c) Insulin
d) Oral antidiabetic agents
CORRECT ANSWER c) Insulin Reason: Insulin is a required hormone for any client with diabetes mellitus, including the pregnant client. Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for use during pregnancy because these agents may cause fetal harm.
The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?
a) Tell the client to push between contractions.
b) Provide gentle support to the fetal head. c) Apply gentle upward traction on the neonate's anterior shoulder.
d) Massage the perineum to stretch the perineal tissues. Give me more questions of the day CORRECT ANSWER b) Provide gentle support to the fetal head. Reason: During a precipitous delivery,
after calling for assistance and helping the client lie down, the nurse should provide support to the fetal head to prevent it from coming out. It is not appropriate to tell the client to push between contractions because this may lead to lacerations. The shoulder should be delivered by applying downward traction until the anterior shoulder appears fully at the introitus, then upward pressure to lift out the other shoulder. Priority should be given to safe delivery of the infant over protecting the perineum by massage.
Twelve hours after a vaginal delivery with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next?
a) Document this as a normal finding in the client's record.
b) Contact the physician for an order for methylergonovine (Methergine).
c) Encourage the client to ambulate to the bathroom and void.
d) Gently massage the fundus to expel the clots
CORRECT ANSWER c) Encourage the client to ambulate to the bathroom and void. Reason: At 12 hours postpartum, the fundus normally should be in the midline and at the level of the umbilicus. When the fundus is firm yet above the umbilicus, and deviated to the right rather than in the midline, the client's bladder is most likely distended. The client should be encouraged to ambulate to the bathroom and attempt to void, because a full bladder can prevent normal involution. A firm but deviated fundus above the level of the umbilicus is not a normal finding and if voiding does not return it to midline, it should be reported to the physician. Methylergonovine (Methergine) is used to treat uterine atony. This client's fundus is firm, not boggy or soft, which would suggest atony. Gentle massage is not necessary because there is no evidence of atony or clots.
A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The primary care provider has ordered I.V. fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4Meq/ L. The nurse should:
a) Notify the primary care provider.
b) Administer the ordered fluids.
c) Verify that the infant has urinated.
d) Have the potassium level redrawn
CORRECT ANSWER c) Verify that the infant has urinated. Reason: Normal serum potassium levels are 3.5-
4.5 Meq/L. Elevated potassium levels can cause life threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potassium through urination before administering the drug. Infants with pyloric stenosis frequently have low potassium levels due to vomiting. A level of 3.4Meq/l is not unexpected and should be corrected with the ordered fluids. The lab value does not need to be redrawn as the findings are consistent with the infant's condition.
In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open heart surgery, the nurse should explain that:
a) The client will remain in the ICU for 5 days.
b) The client will sleep most of the time while in the ICU.
c) Noise and activity within the ICU are minimal.
d) The client will receive medication to relieve pain
CORRECT ANSWER d) The client will receive medication to relieve pain. Reason: Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery, according to the Agency for Health Care Policy and Research. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replacement surgery.
A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents?
a) Wear disposable gloves and protective clothing.
b) Break needles after the infusion is discontinued.
c) Disconnect I.V. tubing with gloved hands.
d) Throw I.V. tubing in the trash after the infusion is stopped
CORRECT ANSWER a) Wear disposable gloves and protective clothing. Reason: A nurse must wear disposable gloves and protective clothing to prevent skin contact with chemotherapeutic agents. The nurse shouldn't recap or break needles. The nurse should use a sterile gauze pad when priming I.V. tubing, connecting and disconnecting tubing, inserting syringes into vials, breaking glass ampules, or other procedures in which chemotherapeutic agents are being handled. Contaminated needles, syringes,
I.V. tubes, and other equipment must be disposed of in a leak-proof, puncture-resistant container.
A client with cholecystitis is taking Propantheline bromide (Pro-Banthine). The expected outcome of this drug is:
a) Increased bile production.
b) Decreased biliary spasm.
c) Absence of infection.
d) Relief from nausea
CORRECT ANSWER b) Decreased biliary spasm. Reason: Propantheline bromide is an anticholinergic used to decrease biliary spasm. Decreasing biliary spasm helps to reduce pain in cholecystitis. Propantheline does not increase bile production or have an antiemetic effect, and it is not effective in treating infecti
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
a) "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear."
b) "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal."
c) "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year."
d) "I will receive parenteral vitamin B12 therapy for the rest of my life."
CORRECT ANSWER d) "I will receive parenteral vitamin B12 therapy for the rest of my life." Reason: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.
A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective coping related to diabetes mellitus?
a) Recent weight gain of 20 lb (9.1 kg)
b) Failure to monitor blood glucose levels
c) Skipping insulin doses during illness
d) Crying whenever diabetes is mentioned
CORRECT ANSWER d) Crying whenever diabetes is mentioned Reason: A client who cries whenever diabetes is mentioned is demonstrating ineffective coping. A recent weight gain and failure to monitor blood glucose levels would support a nursing diagnosis of Noncompliance: Failure to adhere to therapeutic regimen. Skipping insulin doses during illness would support a nursing diagnosis of Deficient knowledge related to treatment of diabetes mellitus.
After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical- surgical unit. Postoperatively, how should the nurse position the client?
a) With the affected hip flexed acutely
b) With the leg on the affected side abducted
c) With the leg on the affected side adducted
d) With the affected hip rotated externally
CORRECT ANSWER b) With the leg on the affected side abducted Reason: The nurse must keep the leg on the affected side abducted at all times after hip surgery to prevent accidental dislodgment of the affected hip joint. Placing a pillow or an A-frame between the legs helps maintain abduction and reminds the client not to cross the legs. The nurse should avoid acutely flexing the client's affected hip (for example, by elevating the head of the bed excessively), adducting the leg on the affected side (such as by moving it toward the midline), or externally rotating the affected hip (such as by removing support along the outer side of the leg) because these positions may cause dislocation of the injured hip joint.
A nurse is monitoring a client for adverse reactions to atropine (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?
a) Tachycardia
b) Increased salivation
c) Hypotension
d) Apnea
CORRECT ANSWER a) Tachycardia Reason: Systemic absorption of atropine can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. The drug also may cause dry mouth. It isn't known to cause hypotension or apnea.
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
a) Nausea or vomiting
b) Abdominal pain or diarrhea
c) Hallucinations or tinnitus
d) Light-headedness or paresthesia
CORRECT ANSWER d) Light-headedness or paresthesia Reason: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.
The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on these data, the nurse should?
a) Change the appliance bag.
b) Notify the physician.
c) Obtain a urine specimen for culture.
d) Encourage a high fluid intake
CORRECT ANSWER d) Encourage a high fluid intake. Reason: Mucus is secreted by the intestinal segment used to create the conduit and is a normal occurrence. The client should be encouraged to maintain a large fluid intake to help flush the mucus out of the conduit. Because mucus in the urine is expected, it is not necessary to change the appliance bag or to notify the physician. The mucus is not an indication of an infection, so a urine culture is not necessary.
As a nurse helps a client ambulate, the client says, "I had trouble sleeping last night." Which action should the nurse take first?
a) Recommending warm milk or a warm shower at bedtime
b) Gathering more information about the client's sleep problem
c) Determining whether the client is worried about something
d) Finding out whether the client is taking medication that may impede sleep
CORRECT ANSWER b) Gathering more information about the client's sleep problem Reason: The nurse first should determine what the client means by "trouble sleeping." The nurse lacks sufficient information to recommend warm milk or a warm shower or to make inferences about the cause of the sleep problem, such as worries or medication use.
The health care provider at a prenatal clinic has ordered multivitamins for a woman who is 3 months' pregnant. The client calls the nurse to report that she has gone to the pharmacy to fill her prescription but is unable to buy it as it costs too much. The nurse should refer the client to:
a) The charge nurse.
b) The hospital finance office.
c) Her hospital social worker.
d) Her insurance company
CORRECT ANSWER c) Her hospital social worker. Reason: The social worker is available to assist the client in finding services within the community to meet client needs. This individual is able to provide the names of pharmacies within the community that offer generic substitutes or others that utilize the client's insurance plan. The charge nurse of the unit would be able to refer the client to the social worker. The hospital finance office does not handle this type of situation and would refer the client back to the
unit. The client's insurance company deals with payments for health care and would refer the client back to the local setting.
A woman is taking oral contraceptives. The nurse teaches the client to report which of the following danger signs?
a) Breakthrough bleeding.
b) Severe calf pain.
c) Mild headache.
d) Weight gain of 3 lb.
CORRECT ANSWER b) Severe calf pain. Reason: Women who take oral contraceptives are at increased risk for thromboembolic conditions. Severe calf pain needs to be investigated as a potential sign of deep vein thrombosis. Breakthrough bleeding, mild headache, or weight gain may be common benign side effects that accompany oral contraceptive use. Clients may be monitored for these side effects without a change in treatment.
Crackles heard on lung auscultation indicate which of the following?
a) Cyanosis.
b) Bronchospasm.
c) Airway narrowing.
d) Fluid-filled alveoli
CORRECT ANSWER d) Fluid-filled alveoli. Reason: Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.
e Nursing Process
Which of the following should be included in the plan of care for a client with a surgical wound that requires a wet-to-dry dressing?
a) Place a dry dressing in the wound.
b) Use Burrow's solution to wet the dressing.
c) Pack the wet dressing tightly into the wound.
d) Cover the wet packing with a dry sterile dressing.
CORRECT ANSWER d) Cover the wet packing with a dry sterile dressing. Reason: A wet-to-dry dressing should be able to dry out between dressing changes. Thus, the dressing should be moist, not dry, when applied. As the moist dressing dries, the wound will be debrided of necrotic tissue, exudate, and so forth. Normal saline is most commonly used to moisten the sponge; Burrow's solution will irritate the wound.
The sponge should not be packed into the wound tightly because the circulation to the site could be impaired. The moist sponge should be placed so that all surfaces of the wound are in contact with the dressing. Then the sponge is covered and protected by a dry sterile dressing to prevent contamination from the external environment.
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child?
a) Encouraging the infant to hold a bottle
b) Keeping the infant on bed rest to conserve energy
c) Rotating caregivers to provide more stimulation
d) Maintaining a consistent, structured environment
CORRECT ANSWER d) Maintaining a consistent, structured environment Reason: The nurse caring for an infant with inorganic failure to thrive should strive to maintain a consistent, structured environment because it reinforces a caring feeding environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.
After teaching a group of parents about temper tantrums, the nurse knows the teaching has been effective when one of the parents states which of the following?
a) "I will ignore the temper tantrum."
b) "I should pick up the child during the tantrum."
c) "I'll talk to my daughter during the tantrum."
d) "I should put my child in time out."
CORRECT ANSWER a) "I will ignore the temper tantrum." Reason: Children who have temper tantrums should be ignored as long as they are safe. They should not receive either positive or negative reinforcement to avoid perpetuating the behavior. Temper tantrums are a toddler's way of achieving independence.
A child diagnosed with tetralogy of Fallot becomes upset, crying and thrashing around when a blood specimen is obtained. The child's color becomes blue and the respiratory rate increases to 44 breaths/minute. Which of the following actions should the nurse do first?
a) Obtain an order for sedation for the child.
b) Assess for an irregular heart rate and rhythm.
c) Explain to the child that it will only hurt for a short time.
d) Place the child in a knee-to-chest position.
CORRECT ANSWER d) Place the child in a knee-to-chest position. Reason: The child is experiencing a tet or hypoxic episode. Therefore the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from the lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of Fallot. As a result, the blood then entering the systemic circulation has a higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position in the crib, or the mother learns to put the infant over her shoulder while holding the child in a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need a sedative. Once the child is in the position, the nurse may assess for an irregular heart rate and rhythm. Explaining to the child that it will only hurt for a short time does nothing to alleviate the hypoxia.
According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage?
a) Trust versus mistrust
b) Initiative versus guilt
c) Industry versus inferiority
d) Identity versus role confusion
CORRECT ANSWER c) Industry versus inferiority Reason: In middle childhood, the 6- to 12-year-old child is mastering the task of industry versus inferiority. The trust versus mistrust task is in infancy (birth to 1 year). In early childhood, the 1- to 3-year-old child is in the stage of initiative versus guilt. Identity versus role confusion occurs during adolescence.
A nurse makes a home visit to a client who was discharged from a psychiatric hospital. The client is irritable and walks about her room slowly and morosely. After 10 minutes, the nurse prepares to leave, but the client plucks at the nurse's sleeve and quickly asks for help rearranging her belongings. She also anxiously makes inconsequential remarks to keep the nurse with her. In view of the fact that the client has previously made a suicidal gesture, which of the following interventions by the nurse should be a priority at this time?
a) Ask the client frankly if she has thoughts of or plans for committing suicide.
b) Avoid bringing up the subject of suicide to prevent giving the client ideas of self-harm.
c) Outline some alternative measures to suicide for the client to use during periods of sadness.
d) To draw out the client, mention others the nurse has known who have felt like the client and attempted suicide
CORRECT ANSWER a) Ask the client frankly if she has thoughts of or plans for committing suicide. Reason: Investigating the presence of suicidal thoughts and plans by overtly asking the client if she is thinking of or planning to commit suicide is a priority nursing action in this situation. Direct questioning about thoughts or plans related to self-harm does not give a person the idea to harm herself. Self-harm is an individual decision. Avoiding the subject when a client appears suicidal is unwise; the safest procedure is to investigate. It would be premature in this situation to outline alternative measures to
suicide. Describing other clients who have attempted suicide is too indirect to be helpful and minimizes the client's feelings.
Which of the following should the nurse teach a client with generalized anxiety disorder to help the client cope with anxiety?
a) Cognitive and behavioral strategies. b) Issue avoidance and denial of problems. c) Rest and sleep. d) Withdrawal from role expectations and role relationships.
CORRECT ANSWER a) Cognitive and behavioral strategies. Reason: A client with generalized anxiety disorder needs to learn cognitive and behavioral strategies to cope with anxiety appropriately. In doing so, the client's anxiety decreases and becomes more manageable. The client may need assertiveness training, reframing, and relaxation exercises to adaptively deal with anxiety.
A client diagnosed with a cognitive disorder is showing signs of confusion, short-term memory loss, and a short attention span. Which of the following therapy groups would be best suited for this client?
a) Insight-oriented.
b) Medication management.
c) Problem solving.
d) Reality-orientation.
CORRECT ANSWER d) Reality-orientation. Reason: Because the client has confusion, short-term memory loss, and a short attention span, a reality-orientation group is recommended to help the client maintain an optimal level of functioning, decrease isolation, and increase self-esteem. Focus is on the "here and now" and provides reality testing, structure, and social support. A client with a cognitive disorder is unlikely to benefit from an insight-oriented group, where the focus is on role relationships. Short-term memory loss and confusion interfere with the ability to learn about medication management. Short-term memory loss and confusion interfere with the ability to describe and solve problems.
Flumazenil (Romazicon) has been ordered for a client who has overdosed on oxazepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect?
a) Seizures
b) Shivering
c) Anxiety
d) Chest pain
CORRECT ANSWER a) Seizures Reason: Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.
A client who's 7 weeks pregnant comes to the clinic for her first prenatal visit. She reports smoking 20 to 25 cigarettes per day. When planning the client's care, the nurse anticipates informing her that if she doesn't stop smoking, her fetus may be at risk for:
a) spina bifida.
b) tetralogy of Fallot.
c) low birth weight.
d) hydronephrosis.
CORRECT ANSWER c) low birth weight. Reason: The risk of intrauterine growth retardation may increase with the number of cigarettes a pregnant woman smokes. Neural tube defects (such as spina bifida), cardiac abnormalities (such as tetralogy of Fallot), and renal disorders (such as hydronephrosis) are associated with multifactorial genetic inheritance, not maternal cigarette smoking.
A client who has been in the latent phase of the first stage of labor is transitioning to the active phase. During the transition, the nurse expects to see which client behavior?
a) A desire for personal contact and touch
b) A full response to teaching
c) Fatigue, a desire for touch, and quietness
d) Withdrawal, irritability, and resistance to touch
CORRECT ANSWER d) Withdrawal, irritability, and resistance to touch Reason: During the transition to the active phase of the first stage of labor, increased pain typically makes the client withdrawn, irritable, and resistant to touch. During the latent phase (the early part of the first stage of labor), when contractions aren't intensely painful, the client typically desires personal contact and touch and responds to teaching and interventions. Fatigue, a desire for touch, and quietness are common during the third and fourth stages of labor.
A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure?
a) Washing the hands
b) Washing the hands and wearing latex gloves
c) Washing the hands and wearing latex gloves and a barrier gown
d) Washing the hands and wearing latex gloves, a barrier gown, and protective eyewear
CORRECT ANSWER b) Washing the hands and wearing latex gloves Reason: During a postpartum assessment, the nurse is likely to come into contact with the client's blood or body fluids, especially when examining the perineal region. Therefore, the nurse must wear latex gloves; hand washing alone
would neither provide adequate protection nor comply with universal precautions. The nurse should wear a barrier gown and protective eyewear in addition to latex gloves only when anticipating splashing of blood or body fluids such as during childbirth. Splashing isn't likely to occur during a postpartum assessment.
When performing an initial assessment of a post-term male neonate weighing 4,000 g (9 lb) who was admitted to the observation nursery after a vaginal delivery with low forceps, the nurse detects Ortolani's sign. Which of the following actions should the nurse do next?
a) Determine the length of the mother's labor.
b) Notify the primary health care provider immediately.
c) Keep the neonate under the radiant warmer for 2 hours.
d) Obtain a blood sample to check for hypoglycemia.
CORRECT ANSWER b) Notify the primary health care provider immediately. Reason: Ortolani's maneuver involves flexing the neonate's knees and hips at right angles and bringing the sides of the knees down to the surface of the examining table. A characteristic click or "clunk," felt or heard, represents a positive Ortolani's sign, suggesting a possible hip dislocation. The nurse should notify the primary health care provider promptly because treatment is needed, while maintaining the dislocated hip in a position of flexion and abduction. Determining the length of the mother's labor provides no useful information related to the nurse's finding. Keeping the infant under the radiant warmer is necessary only if the neonate's temperature is low or unstable. Checking for hypoglycemia is not indicated at this time, unless the neonate is exhibiting jitteriness.
A client is recovering from an acute myocardial infarction (MI). During the first week of the client's recovery, the nurse should stay alert for which abnormal heart sound?
a) Opening snap
b) Graham Steell's murmur
c) Ejection click
d) Pericardial friction rub
CORRECT ANSWER d) Pericardial friction rub Reason: A pericardial friction rub, which sounds like squeaky leather, may occur during the first week following an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole. Graham Steell's murmur is a high-pitched, blowing murmur with a decrescendo pattern; heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect. An ejection click, associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.
A client who is undergoing radiation therapy develops mucositis. Which of the following interventions should be included in the client's plan of care?
a) Increase mouth care to twice per shift.
b) Provide the client with hot tea to drink.
c) Promote regular flossing of teeth.
d) Use half-strength hydrogen peroxide on mouth ulcers.
CORRECT ANSWER c) Promote regular flossing of teeth. Reason: Mucositis is an inflammation of the oral mucosa caused by radiation therapy. It is important that the client with mucositis receive meticulous mouth care, including flossing, to prevent the development of an infection. Mouth care should be provided before and after each meal, at bedtime, and more frequently as needed. Extremes of temperature should be avoided in food and drink. Half-strength hydrogen peroxide is too harsh to use on irritated tissues.
A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?
a) Straw-colored urine
b) Reduced hematocrit
c) Clay-colored stools
d) Elevated urobilinogen in the urine
CORRECT ANSWER c) Clay-colored stools Reason: Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.
When referred to a podiatrist, a client newly diagnosed with diabetes mellitus asks, "Why do you need to check my feet when I'm having a problem with my blood sugar?" The nurse's most helpful response to this statement is:
a) "The physician wants to be sure your shoes fit properly so you won't develop pressure sores."
b) "The circulation in your feet can help us determine how severe your diabetes is."
c) "Diabetes can affect sensation in your feet and you can hurt yourself without realizing it."
d) "It's easier to get foot infections if you have diabetes."
CORRECT ANSWER c) "Diabetes can affect sensation in your feet and you can hurt yourself without realizing it." Reason: The nurse should make the client aware that diabetes affects sensation in the feet and that he might hurt his foot but not feel the wound. Although it's important that the client's shoes fit properly, this isn't the only reason the client's feet need to be checked. Telling the client that diabetes mellitus increases the risk of infection or stating that the circulation in the client's feet indicates the severity of his diabetes doesn't provide the client with complete information.
A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include:
a) administration of opioids for pain control.
b) administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program.
c) administration of monthly intra-articular injections of corticosteroids.
d) vigorous physical therapy for the joints.
CORRECT ANSWER b) administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program. Reason: NSAIDs are routinely used for anti-inflammatory and analgesic effects.
NSAIDs reduce inflammation, which causes pain. Opioids aren't used for pain control in osteoarthritis. Intra-articular injection of corticosteroids is used cautiously for an immediate, short-term effect when a joint is acutely inflamed. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.
Before cataract surgery, the nurse is to instill several types of eye drops. The surgeon writes orders for 5 gtts of antibiotic in OD, and 3 drops of topical steroid drops in OD. The nurse should:
a) Contact the surgeon to rewrite the order.
b) Administer the antibiotic in the left eye and the steroid in the right eye.
c) Administer both types of drops in the right eye.
d) Contact the pharmacist for clarification of the order.
CORRECT ANSWER a) Contact the surgeon to rewrite the order. Reason: The nurse should not administer drugs without a complete order. In this case the order does not contain information about dosage and uses abbreviations that can cause confusion.
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:
a) "I need to keep my inhaler at the bedside."
b) "I should eat a high-protein diet."
c) "I should become involved in a weight loss program."
d) "I should sleep on my side all night long."
CORRECT ANSWER c) "I should become involved in a weight loss program." Reason: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become
involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea.
A nurse is caring for a client diagnosed with ovarian cancer. Diagnostic testing reveals that the cancer has spread outside the pelvis. The client has previously undergone a right oophorectomy and received chemotherapy. The client now wants palliative care instead of aggressive therapy. The nurse determines that the care plan's priority nursing diagnosis should be:
a) Acute pain
b) Impaired home maintenance
c) Noncompliance
d) Ineffective breast-feeding
CORRECT ANSWER a) Acute pain Reason: Palliative care for the client with advanced cancer includes pain management, emotional support, and comfort measures. The client is in the hospital, so home maintenance doesn't apply at this time. The client has chosen palliative care, so she isn't noncompliant. The client isn't breast-feeding, so the diagnosis of Ineffective breast-feeding doesn't apply.
A primiparous woman has recently delivered a term infant. Priority teaching for the patient includes information on:
a) Sudden infant death syndrome (SIDS)
b) Breastfeeding
c) Infant bathing
d) Infant sleep-wake cycles
CORRECT ANSWER b) Breastfeeding Reason: Breastfed infants should eat within the first hour of life and approximately every 2 to 3 hours. Successful breastfeeding will likely require sustained support, encouragement, and instruction from the nurse. Information on SIDS, infant bathing, and sleep-wake cycles are also important topics for the new parent, but they can be covered at any time prior to discharge.
When giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of:
a) 15 degrees.
b) 30 degrees.
c) 45 degrees.
d) 90 degrees.
CORRECT ANSWER d) 90 degrees. Reason: When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate
when administering an intradermal injection. A 30-degree angle isn't used for any type of injection. The nurse may use a 45- or 90-degree angle when giving a subcutaneous injection.
Twenty-four hours after a bone marrow aspiration, the nurse evaluates which of the following as an appropriate client outcome?
a) The client maintains bed rest.
b) There is redness and swelling at the aspiration site.
c) The client requests morphine sulfate for pain.
d) There is no bleeding at the aspiration site.
CORRECT ANSWER d) There is no bleeding at the aspiration site. Reason: After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes for bleeding. For a short period after the procedure, bed rest may be ordered. Signs of infection, such as redness and swelling, are not anticipated at the aspiration site. A mild analgesic may be ordered. If the client continues to need the morphine for longer than 24 hours, the nurse should suspect that internal bleeding or increased pressure at the puncture site may be the cause of the pain and should consult the physician.
A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of:
a) Nursing informatics.
b) Electronic medical records.
c) Telemedicine.
d) Computerized documentation.
CORRECT ANSWER a) Nursing informatics. Reason: Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. A specific application of nursing informatics is the use of PDAs in the clinical setting. The devices are less likely to be used to perform documentation or to constitute client records. Telemedicine involves the remote provision of care.
A parent confides to the nurse that their 8-month-old infant is anxious. Which of the following suggestions by the nurse is most appropriate to help the mother lessen her anxiety about her infant?
a) Limit holding the infant to feeding times.
b) Talk quietly to the infant while he is awake.
c) Play music in his room for most of the day and night.
d) Have a close friend keep the infant for a few days.
CORRECT ANSWER b) Talk quietly to the infant while he is awake. Reason: Infants are sensitive to stress in their caretakers. The best way to handle an anxious infant is to talk quietly to him, thereby soothing the infant. Limiting holding of the infant to feeding periods interferes with meeting the infant's needs for close contact, possibly compromising his ability to develop trust. Playing music in the room for most of the day and night will make it difficult for the infant to differentiate days from nights. Having a friend take the infant for several days will not necessarily take care of the problem because when the infant returns to the mother the same behaviors will recur unless the mother makes some changes.
A parent confides to the nurse that their 8-month-old infant is anxious. Which of the following suggestions by the nurse is most appropriate to help the mother lessen her anxiety about her infant?
a) Limit holding the infant to feeding times.
b) Talk quietly to the infant while he is awake.
c) Play music in his room for most of the day and night.
d) Have a close friend keep the infant for a few days.
A 28-year-old client with an Axis I diagnosis of major depression and an Axis II diagnosis of dependent personality disorder has been living at home with very supportive parents. The client is thinking about independent living on the recommendation of the treatment team. The client states to the nurse, "I don't know if I can make it in an apartment without my parents." The nurse should respond by saying to the client:
a) "You're a 28-year-old adult now, not a child who needs to be cared for."
b) "Your parents won't be around forever. After all, they are getting older."
c) "Your parents need a break, and you need a break from them."
d) "Your parents have been supportive and will continue to be even if you live apart."
CORRECT ANSWER d) "Your parents have been supportive and will continue to be even if you live apart." Reason: Some characteristics of a client with a dependent personality are an inability to make daily decisions without advice and reassurance and the preoccupation with fear of being alone to care for oneself. The client needs others to be responsible for important areas of his life. The nurse should respond, "Your parents have been supportive of you and will continue to be supportive even if you live apart," to gently challenge the client's fears and suggest that they may be unwarranted. Stating, "You're a 28-year-old adult now, not a child who needs to be cared for," or "Your parents need a break, and you need a break from them," is reprimanding and would diminish the client's self-worth. Stating, "Your parents won't be around forever; after all they are getting older," may be true, but it is an insensitive response that may increase the client's anxiety.
A nurse notices that a client with obsessive-compulsive disorder washes his hands for long periods each day. How should the nurse respond to this compulsive behavior?
a) By setting aside times during which the client can focus on the behavior
b) By urging the client to reduce the frequency of the behavior as rapidly as possible
c) By calling attention to or trying to prevent the behavior
d) By discouraging the client from verbalizing his anxieties
CORRECT ANSWER a) By setting aside times during which the client can focus on the behavior Reason: The nurse should set aside times during which the client is free to focus on his compulsive behavior or obsessive thoughts. The nurse should urge the client to reduce the frequency of the compulsive behavior gradually, not rapidly. She shouldn't call attention to the behavior or try to prevent it. Trying to prevent the behavior may frighten and hurt the client. The nurse should encourage the client to verbalize his anxieties to help distract attention from his compulsive behavior.
Which statement about somatoform pain disorder is accurate?
a) The pain is intentionally fabricated by the client to receive attention.
b) The pain is real to the client, even though the pain may not have an organic etiology.
c) The pain is less than would be expected as a result of the underlying disorder the client identifies.
d) The pain is what would be expected as a result of the underlying disorder the client identifies
CORRECT ANSWER b) The pain is real to the client, even though the pain may not have an organic etiology. Reason: In a somatoform pain disorder, the client has pain even though a thorough diagnostic workup reveals no organic cause for it. The nurse must recognize that the pain is real to the client. By refusing to believe that the client is in pain, the nurse impedes the development of a therapeutic trust- based relationship. While somatoform pain offers the client secondary gains, such as attention or avoidance of an unpleasant activity, the pain isn't intentionally fabricated by the client. Even if a pathologic cause of the pain can be identified, the pain is usually in excess of what the pathologic cause would normally be expected to produce.
The nurse should assess the client who is taking risperidone (Risperdal) 1 mg, orally twice a day for:
a) Insomnia.
b) Headache.
c) Anxiety.
d) Orthostatic hypotension
CORRECT ANSWER d) Orthostatic hypotension. Reason: Significant orthostatic hypotension is associated with risperidone (Risperdal) therapy. The nurse should monitor the client's blood pressure sitting and standing and teach the client interventions to manage this adverse effect to prevent risk of injury.
Although insomnia, headache, and anxiety are possible adverse effects of risperidone therapy, they are of less immediate concern than orthostatic hypotension.
A client with a history of polysubstance abuse is admitted to the facility. He complains of nausea and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through withdrawal from which substance?
a) Alcohol
b) Cannabis
c) Cocaine
d) Opioids
CORRECT ANSWER d) Opioids Reason: Piloerection, pupillary dilation, and lacrimation are specific to opioid withdrawal. A client with alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannabis. Symptoms of cocaine withdrawal include depression, anxiety, and agitation.
A client who is 32 weeks pregnant presents to the emergency department with bright red bleeding and no abdominal pain. A nurse should first:
a) perform a pelvic examination.
b) assess the client's blood pressure.
c) assess the fetal heart rate.
d) order a stat hemoglobin and hematocrit.
CORRECT ANSWER c) assess the fetal heart rate. Reason: The nurse should assess the fetal heart rate for distress or viability. She shouldn't attempt to perform a pelvic examination because of the possibility of placenta previa, which presents as bright red bleeding without abdominal pain. The nurse should assess the client's blood pressure after attempting to hear fetal heart tones. Ordering a hemoglobin and hematocrit is a physician intervention, not a nursing intervention.
A nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction?
a) Deep breathing
b) Shallow chest breathing
c) Deep, cleansing breaths
d) Chest panting
CORRECT ANSWER b) Shallow chest breathing Reason: Shallow chest breathing is used during the peak of a contraction during the transitional phase of labor. Deep breathing can cause a woman to hyperventilate and feel light-headed, with numbness or tingling in her fingers or toes. A deep, cleansing breath taken at the beginning and end of each breathing exercise can help prevent hyperventilation.
Chest panting may be used to prevent a woman from pushing before the cervix is fully dilated.
After being treated with heparin therapy for thrombophlebitis, a multiparous client who delivered 4 days ago is to be discharged on oral warfarin (Coumadin). After teaching the client about the medication and possible effects, which of the following client statements indicates successful teaching?
a) "I can take two aspirin if I get uterine cramps."
b) "Protamine sulfate should be available if I need it."
c) "I should use a soft toothbrush to brush my teeth."
d) "I can drink an occasional glass of wine if I desire."
CORRECT ANSWER c) "I should use a soft toothbrush to brush my teeth." Reason: Successful teaching is demonstrated when the client says, "I should use a soft toothbrush to brush my teeth." Heparin therapy can cause the gums to bleed, so a soft toothbrush should be used to minimize this adverse effect. Use of aspirin and other nonsteroidal anti-inflammatory medications should be avoided because of the increased risk for possible hemorrhage. Protamine sulfate is the antidote for heparin therapy. Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the metabolism of oral anticoagulants and should be avoided.
A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the care plan for the neonate during his first 24 hours?
a) Administer insulin subcutaneously.
b) Administer a bolus of glucose I.V.
c) Provide frequent early feedings with formula.
d) Avoid oral feedings.
CORRECT ANSWER c) Provide frequent early feedings with formula. Reason: The neonate of a mother with gestational diabetes may be slightly hyperglycemic immediately after birth because of the high glucose levels that cross the placenta from mother to fetus. During pregnancy, the fetal pancreas secretes increased levels of insulin in response to this increased glucose amount that crosses the placenta from the mother. However, during the first 24 hours of life, this combination of high insulin production in the neonate coupled with the loss of maternal glucose can cause severe hypoglycemia. Frequent, early feedings with formula can prevent hypoglycemia. Insulin shouldn't be administered because the neonate of a mother with gestational diabetes is at risk for hypoglycemia. A bolus of glucose given I.V. may cause rebound hypoglycemia. If glucose is given I.V., it should be administered as a continuous infusion. Oral feedings shouldn't be avoided because early, frequent feedings can help avoid hypoglycemia.
A client with a past medical history of ventricular septal defect repaired in infancy is seen at the prenatal clinic. She is complaining of dyspnea with exertion and being very tired. Her vital signs are 98, 80, 20, BP 116/72. She has + 2 pedal edema and clear breath sounds. As the nurse plans this client's care, which of the following is her cardiac classification according to the New York Heart Association Cardiac Disease classification?
a) Class I.
b) Class II.
c) Class III.
d) Class IV.
CORRECT ANSWER b) Class II. Reason: According to the New York Heart Association Cardiac Disease classification, this client would fit under Class II because she is symptomatic with increased activity (dyspnea with exertion). The New York Heart Association Cardiac Disease Classification identifies Class II clients as having cardiac disease and a slight limitation in physical activity. When physical activity occurs, the client may experience angina, difficulty breathing, palpations, and fatigue. All of the client's other symptoms are within normal limits.
The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should a nurse recommend?
a) Carcinoembryonic antigen (CEA) test after age 50
b) Proctosigmoidoscopy after age 30
c) Annual digital examination after age 40
d) Barium enema after age 20
CORRECT ANSWER c) Annual digital examination after age 40 Reason: The American Cancer Society recommends an annual digital examination after age 40 for the purpose of detecting colorectal cancer. The CEA test is performed on clients who have already been treated for colorectal cancer. It helps monitor a client's response to treatment as well as detect metastasis or recurrence.
Proctosigmoidoscopy is recommended every 3 to 5 years for people older than age 50. Barium enema isn't a screening test.
The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following?
a) Contact the client's audiologist.
b) Cleanse the hearing aid ear mold in normal saline.
c) Irrigate the ear canal.
d) Check the hearing aid's placement
CORRECT ANSWER d) Check the hearing aid's placement. Reason: Inadequate amplification can occur when a hearing aid is not placed properly. The certified audiologist is licensed to dispense hearing aids. The ear mold is the only part of the hearing aid that may be washed frequently; it should be washed daily with soap and water. Irrigation of the ear canal is done to remove impacted cerumen or a foreign body.
The physician ordered I.V. naloxone (Narcan) to reverse the respiratory depression from morphine administration. After administration of the naloxone the nurse should:
a) Check respirations in 5 minutes because naloxone is immediately effective in relieving respiratory depression.
b) Check respirations in 30 minutes because the effects of morphine will have worn off by then.
c) Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone.
d) Monitor respirations each time the client receives morphine sulfate 10 mg I.M.
CORRECT ANSWER c) Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone. Reason: The nurse should monitor the client's respirations closely for 4 to 6 hours because naloxone has a shorter duration of action than opioids. The client may need repeated doses of naloxone to prevent or treat a recurrence of the respiratory depression. Naloxone is usually effective in a few minutes; however, its effects last only 1 to 2 hours and ongoing monitoring of the client's respiratory rate will be necessary. The client's dosage of morphine will be decreased or a new drug will be ordered to prevent another instance of respiratory depression.
When caring for a client after a closed renal biopsy, the nurse should?
a) Maintain the client on strict bed rest in a supine position for 6 hours.
b) Insert an indwelling catheter to monitor urine output.
c) Apply a sandbag to the biopsy site to prevent bleeding.
d) Administer I.V. opioid medications to promote comfort.
CORRECT ANSWER a) Maintain the client on strict bed rest in a supine position for 6 hours. Reason: After a renal biopsy, the client is maintained on strict bed rest in a supine position for at least 6 hours to prevent bleeding. If no bleeding occurs, the client typically resumes general activity after 24 hours. Urine output is monitored, but an indwelling catheter is not typically inserted. A pressure dressing is applied over the site, but a sandbag is not necessary. Opioids to control pain would not be anticipated; local discomfort at the biopsy site can be controlled with analgesics.
A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require:
a) monitoring of arterial oxygen saturation (SaO2).
b) arterial blood gas (ABG) studies.
c) chest auscultation.
d) a chest X-ray.
CORRECT ANSWER d) a chest X-ray. Reason: Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently.
To prevent development of peripheral neuropathies associated with isoniazid administration, the nurse should teach the client to:
a) Avoid excessive sun exposure.
b) Follow a low-cholesterol diet.
c) Obtain extra rest.
d) Supplement the diet with pyridoxine (vitamin B6).
CORRECT ANSWER d) Supplement the diet with pyridoxine (vitamin B6). Reason: Isoniazid competes for the available vitamin B6 in the body and leaves the client at risk for developing neuropathies related to vitamin deficiency. Supplemental vitamin B6 is routinely prescribed to address this issue. Avoiding sun exposure is a preventive measure to lower the risk of skin cancer. Following a low-cholesterol diet lowers the individual's risk of developing atherosclerotic plaque. Rest is important in maintaining homeostasis but has no real impact on neuropathies.
A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation?
a) Use a cool air vaporizer with plain water.
b) Use saline nose drops and then a bulb syringe.
c) Blow into the child's mouth to clear the infant's nose.
d) Administer a nonprescription vasoconstrictive nose spray.
CORRECT ANSWER b) Use saline nose drops and then a bulb syringe. Reason: Although a cool air vaporizer may be recommended to humidify the environment, using saline nose drops and then a bulb syringe before meals and at nap and bed times will allow the child to breathe more easily. Saline helps to loosen secretions and keep the mucous membranes moist. The bulb syringe then gently aids in removing the loosened secretions. Blowing into the child's mouth to clear the nose introduces more organisms to the child. A nonprescription vasoconstrictive nasal spray is not recommended for infants because if the spray is used for longer than 3 days a rebound effect with increased inflammation occurs.
A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess?
a) Severe sore throat, drooling, and inspiratory stridor
b) Low-grade fever, stridor, and a barking cough
c) Pulmonary congestion, a productive cough, and a fever
d) Sore throat, a fever, and general malaise
CORRECT ANSWER a) Severe sore throat, drooling, and inspiratory stridor Reason: A child with acute epiglottiditis appears acutely ill and clinical manifestations may include drooling (because of difficulty swallowing), severe sore throat, hoarseness, a high temperature, and severe inspiratory stridor. A low- grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary
congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles indicate pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis.
The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to:
a) Keep their home warmer than usual.
b) Encourage plenty of outdoor activities.
c) Promote interactions with one friend instead of groups.
d) Limit bathing to prevent skin irritation.
CORRECT ANSWER c) Promote interactions with one friend instead of groups. Reason: Children with hyperthyroidism experience emotional labiality that may strain interpersonal relationships. Focusing on one friend is easier than adapting to group dynamics until the child's condition improves. Because of their high metabolic rate, children with hyperthyroidism complain of being too warm. Bright sunshine may be irritating because of disease-related ophthalmopathy. Sweating is common and bathing should be encouraged.
A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate (Eskalith), the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required?
a) "I can still eat my favorite salty foods."
b) "When my moods fluctuate, I'll increase my dose of lithium."
c) "A good blood level of the drug means the drug concentration has stabilized."
d) "Eating too much watermelon will affect my lithium level."
CORRECT ANSWER b) "When my moods fluctuate, I'll increase my dose of lithium." Reason: A client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice.
A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis?
a) Hypoactive bowel sounds
b) Severe lower back pain
c) Sensory deficits in one arm
d) Weakness and atrophy of the arm muscles
CORRECT ANSWER b) Severe lower back pain Reason: The most common finding in a client with a herniated lumbar disk is severe lower back pain, which radiates to the buttocks, legs, and feet — usually unilaterally. A herniated disk also may cause sensory and motor loss (such as footdrop) in the area innervated by the compressed spinal nerve root. During later stages, it may cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms.
A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and severe, generalized edema. The neonate is immediately transferred to the neonatal intensive care unit. Which nursing diagnosis is most appropriate for the client?
a) Ineffective denial related to a socially unacceptable infection
b) Impaired parenting related to the neonate's transfer to the intensive care unit
c) Deficient fluid volume related to severe edema
d) Fear related to removal and loss of the neonate by statute
CORRECT ANSWER b) Impaired parenting related to the neonate's transfer to the intensive care unit Reason: Because the neonate is severely ill and needs to be placed in the neonatal intensive care unit, the client may have a nursing diagnosis of Impaired parenting related to the neonate's transfer to the neonatal intensive care unit. (Another pertinent nursing diagnosis may be Compromised family coping related to lack of opportunity for bonding.) Rh isoimmunization isn't a socially unacceptable infection. This condition causes an excess fluid volume (not deficient) related to cardiac problems. Rh isoimmunization doesn't lead to loss of the neonate by statute.
The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time?
a) Firm fundus at the symphysis.
b) White, thick vaginal discharge.
c) Striae that are silver in color.
d) Soft breasts without milk.
CORRECT ANSWER a) Firm fundus at the symphysis. Reason: By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle-feeding mother).
The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:
a) peripheral acrocyanosis.
b) bradycardia.
c) lethargy.
d) jaundice.
CORRECT ANSWER c) lethargy. Reason: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia — not bradycardia — is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.
Before discharge, which instruction should a nurse give to a client receiving digoxin (Lanoxin)?
a) "Take an extra dose of digoxin if you miss one dose."
b) "Call the physician if your heart rate is above 90 beats/minute."
c) "Call the physician if your pulse drops below 80 beats/minute."
d) "Take digoxin with meals."
CORRECT ANSWER b) "Call the physician if your heart rate is above 90 beats/minute." Reason: The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute — not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. The client shouldn't take digoxin with meals; doing so slows the absorption rate.
A young man with early-stage testicular cancer is scheduled for a unilateral orchiectomy. The client confides to the nurse that he is concerned about what effects the surgery will have on his sexual performance. Which of the following responses by the nurse provides accurate information about sexual performance after an orchiectomy?
a) "Most impotence resolves in a couple of months."
b) "You could have early ejaculation with this type of surgery."
c) "We will refer you to a sex therapist because you will probably notice erectile dysfunction."
d) "Because your surgery does not involve other organs or tissues, you'll likely not notice much change in your sexual performance."
CORRECT ANSWER d) "Because your surgery does not involve other organs or tissues, you'll likely not notice much change in your sexual performance." Reason: Although there may not be a big change in sexual function with a unilateral orchiectomy, the loss of a gonad and testosterone may result in decreased libido and sterility. Sperm banking may be an option worth exploring if the number and motility of the sperm are adequate. Remember, the population most affected by testicular cancer is generally young men ages 15 to 34, and in this crucial stage of life, sexual anxieties may be a large
A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of the vaginal discharge. Which STD must be reported to the public health department?
a) Bacterial vaginitis
b) Gonorrhea
c) Genital herpes
d) Human papillomavirus (HPV
CORRECT ANSWER b) Gonorrhea Reason: Gonorrhea must be reported to the public health department. Bacterial vaginitis, genital herpes, and HPV aren't reportable diseases.
The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate?
a) Have the client wear eyeglasses at all times.
b) Lightly tape the eyelid shut.
c) Instill artificial tears once every shift.
d) Clean the eyelid with a washcloth every shift.
CORRECT ANSWER b) Lightly tape the eyelid shut. Reason: When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.
Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should:
a) Administer TPN through a nasogastric or gastrostomy tube.
b) Handle TPN using strict aseptic technique.
c) Auscultate for bowel sounds prior to administering TPN.
d) Designate a peripheral intravenous (IV) site for TPN administration.
CORRECT ANSWER b) Handle TPN using strict aseptic technique. Reason: TPN is hypertonic, high-calorie, high-protein, intravenous (IV) fluid that should be provided to clients without functional gastrointestinal tract motility, to better meet their metabolic needs and to support optimal nutrition and healing. TPN is ordered once daily, based on the client's current electrolyte and fluid balance, and must be handled with strict aseptic technique (because of its high glucose content, it is a perfect medium for bacterial growth). Also, because of the high tonicity, TPN must be administered through a central venous access, not a peripheral IV line. There is no specific need to auscultate for bowel sounds to determine whether TPN can safely be administered.
A 57-year-old Hispanic woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do?
a) Ask the client's daughter to serve as an interpreter.
b) Ask one of the Hispanic nursing assistants to serve as an interpreter.
c) Use the limited Spanish she remembers from high school along with nonverbal communication.
d) Obtain a trained medical interpreter.
CORRECT ANSWER d) Obtain a trained medical interpreter. Reason: A trained medical interpreter is required to ensure safety, accuracy of history data, and client confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture. Using the family member as interpreter violates the patient's confidentiality. Using the nursing assistant or limited Spanish and nonverbal communication do not ensure accuracy of interpretation and back-translation into English.
The nurse is assessing the development of a 7-month-old. The child should be able to:
a) Play pat-a-cake.
b) Sit without support.
c) Say two words.
d) Wave bye-bye.
CORRECT ANSWER b) Sit without support. Reason: The majority of infants (90%) can sit without support by 7 months of age. Approximately 75% of infants at 10 months of age are able to play pat-a-cake. The ability to say two words occurs in 90% of children by age 16 months. A child typically can wave bye-bye at about 14 months of age.
A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the primary care provider, he utters a stream of profanities. Which of the following statements best describes the client's behavior?
a) The client's anger is not intended personally.
b) The client's anger is a reliable sign of serious pathology.
c) The client's anger is an intended attack on the primary care provider's skills
d) The client's anger is a sign that his condition is improving.
CORRECT ANSWER a) The client's anger is not intended personally. Reason: Staff members sometimes are the recipients of a client's angry behavior because they are safe targets and are available for attack. The display of anger is rarely intended to be personal. Such behavior is not necessarily a sign of serious pathology but must be weighed in conjunction with other behaviors. An angry outburst is not an attack on a primary care provider's skills. While not necessarily pathologic, the client's behavior isn't a sign that his condition is improving.
Family members of a client with bipolar disorder tell a nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by:
a) flight of ideas and inflated self-esteem.
b) increased sleep and greater distractibility.
c) decreased self-esteem and increased physical restlessness.
d) obsession with following rules and maintaining order.
CORRECT ANSWER a) flight of ideas and inflated self-esteem. Reason: The manic phase of bipolar disorder is characterized by recurrent episodes of a persistently euphoric and expansive or irritable mood. This phase is diagnosed if the client experiences four of the following signs and symptoms for at least 1 week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or sexual activity; physical restlessness; a decreased need for sleep; increased distractibility; and excessive involvement in activities with a high potential for painful but unrecognized consequences.
Obsession with following rules and maintaining order characterizes obsessive-compulsive disorder.
A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing:
a) deeper sleep than CNS depressants.
b) greater sedation than CNS depressants.
c) a calming effect from which the client is easily aroused.
d) more prolonged sedative effects, making the client more difficult to arouse.
CORRECT ANSWER c) a calming effect from which the client is easily aroused. Reason: Shortly after phenothiazine administration, a quieting and calming effect occurs, but the client is easily aroused, alert, and responsive and has good motor coordination.
A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?
a) 7 weeks' gestation
b) 11 weeks' gestation
c) 17 weeks' gestation
d) 21 weeks' gestation
CORRECT ANSWER b) 11 weeks' gestation Reason: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks' gestation.
A client is experiencing an early postpartum hemorrhage. Which item in the client's care plan requires revision?
a) Inserting an indwelling urinary catheter
b) Fundal massage
c) Administration of oxytocics
d) Pad count
d) Pad count Reason: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained uterine contraction.
Just after delivery, a nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?
a) Rewarm the neonate gradually.
b) Rewarm the neonate rapidly.
c) Observe the neonate hourly.
d) Notify the physician when the neonate's temperature is normal.
CORRECT ANSWER a) Rewarm the neonate gradually. Reason: A neonate with a temperature of 94.1° F is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Hourly observation isn't frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the physician of the problem as soon as it's identified.
When assessing a client for early septic shock, the nurse should assess the client for which of the following?
a) Cool, clammy skin.
b) Warm, flushed skin.
c) Increased blood pressure.
d) Hemorrhage
CORRECT ANSWER b) Warm, flushed skin. Reason: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase).
Hemorrhage is not a factor in septic shock.
A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that:
a) the client requires an antiviral agent.
b) enteric precautions must be continued.
c) enteric precautions can be discontinued.
d) the client's infection may be caused by droplet transmission
CORRECT ANSWER b) enteric precautions must be continued. Reason: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn't transmitted by droplets.
Which finding best indicates that a nursing assistant has an understanding of blood glucose meter use?
a) Verbalizing an understanding of blood glucose meter use
b) Documenting a normal blood glucose level
c) Providing documentation of previous certification
d) Demonstrating correct technique
CORRECT ANSWER d) Demonstrating correct technique Reason: The best way to validate blood glucose meter use is to allow the nursing assistant to demonstrate correct technique. Verbalizing understanding doesn't demonstrate that the nursing assistant knows proper technique. Documenting a normal blood glucose level and having previous certification don't demonstrate blood glucose meter use.
The mother of a client with chronic undifferentiated schizophrenia calls the visiting nurse in the outpatient clinic to report that her daughter has not answered the phone in 10 days. "She was doing so well for months. I don't know what's wrong. I'm worried." Which of the following responses by the nurse is most appropriate?
a) "Maybe she's just mad at you. Did you have an argument?"
b) "She may have stopped taking her medications. I'll check on her."
c) "Don't worry about this. It happens sometimes."
d) "Go over to her apartment and see what's going on."
CORRECT ANSWER b) "She may have stopped taking her medications. I'll check on her." Reason: Noncompliance with medications is common in the client with chronic undifferentiated schizophrenia. The nurse has the responsibility to assess this situation. Asking the mother if they've argued or if the client is mad at the mother or telling the mother to go over to the apartment and see what's going on places the blame and responsibility on the mother and therefore is inappropriate. Telling the mother not to worry ignores the seriousness of the client's symptoms.
A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely?
a)Early deceleration pattern. b)Sinusoidal pattern.
c) Variable deceleration pattern.
d) Late deceleration pattern.
CORRECT ANSWER b) Sinusoidal pattern. Reason: The fetal heart rate of a multipara diagnosed with Rh sensitization and probable fetal hydrops and anemia will most likely demonstrate a sinusoidal pattern that resembles a sine wave. It has been hypothesized that this pattern reflects an absence of autonomic nervous control over the fetal heart rate resulting from severe hypoxia. This client will most likely require a cesarean delivery to improve the fetal outcome. Early decelerations are associated with head compression; variable decelerations are associated with cord compression; and late decelerations are associated wit
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next?
a) Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.
b) Ask the client to assume a side-lying position with the knees flexed.
c) Perform massage vigorously at the level of the umbilicus if the fundus feels boggy.
d) Place the client on a bedpan in case the uterine palpation stimulates the client to void.
CORRECT ANSWER a) Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Reason: The nurse should place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents uterine inversion and trauma, which can be very painful to the client. The nurse should ask the client to assume a supine, not side- lying, position with the knees flexed. The fundus can be palpated in this position and the perineal pads can be evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels boggy.
Vigorous massaging may fatigue the uterus and cause it to become firm and then boggy again. The nurse should ask the client to void before fundal evaluation. A full bladder can cause discomfort to the client, the uterus to be deviated to one side, and postpartum hemorrhage.
While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following?
a) Phimosis.
b) Hydrocele.
c) Epispadias.
d) Hypospadias
CORRECT ANSWER d) Hypospadias. Reason: The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
a)Endotracheal suctioning b)Encouragement of coughing c)Use of a cooling blanket d)Incentive spirometry
CORRECT ANSWER a) Endotracheal suctioning Reason: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
A client is scheduled for an excretory urography at10 a.m. An order directs the nurse to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at:a)7:30 a.m.b)8:30 a.m.c)9 a.m.d)9:30 a.m.
CORRECT ANSWER a) 7:30 a.m. Reason: It takes up to 2 hours for lidocaine-prilocaine cream (EMLA cream) to anesthetize an insertion site. Therefore, if the insertion is scheduled for 9:30 a.m., EMLA cream should be applied at 7:30 a.m. The local anesthetic wouldn't be effective if the nurse administered it at the later times.
A worried mother confides in the nurse that she wants to change physicians because her infant is not getting better. The best response by the nurse is which of the following?a)"This doctor has been on our staff for 20 years."b)"I know you are worried, but the doctor has an excellent reputation."c)"You always have an option to change. Tell me about your concerns."d)"I take my own children to this doctor."
CORRECT ANSWER c) "You always have an option to change. Tell me about your concerns." Reason: Asking the mother to talk about her concerns acknowledges the mother's rights and encourages open discussion. The other responses negate the parent's concerns.
A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent?a)Protects the client's right to self- determination in health care decision making.b)Helps the client refuse treatment that he or she does not wish to undergo.c)Helps the client to make a living will regarding future health care required.d)Provides the client with in-depth knowledge about the treatment options available.
CORRECT ANSWER a) Protects the client's right to self-determination in health care decision making. Reason: Informed consent protects the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for:a)Hyperalbuminemia.b)Thrombocytopenia.c)Hypokalemia.d)Hypercalcemia.
CORRECT ANSWER c) Hypokalemia. Reason: Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest.
Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.
When developing a care plan for a client with a do-not-resuscitate (DNR) order, a nurse should:a)withhold food and fluids.b)discontinue pain medications.c)ensure access to spiritual care providers upon the client's request.d)always make the DNR client the last in prioritization of clients.
CORRECT ANSWER c) ensure access to spiritual care providers upon the client's request. Reason: Ensuring access to spiritual care, if requested by the client, is an appropriate nursing action. A nurse should continue to administer appropriate doses of pain medication as needed to promote the client's comfort. A health care provider may not withhold food and fluids unless the client has a living will that specifies this action. A DNR order does not mean that the client does not require nursing care.
Which of the following laboratory findings are expected when a client has diverticulitis?a)Elevated red blood cell count.b)Decreased platelet count.c)Elevated white blood cell count.d)Elevated serum blood urea nitrogen concentration.
CORRECT ANSWER c) Elevated white blood cell count. Reason: Because of the inflammatory nature of diverticulitis, the nurse would anticipate an elevated white blood cell count. The remaining laboratory findings are not associated with diverticulitis. Elevated red blood cell counts occur in clients with polycythemia vera or fluid volume deficit. Decreased platelet counts can occur as a result of aplastic anemias or malignant blood disorders, as an adverse effect of some drugs, and as a result of some heritable conditions. Elevated serum blood urea nitrogen concentration is usually associated with renal conditions.
The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect which of the following?a)Increased forced expiratory volume.b)Normal breath sounds.c)Inspiratory and expiratory wheezing.d)Morning headaches.
CORRECT ANSWER c) Inspiratory and expiratory wheezing. Reason: The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations, there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume [forced expiratory flow (FEF) is the flow (or speed) of air coming out of the lung during the middle portion of a forced expiration] due to bronchial constriction. Morning headaches are found with more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia.
A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching?a)"I'll increase my intake of protein during exacerbations."b)"I should increase my intake of fresh fruits and vegetables during remissions."c)"I'll snack on nuts, olives, and popcorn during flare- ups."d)"I'll incorporate foods rich in omega-3 fatty acids into my diet."
CORRECT ANSWER b) "I should increase my intake of fresh fruits and vegetables during remissions." Reason: A client with diverticulitis needs to modify fiber intake to effectively manage the disease. During episodes of diverticulitis, he should follow a low-fiber diet to help minimize bulk in the stools. A client with diverticulosis should follow a high-fiber diet. Clients with diverticular disease don't need to modify their intake of protein and omega-3 fatty acids.
The nurse is serving on the hospital ethics committee which is considering the ethics of a proposal for the nursing staff to search the room of a client diagnosed with substance abuse while he is off the unit and without his knowledge. Which of the following should be considered concerning the relationship of ethical and legal standards of behavior?a)Ethical standards are generally higher than those required by law.b)Ethical standards are equal to those required by law.c)Ethical standards bear no relationship to legal standards for behavior.d)Ethical standards are irrelevant when the health of a client is at risk.
CORRECT ANSWER a) Ethical standards are generally higher than those required by law. Reason: Some behavior that is legally allowed might not be considered ethically appropriate. Legal and ethical standards are often linked, such as in the commandment "Thou shalt not kill." Ethical standards are never irrelevant, though a client's safety or the safety of others may pose an ethical dilemma for health care personnel. Searching a client's room when they are not there is a violation of their privacy. Room searches can be done with a primary health care provider's order and generally are done with the client present.
Which of the following interventions would be most appropriate for the nurse to recommend to a client to decrease discomfort from hemorrhoids?a)Decrease fiber in the diet.b)Take laxatives to promote bowel movements.c)Use warm sitz baths.d)Decrease physical activity.
CORRECT ANSWER c) Use warm sitz baths. Reason: Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids. Fiber in the diet should be increased to promote regular bowel movements. Laxatives are irritating and should be avoided. Decreasing physical activity will not decrease discomfort.
The nurse has discussed sexuality issues during the prenatal period with a primigravida who is at 32 weeks' gestation. She has had one episode of preterm labor. The nurse determines that the client understands the instructions when she says:a)"I can resume sexual intercourse when the bleeding
stops."b)"I should not get sexually aroused or have any nipple stimulation."c)"I can resume sexual intercourse in 1 to 2 weeks."d)"I should not have sexual intercourse until my next prenatal visit."
CORRECT ANSWER b) "I should not get sexually aroused or have any nipple stimulation." Reason: This client has already had one episode of preterm labor at 32 weeks' gestation. Sexual intercourse, arousal, and nipple stimulation may result in the release of oxytocin which can contribute to continued preterm labor and early delivery. The client should be advised to refrain from these activities until closer to term, which is 6 to 8 weeks later. Telling the client that intercourse is acceptable after the bleeding stops is incorrect and may lead to early delivery of a preterm neonate. The client should not have intercourse for at least 6 weeks because of the danger of inducing labor. There is no indication when the client's next prenatal visit is scheduled.
Which of the following client statements indicates that the client with hepatitis B understands discharge teaching?a)"I will not drink alcohol for at least 1 year."b)"I must avoid sexual intercourse."c)"I should be able to resume normal activity in a week or two.d)"Because hepatitis B is a chronic disease, I know I will always be jaundiced."
CORRECT ANSWER a) "I will not drink alcohol for at least 1 year." Reason: It is important that the client understand that alcohol should be avoided for at least 1 year after an episode of hepatitis. Sexual intercourse does not need to be avoided, but the client should be instructed to use condoms until the hepatitis B surface antigen measurement is negative. The client will need to restrict activity until liver function test results are normal; this will not occur within 1 to 2 weeks. Jaundice will subside as the client recovers; it is not a permanent condition.
A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem?a)Abruptio placentae.b)Placenta previa.c)Disseminated intravascular coagulation.d)Threatened abortion.
CORRECT ANSWER c) Disseminated intravascular coagulation. Reason: A fetus that has died and is retained in utero places the mother at risk for disseminated intravascular coagulation (DIC) because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. The longer the fetus is retained in utero, the greater the risk of DIC. This client has no risk factors, history, or signs and symptoms that put her at risk for either abruptio placentae or placenta previa, such as sharp pain and "woody," firm consistency of the abdomen (abruption) or painless bright red vaginal bleeding (previa). There is no evidence that she is threatening to abort as she has no complaints of cramping or vaginal bleeding.
A parent brings a 5-year-old child to a vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. To determine the current evidence for best practices for scheduling missed vaccinations the nurse should:a)Ask the primary care provider.b)Check the website at the Center for Disease Control and Prevention (CDC).c)Read the vaccine manufacturer's insert.d)Contact the pharmacist.
CORRECT ANSWER b) Check the website at the Center for Disease Control and Prevention (CDC). Reason: The CDC is the federal body that is ultimately responsible for vaccination recommendations for adults and children. A division of the CDC, the Advisory Committee on Immunization Practices, reviews
vaccination evidence and updates recommendation on a yearly basis. The CDC publishes current vaccination catch-up schedules that are readily available on their website. The lack of vaccinations is a strong indicator that the child probably does not have a primary care provider. If consulted, the pharmacist would most likely have to review the CDC guidelines that are equally available to the nurse. Reading the manufacturer's inserts for multiple vaccines would be time consuming and synthesis of the information could possibly lead to errors.
Which of the following statements would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?a)Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks.b)Activity level is determined by the client's tolerance; she can be as active as she wishes.c)Activity level will be restricted for several months, so she should plan on being sedentary.d)Activity level can return to normal and may include regular aerobic exercises.
a) Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks. Reason: The scarring of the retinal tear needs time to heal completely. Therefore, resumption of activity should be gradual; the client may resume her usual activities in 5 to 6 weeks. Successful healing should allow the client to return to her previous level of functioning.
A nurse preceptor is working with a student nurse who is administering medications. Which statement by the student indicates an understanding of the action of an antacid?a)"The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity."b)"The action occurs in the small intestine, where the drug coats the lining and prevents further ulceration."c)"The action occurs in the esophagus by increasing peristalsis and improving movement of food into the stomach."d)"The action occurs in the large intestine by increasing electrolyte absorption into the system that decreases pepsin absorption."
CORRECT ANSWER a) "The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity." Reason: The action of an antacid occurs in the stomach. The anions of an antacid combine with the acidic hydrogen cations secreted by the stomach to form water, thereby increasing the pH of the stomach contents. Increasing the pH and decreasing the pepsin activity provide symptomatic relief from peptic ulcer disease. Antacids don't work in the large or small intestine or in the esophagus.
A nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to:a)start using insulin.b)start taking an oral antidiabetic drug.c)monitor her urine for glucose.d)be taught about diet.
CORRECT ANSWER d) be taught about diet. Reason: The client will need to watch her overall diet intake to control her blood glucose level. The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. Oral antidiabetic drugs aren't used in pregnant clients. Urine glucose levels aren't an accurate indication of blood glucose levels.
The nurse meets with the client and his wife to discuss depression and the client's medication. Which of the following comments by the wife would indicate that the nurse's teaching about disease process and medications has been effective?a)"His depression is almost cured."b)"He's intelligent and won't need to
depend on a pill much longer."c)"It's important for him to take his medication so that the depression will not return or get worse."d)"It's important to watch for physical dependency on Zoloft."
CORRECT ANSWER c) "It's important for him to take his medication so that the depression will not return or get worse." Reason: Improved balance of neurotransmitters is achieved with medication. Clients with endogenous depression must take antidepressants to prevent a return or worsening of depressive symptoms. Depression is a chronic disease characterized by periods of remission; however, it is not cured. Depression is not dependent on the client's intelligence to will the illness away. Zoloft is not physically addictive.
A nurse is developing a nursing diagnosis for a client. Which information should she include?a)Actions to achieve goalsb)Expected outcomesc)Factors influencing the client's problemd)Nursing history
CORRECT ANSWER c) Factors influencing the client's problem Reason: A nursing diagnosis is a written statement describing a client's actual or potential health problem. It includes a specified diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the evaluation step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process.
A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?a)Diaphragmatic breathingb)Use of accessory musclesc)Pursed-lip breathingd)Controlled breathing
CORRECT ANSWER b) Use of accessory muscles Reason: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?a)Trendelenburg'sb)30-degree head elevationc)Flatd)Side-lying
CORRECT ANSWER b) 30-degree head elevation Reason: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.
Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area? a)The client will be maintained on bed rest for several days.b)Ambulation is restricted by the presence of drainage tubes.c)The operative incision is near the diaphragm.d)The presence of a nasogastric tube inhibits deep breathing.
CORRECT ANSWER c) The operative incision is near the diaphragm. Reason: The incisions made for upper abdominal surgeries, such as cholecystectomies, are near the diaphragm and make deep breathing painful. Incentive spirometry, which encourages deep breathing, is essential to prevent atelectasis after surgery. The client is not maintained on bed rest for several days. The client is encouraged to ambulate
by the first postoperative day, even with drainage tubes in place. Nasogastric tubes do not inhibit deep breathing and coughing.
atelectasis
1. The absence of gas from all or part of the lung, due to failure of expansion of thealveoli. 2. A congenital condition characterized by incomplete expansion of the lungs.
A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at work and is being transported to the hospital by ambulance. Which of the following should the nurse do upon the client's arrival?a)Position the client in a supine position.b)Auscultate breath sounds every 4 hours.c)Monitor the vital signs every 4 hours.d)Admit the client to a quiet, darkened room.
CORRECT ANSWER d) Admit the client to a quiet, darkened room. Reason: Because of her age and report of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the absence of any underlying cause. Although the actual cause is unknown, adolescents and women older than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible.
Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema, breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least every hour.
A nurse is facilitating mandated group therapy for clients who have sexually abused children. Children who are victims of sexual abuse are typically:a)from any segment of the population.b)of low socioeconomic background.c)strangers to the abuser.d)willing to engage in sexual acts with adults.
CORRECT ANSWER a) from any segment of the population. Reason: Victims of childhood sexual abuse come from all segments of the population and from all socioeconomic backgrounds. Most victims know their abuser. Children rarely willingly engage in sexual acts with adults because they don't have full decision-making capacities.
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?a)Sit with the client for a few minutes.b)Administer an analgesic.c)Inform the nurse manager.d)Call the physician immediately.
CORRECT ANSWER d) Call the physician immediately. Reason: The nurse should notify the physician immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse manager isn't necessary.
A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet?a)Lean beef.b)Air-popped popcorn.c)Hot chocolate.d)Raw vegetables.
CORRECT ANSWER c) Hot chocolate. Reason: With GERD, eating substances that decrease lower esophageal sphincter pressure causes heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into the lower end of the esophagus. Foods that can cause a decrease in
esophageal sphincter pressure include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be acceptable.
A woman who has recently immigrated from Africa who delivered a term neonate a short time ago requests that a "special bracelet" be placed on the baby's wrist. The nurse should:a)Tell the mother that the bracelet is not recommended for cleanliness reasons.b)Apply the bracelet on the neonate's wrist as the mother requests.c)Place the bracelet on the neonate, limiting its use to when the neonate is with the mother.d)Recommend that the mother wait until she is discharged to apply the bracelet.
CORRECT ANSWER b) Apply the bracelet on the neonate's wrist as the mother requests. Reason: The nurse should abide by the mother's request and place the bracelet on the neonate. In some cultures, amulets and other special objects are viewed as good luck symbols. By allowing the bracelet, the nurse demonstrates culturally sensitive care, promoting trust. The neonate can wear the bracelet while with the mother or in the nursery. The bracelet can be used while the neonate is being bathed, or if necessary and acceptable to the client removed and replaced afterward.
A client who took an overdose of Tylenol in a suicide attempt is transferred overnight to the psychiatric inpatient unit from the intensive care unit. The night shift nurse called the primary health care provider on call to obtain initial prescriptions. The primary health care provider prescribes the typical routine medications for clients on this unit: Milk of Magnesia, Maalox and Tylenol as needed. Prior to implementing the prescriptions, the nurse should?a)Ask the primary health care provider about holding all the client's PM prescriptions.b)Question the primary health care provider about the Tylenol prescription.c)Request a prescription for a medication to relieve agitation.d)Suggest the primary health care provider write a prescription for intravenous fluids.
CORRECT ANSWER b) Question the primary health care provider about the Tylenol prescription. Reason: The nurse should question the Tylenol order because the client overdosed on Tylenol, and that analgesic would be contraindicated as putting further stress on the liver. There is no need to hold the PM Milk of Magnesia or Maalox. There is no indication that the client is agitated or needs medication for agitation. There is little likelihood that the client needs an IV after being transferred out of an intensive care unit, as the client will be able to take oral fluids.
A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which action is a part of the child's care?a)Taking vital signs every 4 hours and obtaining daily weightb)Obtaining a blood sample for electrolyte analysis every morningc)Checking every urine specimen for protein and specific gravityd)Ensuring that the child has accurate intake and output and eats a high-protein diet
CORRECT ANSWER a) Taking vital signs every 4 hours and obtaining daily weight Reason: Because major complications — such as hypertensive encephalopathy, acute renal failure, and cardiac decompensation
— can occur, monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. Obtaining daily weight and monitoring intake and output also provide evidence of the child's fluid balance status. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Typically, protein intake remains normal for the child's age and is only increased if the child is losing large amounts of protein in the urine. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte
levels may be done, but their frequency is determined by the child's status. These actions are less important nursing measures in this situation.
A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which action is a part of the child's care?a)Taking vital signs every 4 hours and obtaining daily weightb)Obtaining a blood sample for electrolyte analysis every morningc)Checking every urine specimen for protein and specific gravityd)Ensuring that the child has accurate intake and output and eats a high-protein diet
CORRECT ANSWER a) Taking vital signs every 4 hours and obtaining daily weight Reason: Because major complications — such as hypertensive encephalopathy, acute renal failure, and cardiac decompensation
— can occur, monitoring vital signs (including blood pressure) is an important measure for a child with acute glomerulonephritis. Obtaining daily weight and monitoring intake and output also provide evidence of the child's fluid balance status. Sodium and water restrictions may be ordered depending on the severity of the edema and the extent of impaired renal function. Typically, protein intake remains normal for the child's age and is only increased if the child is losing large amounts of protein in the urine. Checking urine specimens for protein and specific gravity and daily monitoring of serum electrolyte levels may be done, but their frequency is determined by the child's status. These actions are less important nursing measures in this situation.
Hypertensive encephalopathy
is a syndrome consisting of a sudden elevation of arterial pressure usually preceded by severe headache and followed by convulsions, coma or a variety of transitory cerebral phenomena.
Cardiac decompensation
a condition of congestive heart failure (CHF) in which the heart is unable to ensure adequate cellular perfusion in all parts of the body without assistance. Causes may include myocardial infarction, increased workload, infection, toxins, or defective heart valves.
A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3–, 26 mEq/L. Based on these values, the nurse should suspect which condition?a)Respiratory acidosisb)Respiratory alkalosisc)Metabolic acidosisd)Metabolic alkalosis
CORRECT ANSWER a) Respiratory acidosis Reason: This client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3–) values are below normal. In metabolic alkalosis, the pH and HCO3– values are above normal.
The nurse walks into a client's room to administer the 9:00 a.m. medications and notices that the client is in an awkward position in bed. What is the nurse's first action?a)Ask the client his name.b)Check the client's name band.c)Straighten the client's pillow behind his back.d)Give the client his medications.
CORRECT ANSWER c) Straighten the client's pillow behind his back. Reason: The nurse should first help the client into a position of comfort even though the primary purpose for entering the room was to administer medication. After attending to the client's basic care needs, the nurse can proceed with the
proper identification of the client, such as asking the client his name and checking his armband, so that the medication can be administered.
Hi Abbi,
Your question of the day is below! Click an answer and see if you're correct. Good luck! June 24th, 2015Category: Respiratory DisordersA client is prescribed metaproterenol (Alupent) via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report adverse effects. Which of the following are potential adverse effects of metaproterenol?a)Irregular heartbeat.b)Constipation.c)Pedal edema.d)Decreased pulse rate.
CORRECT ANSWER a) Irregular heartbeat. Reason: Irregular heartbeats should be reported promptly to the care provider. Metaproterenol (Alupent) may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.
A client with an incomplete small-bowel obstruction is to be treated with a Cantor tube. Which of the following measures would most likely be included in the client's care once the Cantor tube has passed into the duodenum?a)Maintain bed rest with bathroom privileges.b)Advance the tube 2 to 4 inches at specified times.c)Avoid frequent mouth care.d)Provide ice chips for the client to suck.
CORRECT ANSWER b) Advance the tube 2 to 4 inches at specified times. Reason: Once the intestinal tube has passed into the duodenum, it is usually advanced as ordered 2 to 4 inches every 30 to 60 minutes.
This, along with gravity and peristalsis, enables passage of the tube forward. The client is encouraged to walk, which also facilitates tube progression. A client with an intestinal tube needs frequent mouth care to stimulate saliva secretion, to maintain a healthy oral cavity, and to promote comfort regardless of where the tube is placed in the intestine. Ice chips are contraindicated because hypotonic fluid will draw extra fluid into an already distended bowel.
A primigravid client gives birth to a full-term girl. When teaching the client and her partner how to change their neonate's diaper, the nurse should instruct them to:a)fold a cloth diaper so that a double thickness covers the front.b)clean and dry the neonate's perineal area from front to back.c)place a disposable diaper over a cloth diaper to provide extra protection.d)position the neonate so that urine will fall to the back of the diaper.
CORRECT ANSWER b) clean and dry the neonate's perineal area from front to back. Reason: When changing a female neonate's diaper, the caregiver should clean the perineal area from front to back to prevent infection and then dry the area thoroughly to minimize skin breakdown. For a male, the caregiver should clean and dry under and around the scrotum. Because of anatomic factors, a female's diaper should have the double thickness toward the back. The diaper, not the neonate, should be positioned properly. Placing a disposable diaper over a cloth diaper isn't necessary. The direction of urine flow can't be ensured.
When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which of the following points?a)Halfway between the client's symphysis pubis and umbilicus.b)At about the level of the client's umbilicus.c)Between the client's umbilicus and xiphoid process.d)Near the client's xiphoid process and compressing the diaphragm.
CORRECT ANSWER b) At about the level of the client's umbilicus. Reason: Measurement of the client's fundal height is a gross estimate of fetal gestational age. At 20 weeks' gestation, the fundal height should be at about the level of the client's umbilicus. The fundus typically is over the symphysis pubis at 12 weeks. A fundal height measurement between these two areas would suggest a fetus with a gestational age between 12 and 20 weeks. The fundal height increases approximately 1 cm/week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approximately 36 weeks' gestation. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fundus then commonly returns to about 4 cm below the xiphoid owing to lightening at 40 weeks. Additionally, pressure on the diaphragm occurs late in pregnancy.
Therefore, a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older.
The client is taking risperidone (Rispeodal) to treat the positive and negative symptoms of schizophrenia. Improvement of which of the following negative symptoms indicate the drug is effective? a.) abnormal thought form b.) hallucinations and delusions c.) bizarre behavior d.) asocial behavior and anergia
CORRECT ANSWER d) Asocial behavior and anergia. Reason: Asocial behavior, anergia, alogia, and affective flattening are some of the negative symptoms of schizophrenia that may improve with risperidone therapy. Abnormal thought form is a positive symptom of schizophrenia. Hallucinations and delusions are positive symptoms of schizophrenia. Bizarre behavior is a positive symptom of schizophrenia.
Anergia
(noun) Lack of energy; inactivity.
Alogia
an inability to speak, especially as the result of a brain lesion.
The wife of a 67-year-old client who has been taking imipramine (Tofranil) for 3 days asks the nurse why her husband isn't better. The nurse should tell the wife:a)"It takes 2 to 4 weeks before the full therapeutic effects are experienced."b)"Your husband may need an increase in dosage."c)"A different antidepressant may be necessary."d)"It can take 6 weeks to see if the medication will help your husband."
CORRECT ANSWER a) "It takes 2 to 4 weeks before the full therapeutic effects are experienced." Reason: Imipramine, a tricyclic antidepressant, typically requires 2 to 4 weeks of therapy before the full therapeutic effects are experienced. Because the client has been taking the drug for only 3 days, it is too soon to determine if the current dosage of imipramine is effective. It is also too soon to consider taking another antidepressant.
Peripheral resistance.
is the resistance (The resistance offered by the peripheral circulation is known as the systemic vascular resistance ( SVR)) of the arteries to blood flow. As the arteries constrict, the resistance increases and as they dilate, resistance decreases. Peripheral resistance is determined by three factors: Autonomic activity: sympathetic activity constricts peripheralarteries.
When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include:a)increased coronary artery blood flow. b)decreased posterior thoracic curve.c)decreased peripheral resistance.d)delayed gastric emptying.
CORRECT ANSWER d) delayed gastric emptying. Reason: Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.
After staying several hours with her 9-year-old daughter who is admitted to the hospital with an asthma attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which of the following findings should lead the nurse to believe the child is experiencing anxiety?a)Not able to get comfortable.b)Frequent requests for someone to stay in the room.c)Inability to remember her exact address.d)Verbalization of a feeling of tightness in her chest.
CORRECT ANSWER b) Frequent requests for someone to stay in the room. Reason: A 9-year-old child should be able to tolerate being alone. Frequently asking for someone to be in the room indicates a degree of psychological distress that, at this age, suggests anxiety. The inability to get comfortable is more characteristic of a child in pain. Inability to answer questions correctly may reflect a state of anoxia or a lack of knowledge. Tightness in the chest occurs as a result of bronchial spasms.
A client diagnosed with pain disorder is talking with the nurse about fishing when he suddenly reverts to talking about the pain in his arm. Which of the following should the nurse do next?a)Allow the client to talk about his pain.b)Ask the client if he needs more pain medication.c)Get up and leave the client.d)Redirect the interaction back to fishing.
CORRECT ANSWER d) Redirect the interaction back to fishing. Reason: The nurse should redirect the interaction back to fishing or another focus whenever the client begins to ruminate about physical symptoms or impairment. Doing so helps the client talk about topics that are more therapeutic and beneficial to recovery. Allowing the client to talk about his pain or asking if he needs additional pain medication is not therapeutic because it reinforces the client's need for the symptom. Getting up and leaving the client is not appropriate unless the nurse has set limits previously by saying, "I will get up and leave if you continue to talk about your pain."
A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should:a)place the client in a supine position and prepare to perform cardiopulmonary resuscitation.b)place the client in high-Fowler's position and administer supplemental oxygen.c)turn the client on his left side and place the bed in Trendelenburg's position.d)position the client in the shock position with his legs elevated.
CORRECT ANSWER c) turn the client on his left side and place the bed in Trendelenburg's position. Reason: A nurse who suspects an air embolism should place the client on his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.
Fowler's Position
Semi-Fowler's position is the position of a patient who is lying in bed in a supine position with the head of the bed at approximately 30 to 45 degrees. Upright at 90 degrees is full or high Fowler's position.
Recumbent On your side
Suspine & Prone position
suspine - on your backProne - on your stomach Trendelenburg position
the body is laid flat on the back ( supine position) with the feet higher than the head by 15-30 degrees, in contrast to the reverse Trendelenburg position, where the body is tilted in the opposite direction.
A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which of the following indicators of early shock?a)Tachycardia.b)Dry, flushed skin.c)Increased urine output.d)Loss of consciousness.
CORRECT ANSWER a) Tachycardia. Reason: In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation. The skin becomes cool and clammy. Urine output in early shock may be normal or slightly decreased. The client may experience increased restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock.
Which of the following is an early symptom of glaucoma?a)Hazy vision.b)Loss of central vision.c)Blurred or "sooty" vision.d)Impaired peripheral vision.
CORRECT ANSWER d) Impaired peripheral vision. Reason: In glaucoma, peripheral vision is impaired long before central vision is impaired. Hazy, blurred, or distorted vision is consistent with a diagnosis of cataracts. Loss of central vision is consistent with senile macular degeneration but it occurs late in glaucoma. Blurred or "sooty" vision is consistent with a diagnosis of detached retina.
The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is:a)Relief from spasms of the diaphragm.b)Relaxation of smooth muscles in the bronchioles.c)Efficient pulmonary circulation.d)Stimulation of the medullary respiratory center.
CORRECT ANSWER b) Relaxation of smooth muscles in the bronchioles. Reason: Aminophylline, a bronchodilator that relaxes smooth muscles in the bronchioles, is used in the treatment of emphysema to improve ventilation by dilating the bronchioles. Aminophylline does not have an effect on the diaphragm or the medullary respiratory center and does not promote pulmonary circulation.
A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to:a)remove the raised skin because the blister has already broken.b)wash the area with soap and water to disinfect it.c)apply a weakened alcohol solution to clean the area.d)clean the area with normal saline solution and cover it with a protective dressing.
CORRECT ANSWER d) clean the area with normal saline solution and cover it with a protective dressing. Reason: The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened; removing the skin exposes a larger area to the risk of infection.
Nurses teach infant care and safety classes to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints for infants is correct?
a) An infant should ride in a front-facing car seat until he weighs 20 lb (9.1 kg) and is 1 year old.
b) An infant should ride in a rear-facing car seat until he weighs 25 lb (11.3 kg) or is 1 year old.
c)An infant should ride in a front-facing car seat until he weighs 30 lb (13.6 kg) or is 2 years old.
d) An infant should ride in a rear-facing car seat until he weighs 20 lb and is 1 year old.
b)An infant should ride in a rear-facing car seat until he weighs 25 lb (11.3 kg) or is 1 year old.
An 18-year-old high school senior wishes to obtain birth control through her parents' insurance but does not want the information disclosed. The nurse tells the client that under the Health Information Portability and Accountability Act (HIPAA) parents:
a) Have the right to review a minor's medical records until high school graduation.
b) Have the right to review a minor's medical record if they are responsible for the payment.
c) May not view the medical record, but may learn of the visit through the insurance bill.
d) May not view the minor's medical record or the insurance bill.
CORRECT ANSWER c) May not view the medical record, but may learn of the visit through the insurance bill.Reason: Under HIPAA, 18-year-olds have the right to medical privacy and their medical records may not be disclosed to their parents without their permission. However, the adolescent must be made aware of the fact that information is sent to third party payers for the purpose of reimbursement. Those payers send the primary insurer, in this case the parent, a statement of benefits. HIPAA protects the right to medical privacy of all 18-year-olds regardless of their educational status. Even if parents are responsible for payment, they may not view the patient's chart without the consent of the adolescent.
The nurse is assessing a client's testes. Which of the following findings indicate the testes are normal? a)Soft.b)Egg-shaped.c)Spongy.d)Lumpy.
CORRECT ANSWER b) Egg-shaped.Reason: Normal testes feel smooth, egg-shaped, and firm to the touch, without lumps. The surface should feel smooth and rubbery. The testes should not be soft or spongy to the touch. Testicular malignancies are usually nontender, nonpainful hard lumps. Lumps, swelling, nodules, or signs of inflammation should be reported to the physician.
The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?
a) Minimal leaking.
b) No swelling.
c) Tissue pallor.
d) Evidence of a bleb or wheal.
CORRECT ANSWER d) Evidence of a bleb or wheal.Reason: A properly administered intradermal injection shows evidence of a bleb or wheal at the injection site. There should be no leaking of medication from the bleb; it needs to be absorbed into the tissue. Lack of swelling at the injection site means that the injection was given too deeply. The presence of tissue pallor does not indicate that the injection was given correctly.
An Arab client with pneumonia has been admitted to the health care facility. What should the nurse avoid while conducting the interview of the client?a)Giving a light handshake.b)Maintaining eye contact.c)Asking about the client's symptoms.d)Asking about the client's medical history.
CORRECT ANSWER b) Maintaining eye contact.Reason: While interviewing an Arab client, the nurse should avoid maintaining eye contact. In Arab culture, maintaining eye contact is sexually suggestive; if the nurse does so during the interview, it may give the wrong message to the client. However, the nurse may give a light handshake or ask about the client's personal life and medical history during the interview.
A physician has ordered penicillin G potassium (Pfizerpen), I.V., for a client with a severe streptococcal infection. A nurse determines that the client may be allergic to penicillin. When considering best practice, what should the nurse's priority intervention be?a) Holding the penicillin G potassium and charting that it was held because the client is allergicb) Administering the penicillin G potassium and staying alert for any reactionc) Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillind) Administering the penicillin G potassium but notifying the pharmacist that the client might experience an allergic reaction
CORRECT ANSWER c) Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillinReason: The nurse should hold the penicillin G potassium, even if the client isn't sure he's allergic to penicillin, and notify the physician so he may order a different antibiotic. Many clients can't act as their own advocates; they rely on nurses to protect their rights. An allergy to penicillin G potassium is suspected, but not comfirmed. Administering penicillin G potassium could cause a life- threatening reaction. Administering the medication, then watching for a reaction or notifying the pharmacist that a reaction might occur, isn't best practice. If a client is allergic to penicillin, a nurse should alert the pharmacist and label the client's chart appropriately.
A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for:a)nausea and vomiting.b)dyspnea and cyanosis.c)fatigue and weakness.d)thrush and circumoral pallor.
CORRECT ANSWER c) fatigue and weakness.Reason: RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Nausea and vomiting may occur in CRF but don't result from faulty RBC production. Dyspnea and cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor, which reflects decreased oxygenation, aren't signs of CRF.
A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine (Mucomyst). Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it:a)is a respiratory depressant.b)is a respiratory stimulant.c)may induce bronchospasm.d)inhibits the cough reflex.
CORRECT ANSWER c) may induce bronchospasm.Reason: Acetylcysteine must be used cautiously in a client with asthma because it may induce bronchospasm. The drug isn't a respiratory depressant or stimulant. It's a mucolytic agent that decreases the viscosity of respiratory secretions by altering the molecular composition of mucus. Acetylcysteine doesn't inhibit the cough reflex.
A 75-year-old client is newly diagnosed with diabetes. The nurse is instructing him about blood glucose testing. After the session, the client states, "I can't be expected to remember all this stuff." The nurse should recognize this response as most likely related to which of the following?a)Moderate to severe anxiety.b)Disinterest in the illness.c)Early-onset dementia.d)Normal reaction to learning a new skill.
CORRECT ANSWER a) Moderate to severe anxiety.Reason: Anxiety, especially at higher levels, interferes with learning and memory retention. After the client's anxiety lessens, it will be easier for him to learn the steps of the blood glucose monitoring. Because the client's illness is a chronic, lifelong illness that severely changes his lifestyle, it is unlikely that he is uninterested in the illness or how to treat it. It is also unlikely that dementia would be the cause of the client's frustration and lack of memory. The client's response indicates anxiety. Client responses that would indicate lessening anxiety would be questions to the nurse or requests to repeat part of the instruction.
Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that suggests necrotizing fasciitis is:a)erythema.
b)leukocytosis. c)pressurelike pain. d)swelling.
CORRECT ANSWER c) pressurelike pain.Reason: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.
A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision?a)Autonomy
b)Fidelity c)Nonmaleficence d)Veracity
CORRECT ANSWER a) AutonomyReason: Autonomy refers to an individual's right to make his own decisions. Fidelity is equated with faithfulness. Nonmaleficence is the duty to "do no harm." Veracity refers to telling the truth.
A 45-year-old single mother of three teenaged boys has metastatic breast cancer. Her parents live 750 miles away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the client to consider high-dose chemotherapy. She is concerned about her children's welfare during the treatment. When assessing the client's present support systems, the nurse will be most concerned about the potential problems with:a)Denial as a primary coping mechanism.b)Support systems and coping strategies.c)Decision-making abilities.d)Transportation and money for the boys.
CORRECT ANSWER b) Support systems and coping strategies.Reason: The client's resources for coping with the emotional and practical needs of herself and her family need to be assessed because usual coping strategies and support systems are often inadequate in especially stressful situations. The nurse may be concerned with the client's use of denial, decision-making abilities, and ability to pay for transportation; however, the client's support systems will be of more importance in this situation.
A nurse should monitor a client receiving lidocaine (Xylocaine) for toxicity. Which signs or symptoms in a client suggest lidocaine toxicity?a)Nausea and vomitingb)Pupillary changesc)Confusion and restlessnessd)Hypertension
CORRECT ANSWER c) Confusion and restlessnessReason: Confusion and restlessness are signs of lidocaine toxicity. Nausea and vomiting may occur with oral administration of mexiletine (Mexitil) or tocainide (Tonocard) — other class IB drugs. Pupillary changes and hypertension aren't signs of lidocaine toxicity, although visual changes and hypotension may occur as adverse reactions to class IB drugs.
A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result?a)Bradycardia.b)Rapid eye movement.c)Seizures.d)Tachycardia.
CORRECT ANSWER a) Bradycardia.Reason: As a result of vigorous suctioning the nurse must watch for bradycardia due to potential vagus nerve stimulation. Rapid eye movement is not associated with vagus nerve stimulation. Vagal stimulation will not cause seizures or tachycardia.
A primiparous client at 4 hours after a vaginal delivery and manual removal of the placenta voids for the first time. The nurse palpates the fundus, noting it to be 1 cm above the umbilicus, slightly firm, and deviated to the left side, and notes a moderate amount of lochia rubra. The nurse notifies the physician based on the interpretation that the assessment indicates which of the following?a)Perineal lacerations.b)Retained placental fragments.c)Cervical lacerations.d)Urine retention.
CORRECT ANSWER b) Retained placental fragments.Reason: At 4 hours postpartum, the fundus should be midline and at the level of the umbilicus. Whenever the placenta is manually removed after delivery, there is a possibility that all of the placenta has not been removed. Sometimes small pieces of the placenta are retained, a common cause of late postpartum hemorrhage. The client is exhibiting signs and symptoms associated with retained placental fragments. The client will continue to bleed until the fragments are expelled. Perineal and cervical lacerations are characterized by bright red bleeding and a firmly contracted fundus at the level that is expected. Urine retention is characterized by a full bladder, which can be observed by a bulge or fullness just above the symphysis pubis. Also, the client's fundus would be deviated to one side and boggy to the touch.
Which finding indicates placental detachment?a)An abrupt lengthening of the cordb)A decrease in the number of contractionsc)Relaxation of the uterusd)Decreased vaginal bleeding
CORRECT ANSWER a) An abrupt lengthening of the cord Reason: An abrupt lengthening of the cord, an increase (not a decrease) in the number of contractions, and an increase (not a decrease) in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus. Relaxation of the uterus isn't an indication for detachment of the placenta.
The primary health care provider orders intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside?
a)Diazepam (Valium).b)Hydralazine (Apresoline).c)Calcium gluconate.d)Phenytoin (Dilantin).
CORRECT ANSWER c) Calcium gluconate.Reason: The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The antidote for magnesium sulfate toxicity is calcium gluconate, which should be readily available at the client's bedside. Diazepam (Valium), used to treat anxiety, usually is not given to pregnant women. Hydralazine (Apresoline) would be used to treat hypertension, and phenytoin (Dilantin) would be used to treat seizures.
After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium (Nembutal) at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective in the client does not develop:
a)Psychosis.b)Seizures.c)Hypotension.d)Hypothermia.
CORRECT ANSWER b) Seizures.Reason: Generalized seizures may occur on the second or third day of withdrawal from barbiturates. Without treatment, the seizures may be fatal. Psychosis is a possibility but is not fatal and will not be prevented by the pentobarbital sodium regimen. Orthostatic hypotension is possible but is unlikely to be fatal; it is also not treatable by the pentobarbital sodium regimen.
Hyperthermia, rather than hypothermia, occurs during withdrawal.
A nurse is evaluating a client's electrocardiogram (ECG). Which ECG change can result from amitriptyline (Elavil) therapy?
a)Presence of U waves b)Depressed ST segment c)Widening QT interval d)Prolonged PR interval
CORRECT ANSWER c) Widening QT intervalReason: Amitriptyline therapy may cause a conduction delay, demonstrated by a widening QT interval on the ECG. U waves, a depressed ST segment, and a prolonged PR interval aren't typically induced by amitriptyline therapy.
A client with obsessive-compulsive disorder may use reaction formation as a defense mechanism to cope with anxiety and stress. What typically occurs in reaction formation?a)The client assumes an attitude that contradicts an impulse he harbors.b)The client believes his thoughts can control other people and events.c)The client persistently thinks and talks about a particular idea or subject.d)The client uses a specific act to negate a previous act.
CORRECT ANSWER a) The client assumes an attitude that contradicts an impulse he harbors.Reason: Reaction formation is a defense mechanism in which a person assumes an attitude that contradicts an impulse or a wish that he harbors. The belief that one's thoughts can control other people and events is called "magical thinking." Persistent thoughts and discussion of a particular idea or subject are called "rumination." Use of an act to negate a previous act is called "undoing."
A client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which technique?a)Presenting realityb)Making observationsc)Restatingd)Exploring
CORRECT ANSWER d) ExploringReason: The nurse is using the technique of exploring because she's willing to delve further into the client's concern. She isn't presenting reality or making observations or simply restating. The nurse is encouraging the client to explore his feelings.
A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother?a)"What do you think about having your mother leave the room now?"b)"Mother, do you think your daughter is sexually active?"c)"Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter."d)"The two of you seem like you share everything. I am going to ask questions about sexual history now."
CORRECT ANSWER c) "Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter."Reason: Confidentiality and privacy are critical developmental needs for the adolescent. These needs are important to enable the nurse to establish a relationship of trust with the adolescent. A sexual history should be conducted with a teen without parents. Therefore, the nurse should not ask the mother to provide information or put the daughter in a position of having to make a decision about her mother remaining in the room. Inform the adolescent that this information is confidential, and will not be shared with the parent. Inform the adolescent that issues of abuse or life-threatening issues are required by law to be disclosed to the authorities, and all other information is private.
A parent asks the nurse about head lice (pediculosis capitis) infestation during a visit to the clinic. Which of the following symptoms should the nurse tell the parent is most common in a child infected with head lice?a)Itching of the scalp.b)Scaling of the scalp.c)Serous weeping on the scalp surface.d)Pinpoint hemorrhagic spots on the scalp surface.
CORRECT ANSWER a) Itching of the scalp.Reason: The most common characteristic of head lice infestation (pediculosis capitis) is severe itching. The head is the most common site of lice infestation. If the child scratches, scaling may occur. Itching also occurs when lice infest other parts of the body.
Scratch marks are almost always found when lice are present. Weeping on the scalp surface may be an indication of an infection or other dermatologic condition. Hemorrhagic spots are not a symptom of head lice, but may be caused by scratch marks.
A dehydrated 3 year old has vomited three times in the last hour and continues to have frequent diarrhea. The child was admitted 2 days ago with gastroenteritis caused by rotavirus. The child weighs 22 kg, has a normal saline lock in the right hand, and has had 30 ml of urine output in the last 4 hours.
Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the
nurse calls the primary healthcare provider with a recommendation for:a)Giving a dose of loperaminde (Immodium).b)Starting a fluid bolus of normal saline.c)Beginning an intravenous (IV) antibiotic.d)Establishing a Foley catheter.
CORRECT ANSWER b) Starting a fluid bolus of normal saline.Reason: The child is dehydrated, cannot retain oral fluids, and continues to have diarrhea. A normal saline bolus should be given followed by maintenance IV fluids. Anti-diarrheal medications are not recommended for children and will prolong the illness. The child has gastroenteritis caused by a viral illness. IV antibiotics are not indicated for viral illnesses.
S.B.A.R.
SBAR = SituationBackgroundAssessmentRecommendation A.D.P.I.E.
A.D.O.P.I.E.
Assessment Diagnosis (Observation)Planning InterventionEvaluation
After teaching the parents of an 18-month-old who was treated for a foreign body obstruction about the three cardinal signs indicative of choking, the nurse determines that the teaching has been successful when the parents state that a child is choking when he or she cannot speak, turns blue, and does which of the following?a)Vomits.b)Gasps.c)Gags.d)Collapses.
CORRECT ANSWER d) Collapses.Reason: The three cardinal signs indicating that a child is truly choking and requires immediate life-saving interventions include inability to speak, blue color (cyanosis), and collapse. Vomiting does not occur while a child is unable to breathe. Once the object is dislodged, however, vomiting may occur. Gasping, a sudden intake of air, indicates that the child is still able to inhale. When a child is choking, air is not being exchanged, so gagging will not occur.
The nurse is assigning tasks to unlicensed assistive personnel (UAP) for a client with an abdominal hysterectomy on the first postoperative day. Which of the following can NOT be delegated to the UAP? a)Taking vital signs.b)Recording intake and output.c)Giving perineal care.d)Assessing the incision site.
CORRECT ANSWER d) Assessing the incision site.Reason: The registered nurse is responsible for monitoring the surgical site for condition of the dressing, status of the incision, and signs and symptoms of complications. Unlicensed assistive personnel who have been trained to report abnormalities to the registered nurse supervising the care may take vital signs, record intake and output, and give perineal care.
A health care provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames?a)5 minutes.b)10 minutes.c)20 minutes.d)30 minutes.
CORRECT ANSWER c) 20 minutes.
Reason: A dose of 0.5 mg of protamine sulfate reverses a 100-unit dose of heparin within 20 minutes. The nurse should administer protamine sulfate by I.V. push slowly to avoid adverse effects, such as hypotension, dyspnea, bradycardia, and anaphylaxis.
Before preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary purpose of preoperative teaching?a)To determine whether the client is psychologically ready for surgeryb)To express concerns to the client about the surgeryc)To reduce the risk of postoperative complicationsd)To explain the risks associated with the surgery and obtain informed consent
CORRECT ANSWER c) To reduce the risk of postoperative complicationsReason: Preoperative teaching helps reduce the risk of postoperative complications by telling the client what to expect and providing a chance for him to practice, before surgery, any required postoperative activities, such as breathing and leg exercises. The physician — not the nurse — is responsible for determining the client's psychological readiness for surgery. It's inappropriate for the nurse to express personal concerns about surgery to a client. The physician should describe alternative treatments and explain the risks to the client when obtaining informed consent.
The nurse-manager of a home health facility includes which item in the capital budget?a)Salaries and benefits for her staffb)A $1,200 computer upgradec)Office suppliesd)Client-education materials costing
$300
CORRECT ANSWER b) A $1,200 computer upgradeReason: Capital budgets generally include items valued at more than $500. Salaries and benefits are part of the personnel budget. Office supplies and client education materials are part of the operating budget.
Of the following findings in the client's history, which would be the least likely to have predisposed the client to renal calculi?a)Having had several urinary tract infections in the past 2 years.b)Having taken large doses of vitamin C over the past several years.c)Drinking less than the recommended amount of milk.d)Having been on prolonged bed rest after an accident the previous year.
CORRECT ANSWER c) Drinking less than the recommended amount of milk.Reason: A high, rather than low, milk intake predisposes to renal calculi formation, owing to the calcium in milk. Recurrent urinary tract infections are implicated in stone formation as certain bacteria promote stone formation. High daily doses of vitamins C are a risk factor because they can increase the citric acid level. Prolonged immobility is a risk factor for renal calculi because it causes calcium to be released into the bloodstream.
Which of the following alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago?a)Increased blood pressure and decreased pulse and respiratory rates.b)Sanguineous drainage from the chest tube at a rate of 50 ml/hour during the past 3 hours.c)Restlessness and shortness of breath.d)Urine output of 180 ml during the past 3 hours.
CORRECT ANSWER c) Restlessness and shortness of breath.Reason: Restlessness indicates cerebral hypoxia due to decreased circulating volume. Shortness of breath occurs because blood collecting in the pleural space faster than suction can remove it prevents the lung from reexpanding. Increased blood pressure and decreased pulse and respiratory rates are classic late signs of increased intracranial pressure. Decreasing blood pressure and increasing pulse and respiratory rates occur with hypovolemic shock. Sanguineous drainage that changes to serosanguineous drainage at a rate less than 100 ml/hour is normal in the early postoperative period. Urine output of 180 ml over the past 3 hours indicates normal kidney perfusion.
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse
should consider which finding most significant?a)Decreased level of consciousness (LOC)b)Elevated blood pressurec)Increased urine outputd)Decreased heart rate
CORRECT ANSWER c) Increased urine outputReason: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:a)10 g of carbohydrates.b)15 g of carbohydrates.c)20 g of carbohydrates.d)25 g of carbohydrates.
CORRECT ANSWER b) 15 g of carbohydrates.Reason: The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates.
A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. Which is the nurse's best response?a)"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid."b)"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor."c)"The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction."d)"The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."
CORRECT ANSWER b) "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor."Reason: Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of red blood cells in this condition.
A nurse is performing a baseline assessment of a client's skin integrity. What is the priority assessment parameter?a)Family history of pressure ulcersb)Presence of pressure ulcers on the clientc)Potential areas of pressure ulcer developmentd)Overall risk of developing pressure ulcers
CORRECT ANSWER d) Overall risk of developing pressure ulcersReason: When assessing skin integrity, the overall risk potential of developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.
Prochlorperazine (Compazine) is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which of the following? a)Nausea.b)Dizziness.c)Abdominal spasms.d)Abdominal distention.
CORRECT ANSWER a) Nausea.Reason: Prochlorperazine is administered postoperatively to control nausea and vomiting. Prochlorperazine is also used in psychotherapy because of its effects on mood and behavior. It is not used to treat dizziness, abdominal spasms, or abdominal distention.
A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client?a)Wear sterile gloves.b)Place incontinence pads in the regular trash container.c)Wear personal
protective equipment when handling blood, body fluids, and feces.d)Provide a urinal or bedpan to decrease the likelihood of soiling linens.
CORRECT ANSWER c) Wear personal protective equipment when handling blood, body fluids, and feces.Reason: Chemotherapy drugs are present in the waste and body fluids of clients for 48 hours after administration. The nurse should wear personal protective equipment when handling blood, body fluids, or feces. Gloves offer minimal protection against exposure. The nurse should wear a face shield, gown, and gloves when exposure to blood or body fluid is likely. Placing incontinence pads in the regular trash container and providing a urinal or bedpan don't protect the nurse caring for the client.
A client with chronic heart failure is receiving digoxin (Lanoxin), 0.25 mg by mouth daily, and furosemide (Lasix), 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause:a)visual disturbances.b)taste and smell alterations.c)dry mouth and urine retention.d)nocturia and sleep disturbances.
CORRECT ANSWER a) visual disturbances.Reason: Digoxin toxicity may cause visual disturbances (such as, flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (such as headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (abnormal heart rate and arrhythmias). Digoxin toxicity doesn't cause taste and smell alterations. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night.
During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. Which of the following should the nurse do first?a)Start mouth-to-mouth resuscitation.b)Contact the neonatal resuscitation team.c)Raise the neonate's head and pat the back gently.d)Clear the neonate's airway with suction or gravity.
CORRECT ANSWER d) Clear the neonate's airway with suction or gravity.Reason: If a neonate gags on mucus and becomes cyanotic during the first feeding, the airway is most likely closed. The nurse should clear the airway by gravity (by lowering the infant's head) or suction. Starting mouth-to-mouth resuscitation is not indicated unless the neonate remains cyanotic and lowering his head or suctioning doesn't clear his airway. Contacting the neonatal resuscitation team is not warranted unless the infant remains cyanotic even after measures to clear the airway. Raising the neonate's head and patting the back are not appropriate actions for removing mucus. Doing so allows the mucus to remain lodged causing further breathing difficulties.
On the second postpartum day a gravida 6, para 5 complains of intermittent abdominal cramping. The nurse should assess for:a)endometritis.b)postpartum hemorrhage.c)subinvolution.d)afterpains.
CORRECT ANSWER d) afterpains.Reason: In a multiparous client, decreased uterine muscle tone causes alternating relaxation and contraction during uterine involution, which leads to afterpains. The client's symptoms don't suggest endometritis, hemorrhage, or subinvolution.
Which nursing action is required before a client in labor receives epidural anesthesia?a)Give a fluid bolus of 500 ml.b)Check for maternal pupil dilation.c)Assess maternal reflexes.d)Assess maternal gait.
CORRECT ANSWER a) Give a fluid bolus of 500 ml.Reason: One of the major adverse effects of epidural administration is hypotension. Therefore, a 500-ml fluid bolus is usually administered to prevent hypotension in the client who wishes to receive an epidural for pain relief. Assessing maternal reflexes, pupil response, and gait isn't necessary.
A nurse is assessing the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect?a)Absent pedal pulsesb)Bilateral dependent edemac)Sluggish capillary refilld)Unilateral calf enlargement
CORRECT ANSWER b) Bilateral dependent edemaReason: As the uterus grows heavier during pregnancy, femoral venous pressure rises, leading to bilateral dependent edema. Factors interfering with venous return, such as sitting or standing for long periods, contribute to edema. Absence of pedal pulses and sluggish capillary refill signal inadequate circulation to the legs — an unexpected finding during pregnancy. Unilateral calf enlargement, also an abnormal finding, may indicate thrombosis.
Which of the following is a priority during the first 24 hours of hospitalization for a comatose client with suspected drug overdose?a)Educate regarding drug abuse.b)Minimize pain.c)Maintain intact skin.d)Increase caloric intake.
CORRECT ANSWER c) Maintain intact skin.Reason: Maintaining intact skin is a priority for the unconscious client. Unconscious clients need to be turned every hour to prevent complications of immobility, which include pressure ulcers and stasis pneumonia. The unconscious client cannot be educated at this time. Pain is not a concern. During the first 24 hours, the unconscious client will mostly likely be on nothing-by-mouth status.
A client with chronic undifferentiated schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking to himself. This behavior is characteristic of:a)delusion.b)looseness of association.c)illusion.d)hallucination.
CORRECT ANSWER d) hallucination.Reason: Auditory hallucination, in which one hears voices when no external stimuli exist, is common in schizophrenic clients. Such behaviors as laughing, yelling, and talking to oneself suggest such a hallucination. Delusions, also common in schizophrenia, are false beliefs or ideas that arise without external stimuli. Clients with schizophrenia may exhibit looseness of association, a pattern of thinking and communicating in which ideas aren't clearly linked to one another. Illusion is a less severe perceptual disturbance in which the client misinterprets actual external stimuli. Illusions are rarely associated with schizophrenia.
A client was hospitalized for 1 week with major depression with suicidal ideation. He is taking venlafaxine (Effexor), 75 mg three times a day, and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse should make which judgment about the client? a)The client is decompensating and in need of being readmitted to the hospital.b)The client needs an adjustment or increase in his dose of antidepressant.c)The depression is improving and the suicidal ideation is lessening.d)The presence of suicidal ideation warrants a telephone call to the client's primary care provider.
CORRECT ANSWER c) The depression is improving and the suicidal ideation is lessening.Reason: The client's statements about being in control of his behavior and his or her plans to return to work indicate
an improvement in depression and that suicidal ideation, although present, is decreasing. Nothing in his comments or behavior indicate he is decompensating. There is no evidence to support an increase or adjustment in the dose of Effexor or a call to the primary care provider. Typically, the cognitive components of depression are the last symptoms eliminated. For the client to be experiencing some suicidal ideation in the second week of psychopharmacologic treatment is not unusual.
Based on a client's history of violence toward others and her inability to cope with anger, which of the following should the nurse use as the most important indicator of goal achievement before discharge? a)Acknowledgment of her angry feelings.b)Ability to describe situations that provoke angry feelings.c)Development of a list of how she has handled her anger in the past.d)Verbalization of her feelings in an appropriate manner.
CORRECT ANSWER d) Verbalization of her feelings in an appropriate manner.Reason: Verbalizing feelings, especially feelings of anger, in an appropriate manner is an adaptive method of coping that reduces the chance that the client will act out these feelings toward others. The client's ability to verbalize her feelings indicates a change in behavior, a crucial indicator of goal achievement. Although acknowledging feelings of anger and describing situations that precipitate angry feelings are important in helping the client reach her goal, they are not appropriate indicators that she has changed her behavior. Asking the client to list how she has handled anger in the past is helpful if the nurse discusses coping methods with the client. However, based on this client's history, this would not be helpful because the nurse and client are already aware of the client's aggression toward others.
A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately:a)Put the client to bed.b)Obtain the child's blood pressure.c)Notify the physician.d)Administer acetaminophen (Tylenol).
CORRECT ANSWER b) Obtain the child's blood pressure.Reason: Hypertension occurs with acute glomerulonephritis. The symptoms of headache and blurred vision may indicate an elevated blood pressure. Hypertension in acute glomerulonephritis occurs due to the inability of the kidneys to remove fluid and sodium; the fluid is reabsorbed, causing fluid volume excess. The nurse must verify that these symptoms are due to hypertension. Calling the physician before confirming the cause of the symptoms would not assist the physician in his treatment. Putting the client to bed may help treat an elevated blood pressure, but first the nurse must establish that high blood pressure is the cause of the symptoms. Administering Tylenol for high blood pressure is not recommended.
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