A nurse is caring for a school age child on a children's mental health unit. What comment by the nurse would foster rapport to engage the client in conversation? Show
"Do you like school?" "Tell me about your favorite video game." This open-ended statement encourages the child to respond with more than just the name of the game. This would foster rapport and encourage communication. A nurse is planning recreational activity for a young adult client with an acute exacerbation of schizophrenia. Assuming that the client is capable of all of the following, which activity should the nurse consider appropriate? Walking with a staff member around the gated grounds Walking with a staff member around the gated grounds This client should be encouraged to participate in nonthreatening, noncompetitive physical activities. This also provides an opportunity for verbal interaction with a member of the health care team. A nurse is caring for a child who is diagnosed with strabismus. The nurse explains to the parents that to prevent the development of amblyopia, it will be necessary to do which of the following? Patch the unaffected eye. Patch the unaffected eye Amblyopia is a disorder of the eye in which unilateral central blindness occurs as a result of another condition, such as strabismus. In strabismus, muscle weakness allows one eye to wander so that the child cannot focus on an object with both eyes at the same time. This confusion causes the brain to ignore the signals from the weak eye in favor of the strong one. This will result in central blindness if not treated by 6 years of age. To strengthen the weak eye muscles, the unaffected eye is patched. During preoperative teaching for a client scheduled for laser assisted in situ keratomileusis (LASIK) surgery, the nurse should tell the client that he may need to wear reading glasses after the surgery. may need to wear reading glasses after the surgery. LASIK is a type of refractive laser eye surgery ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, many people develop presbyopia (farsightedness) with age and may need reading glasses, despite having had LASIK surgery. A nurse is reinforcing teaching with the family of a child who has Asperger's syndrome. Which comment would indicate to the nurse that adequate learning has taken place? "Aricept may slow the progression of the disorder." "It will help our child if we keep a structured daily routine." The child with Asperger's syndrome has a high functioning form of autism spectrum disorder; typically the child will have normal to high cognitive skills. A structured environment can help to minimize the problems these children experience with sudden schedule changes, socialization requirements, and the preference for ritualistic behavior. A nurse has been notified by the post anesthesia care unit that a client who has had a subtotal thyroidectomy is returning to the nursing unit. Which emergency equipment should the nurse have available on the unit for this client? Cardiac monitor Tracheostomy tray In the event of laryngeal edema or tetany, respiratory distress could result in airway obstruction. Emergency intubation may be difficult due to laryngeal swelling, and endotracheal intubation may increase the risk for hemorrhage by increasing tension on the incision during insertion. A tracheostomy tray should be easily accessible. A nurse is caring for a client with a tracheostomy who is receiving mechanical ventilation. The low-pressure alarm on the ventilator sounds, indicating which of the following to the nurse? Excessive airway secretions A leak within the ventilator circuitry The low-pressure alarm means that either the tubing has come apart or that client has become disconnected from the ventilator tubing. Almost all low-pressure alarms are the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator. A nurse has delegated an assistive personnel (AP) to provide one on one observation to a client who is recovering from a closed head injury. The nurse notes that the client is impulsive and has experienced one fall. Which of the following actions by the AP indicates to the nurse further teaching is needed? Accompanies the client to physical and occupational therapy Ambulates the client's roommate while the client sleeps One-on-one observation requires constant supervision of the client. The client might wake up while the AP is out of the room, get out of bed, and fall. A client is scheduled to have an electroencephalogram (EEG) in the morning. While preparing the client for the EEG, it is appropriate for the nurse to tell the client which of the following? "You will be given a sedative for the procedure, so
you won't feel the small electrical shock." "You need to shampoo your hair tonight, and don't put any styling products on it afterwards." An electroencephalogram (EEG) is a painless test that records the electrical activity of the brain. During the test, electrodes are attached to the scalp to record the tiny electrical charges released by the nerve cells in the brain. So that the electrodes will adhere properly to the scalp, the client's hair has to be clean and free of oil and hair-care products. A nurse is caring for a client who is receiving IV ampicillin (Unasyn). Which of the following actions should the nurse take first if the client develops urticaria and dyspnea? Administer diphenhydramine (Benadryl). Stop the ampicillin infusion. The greatest risk to the client is an allergic reaction that may progress to anaphylaxis. The nurse should stop the infusion immediately so that further exposure to the client of the potential allergen is halted. TEST-TAKING STRATEGY: This question requires you to choose a priority action for a client with drug toxicity when all the actions appear plausible. Any time that a question involving medication toxicity requires you to make a choice about which action the nurse should take first, a choice that has the nurse discontinuing the client's exposure to the medication or toxic substance should always be the first choice. A community health nurse is conducting a class on body mechanics for county office workers. Which of the following should the nurse include in the teaching? (Select all that apply.) "Sit with your back supported." "Sit with your back supported." "Sit with your back supported" is correct. Sitting with the back supported while at the computer helps to prevent back strain, which can lead to lower-back disc disease. "Knees should be at the hip level" is correct. Keeping the knees at the hip level while at the computer helps to prevent unnecessary strain on the hips and lower back. "Wrist and forearms should be parallel to the ground" is correct. Keeping the wrist and the forearms parallel to the ground while typing will help to prevent unnecessary strain on the wrists that could result in carpal tunnel syndrome. "Keep the elbows far away from the body" is incorrect. The arms should be kept close to the body. Keeping elbows far way from the body puts undue strain on the shoulders and the arms. "Adjust the monitor screen so that you have to tilt your head slightly to look at it" is incorrect. The head should be level when looking at the computer screen. Tilting the screen, and tilting the head to look at it, can place undue strain on the cervical spine (neck) region. A nurse is reviewing the laboratory data of a client who reports symptoms that suggest systemic lupus erythematosus (SLE). If this diagnosis is accurate, the nurse expects to note an increased platelet aggregation. erythrocyte sedimentation rate (ESR). SLE is a chronic systemic autoimmune disease that causes skin, heart, lung, and kidney inflammation. Like most autoimmune diseases, a series of exacerbations and remissions is typical and, while it varies considerably in severity, clients typically die from end-stage renal disease. Diagnosis is based on the client's history of manifestations and serologic tests. Most clients with an exacerbation of SLE will have an increased ESR. A client with an acute visual disturbance describes it as a "curtain" pulled over the visual area with occasional flashes of light. The nurse should notify the provider immediately of the possibility of cataracts. a detached retina. The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. A detached retina is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field. A client with Addison's disease comes to the emergency department reporting nausea, vomiting, diarrhea, and abdominal pain. To prevent Addisonian crisis, the nurse anticipates that the provider will prescribe IV administration of calcium. corticosteroids. Addison's disease is characterized by adrenal gland hypofunction and inadequate production of glucocorticoids. Acute adrenal insufficiency can be a life-threatening event, with severe fluid and electrolyte imbalances. Without treatment, sodium levels fall and potassium levels increase. Rapid infusion of IV fluids, such as 0.9% sodium chloride boluses, with administration of high dose corticosteroids, such as hydrocortisone sodium succinate (Solu-Cortef), are started as soon as venous access is established. A nurse is assisting with breastfeeding immediately following the birth of a newborn. Which of the following is the most important benefit of breastfeeding during the fourth stage of labor? The nurse is available to assist the mother with breastfeeding techniques. Oxytocin secretion is stimulated causing uterine contractions. Production and secretion of oxytocin causes the uterus to contract, thus promoting involution and decreasing the risk for maternal hemorrhage and blood loss. A nurse is performing an assessment on a client. Which of the following in the client's history is a contraindication to use of sildenafil (Viagra)? Diabetes mellitus Current use of isosorbide (Isordil) for heart failure Sildenafil (Viagra), a medication used in the treatment of erectile dysfunction, is contraindicated in clients taking any nitrates, such as isosorbide (Isordil). These medications taken concurrently may cause life-threatening hypotension. A nurse is caring for a client who has recently had a myocardial infarction (MI). The client calls the nurse to report some manifestations similar to those the client experienced the day of the MI. Which of the following should alert the nurse to the possibility of a recurrence? (Select all that apply.) Nausea and vomiting Nausea
and vomiting A client asks the nurse if it is common to experience vaginal yeast infections during pregnancy. Which of the following is an appropriate response? "Have you discussed this with your primary care provider yet?" "The hormonal changes in pregnancy affect the vaginal pH, making yeast infections common." This is an information-seeking question, so the therapeutic response is an answer that provides the client with the information that is requested. This therapeutic answer not only tells the client that the infections are common, but also gives the client information about why this occurs. A nurse is participating in a disaster drill with the local health department. Staged victims are being used in the drill to simulate a bomb explosion at a sporting event. The nurse is one of the first responders on the scene and starts to triage the victims. Which of the following actions should the nurse take first? Call out to people who can walk and ask them to move from the incident area to the concession stand. Call out to people who can walk and ask them to move from the incident area to the concession stand. All clients who can walk are asked to move away from the incident area to a specific location. This allows the nurse to quickly assess those who may need immediate assistance and reduces the chance of further injury from the disaster to these people. A client is admitted with a suspected diagnosis of tuberculosis. Which nursing action is of highest priority? Place the client on airborne isolation. Place the client on airborne isolation. Clients strongly suspected of having tuberculosis (TB) should be placed on airborne isolation precautions immediately because of the highly communicable nature of the infection. Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air, including Mycobacterium tuberculosis, the agent that causes TB. A nurse is caring for a 3-year-old toddler who is undergoing insertion of pressure equalization (PE) tubes. The toddler's parent asks the nurse, "When will these tubes be removed?" Which of the following responses by the nurse is the most appropriate? "When the doctor determines it is time to remove the tubes, your toddler will be admitted to the ambulatory surgery center." "The tubes remain in place for approximately 1 to 2 years until they fall out on their own." Children generally outgrow PE tubes, and they usually fall out on their own about 1 to 2 years after insertion. A nurse manager notes that several staff members are late in completing an annual mandatory educational session related to restraint safety. Which of the following actions should the nurse plan to take? Make a general announcement at the next staff meeting asking all employees to check their compliance with the requirement. Send an e-mail to each noncompliant employee that includes a link to future upcoming educational sessions. E-mail provides a simple, yet efficient way for the nurse manager to get the news out to each noncompliant employee without embarrassing anyone with a public announcement. In addition, including the appropriate link in the e-mail facilitates the employee's compliance by helping the employee to identify upcoming session(s) that coordinate with the employee's work schedule. A nurse is developing a plan of care for a client with gastroesophageal reflux disease (GERD). Because of the complications commonly associated with this disorder, the nurse plans to monitor the client for aspiration. aspiration. Aspiration is a common complication associated with GERD. GERD results when the esophageal sphincter malfunctions, allowing gastric acid and undigested food to back up into the esophagus placing the client at risk for aspiration. GERD is characterized by effortless, uncontrolled regurgitation whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion, but aspiration is also possible. Therefore, the client should be monitored for crackles in the lung fields, which is an indication of aspiration. A nurse is caring for a 2 year old child. The parents request a toy for their child. The nurse understands that the most appropriate toy from the playroom for this child is which of the following? Doll with clothes 10-piece wood puzzle Age-appropriate toys for a 2-year-old child include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. These toys all allow for manipulation and exploration and meet the child's developmental and diversional activity needs. A clinic nurse is assessing a 66 year old client a for a routine physical. The client is new to the area and does not have old medical or immunization records available. When the nurse asks if the client has received the pneumococcal vaccine, the client replies, "I am not sure but I haven't had any immunizations in at least 5 years." The nurse should recognize that in this circumstance it is unsafe for the client to receive another vaccination. the client should receive the pneumococcal vaccine. One dose of the pneumococcal vaccine should be given to all clients age 65 or older. If the client received the immunization more than 5 years ago and was less than 65 years of age, the CDC recommends a one-time revaccination.
A nurse is caring for a child who is receiving bleomycin (Blenoxane) IV and is not voiding adequately. What is the appropriate nursing action? Assess the child's hydration status. Assess the child's hydration status. The nurse should monitor renal function with bleomycin and other antibiotic antineoplastic medications. Monitoring includes checking laboratory values for BUN and creatinine clearance, as well as I&O. A nurse is caring for a 2 year old child who was admitted for laryngotracheobronchitis. The child is placed in a crib with a cool mist tent. Which toy would be most suitable for the child at this time? A
stuffed teddy bear A plastic fire engine Acute laryngotracheobronchitis, or croup, is a condition of respiratory difficulty caused by infection, inflammation, and swelling of the upper airway (larynx, trachea, and bronchus). The cool mist tent is ordered to provide a high-humidity environment to ease the child's work of breathing. Consequently, the nurse selects an age-appropriate toy made of plastic that can be easily wiped clean and dry. A nurse is providing teaching to a client who is prescribed doxycycline (Vibramycin) for actinomycosis. The nurse should observe the client for which of the following? Photosensitivity Photosensitivity Doxycycline is a tetracycline antibiotic. Photosensitivity is an adverse effect of tetracyclines in which the skin reacts abnormally to light, especially ultraviolet radiation or sunlight. The result is an intense sunburn reaction with erythema, maculas, and gray-blue patches. Prevention involves avoiding direct exposure to sunlight and ultraviolet light and using a sunscreen with a sun protection factor (SPF) of 15 or greater. A nurse observes tachycardia, dyspnea, dry cough, and distended neck veins in a client with leukemia who is receiving a blood transfusion of packed red blood cells. Which intervention should the nurse use to prevent these manifestations with the client's next transfusion? Warm the unit of blood to room temperature before administering it. Use a transfusion pump to regulate and maintain the flow rate. These are the manifestations of a hypervolemic reaction due to circulatory overload, likely if the blood is transfused too rapidly for the client's size or condition. To prevent this problem with future transfusions, the nurse must ensure that the proper amount of blood is transfused and that a transfusion pump is used to regulate the flow rate. A client has pseudomembranous colitis caused by clostridium difficile. The priority nursing intervention for this client is performing hand hygiene before and after contact with the client. performing hand hygiene before and after contact with the client. C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two virulent exotoxins that attack the lining of the intestine. The toxins destroy cells and produce pseudomembranes, patches (plaques) of inflammatory cells, and decaying cellular debris on the interior surface of the colon. The spores of C. difficile are easily transported from one client to another without hand hygiene. A nurse is planning to delegate care of a postoperative client following an appendectomy. Which of the following should the nurse delegate to an assistive personnel (AP)? Teach the client to use the patient-controlled analgesia pump. Record urinary output after emptying the indwelling urinary catheter. Emptying an indwelling urinary catheter and recording I&O is within the scope of practice for an AP. A nurse on a mental health unit is taking care of a client diagnosed with depression. Which nursing intervention would foster a therapeutic environment for this client? Tell the client that the nurse will talk to him at her request. Build trust with the client by sitting quietly with him. Building trust with the client will give him the idea that the nurse is interested in his issues. Establishing client trust encourages him to speak more openly about issues and concerns. A pregnant client who is Hindu is being seen at the women's health center for a 12 week check up. The primary care provider tells the client that she must get more protein in her diet and suggests that the client eat more animal products. Although the client initially states that she agrees, after the primary care provider leaves the examination room, the client tells the nurse that "eating animal products will cause her to miscarry." Which of the following is an appropriate response? "Let's discuss other foods that are also high in protein that you could substitute for meat." "Let's discuss other foods that are also high in protein that you could substitute for meat." Many cultures have beliefs about food that should or should not be consumed during life transitions, such as pregnancy. The nurse is also aware that many Hindu clients are vegetarian due to religious reasons. The nurse should discuss alternative protein sources with the client to help the client identify those consistent with both her religious and traditional medical beliefs. During a client care unit meeting, the nurse manager discusses potential problems with data security related to confidential client information. The nurse manager explains that safe, effective environments where client information may be discussed include areas closed off from the public. areas closed off from the public. Client information may be discussed in a room on the unit with a closed door to prevent accidental disclosure of a client's personal health information. A nurse is talking with a parent of a preschooler. The parent reports that it is very difficult to get her child to go to bed at a proper time consistently. She tells the nurse that the child gets out of bed, enters her room, and cries when told to stay in bed. Which instructions should the nurse give the parent to foster a consistent bedtime for this child? "Use a stable relaxing
routine, such as a bath and story time before bed." "Use a stable relaxing routine, such as a bath and story time before bed." Routines are very reassuring to preschoolers because they allow the child to be able to anticipate their environment and adapt appropriately. These actions will help the child to settle down prior to bedtime. They also provide for parental-child interaction prior to bed. A nurse is caring for a client who has had a bone marrow transplant and is on protective isolation. Which of the following statements indicates that the client understands the restrictions of this type of isolation? "I must keep the door to my room closed at all times." "I must keep the door to my room closed at all times." Protective isolation is prescribed to protect immunocompromised clients from exposure to potentially lethal micro-organisms and includes keeping the door to the room closed at all times. A nurse at the family planning clinic is preparing to teach a class on the use of a diaphragm. Which of the following should the nurse include in the teaching session? "When using a diaphragm, it is necessary to also use spermicidal jelly." "When using a diaphragm, it is necessary to also use spermicidal jelly." A diaphragm is a barrier device used to prevent pregnancy. It is inserted by the client prior to sexual intercourse. Use of a diaphragm alone is not 100% effective at preventing pregnancy, but the use of spermicidal jelly with it increases the effectiveness of the device. A client's provider informs the nurse that the client's abdominal aortic aneurysm (AAA) is extending. The nurse must assess the client for increases in blood pressure and respiratory rate. abdominal pain with the onset of back pain. An aortic aneurysm is a weak spot in the wall of the aorta, the primary artery that carries blood from the heart to the head and extremities and allows the aorta to expand and increase in diameter. Increasing abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots. At the first prenatal visit, a nurse learns that a pregnant client is lactose intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client? Collard greens Collard greens Collard greens are a good source of lactose-free calcium. One cup of collard greens provides approximately the same amount of calcium as 1 cup of milk. A nurse is caring for a 3-year-old child who has persistent otitis media. When obtaining the history of the child from her parent, which of the following would be the most appropriate for the nurse to ask regarding the child's recurrent otitis media? "Is the child playing with other children with otitis media?" "Does anyone smoke around, or in the same house as, the child?" Otitis media is an infection of the middle ear (eustachian tube behind the tympanic membrane). Allergies to common irritants, such as smoke, can cause eustachian tube congestion and chronic otitis media. A nurse is caring for a toddler with acquired immune deficiency syndrome. During the assessment, the nurse understands that which of the following would indicate an opportunistic infection? Koplik spots Candidiasis Candidiasis, or oral thrush, is caused by the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of infants, diabetics, and other clients with immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that may appear like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection noted in a human immunodeficiency virus (HIV) positive child who is developing AIDS. A nurse is caring for a hospitalized client who is dying. The family has been involved in the client's care for several days. The family is exploring the possibility of caring for the client at home. Which of the following statements indicates that the nurse has a good understanding of family-centered care? "I have contacted various community resources that will be helpful." "Let's set up a meeting time with the primary care provider to discuss your options for home care." In family-centered care, the client and family help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered care environment. A client who has been treated for a transient ischemic attack (TIA) is being discharged. The nurse's discharge teaching plan related to this admission should reinforce the importance of monitoring blood pressure at regular intervals, blood pressure at regular intervals. Transient ischemic attacks (TIA) are caused by a temporary disturbance of blood supply to the brain, resulting in brief neurologic dysfunction. One third of clients who have had a TIA later have recurrent TIAs, and another one third have a cerebrovascular accident (CVA) that results in permanent nerve cell loss. The most common causes of TIA are atherosclerotic plaque in the carotid arteries and hypertension. Consequently, managing hypertension is important in reducing the risk of CVA. A nurse is caring for an infant with dehydration. Which of the following is the most accurate assessment for hydration status? Obtain daily weights. Obtain daily weights. Daily weights are the most sensitive indicator of fluid balance in clients of all ages. Daily weights are especially critical in children under 2 years of age because a greater portion of body weight is composed of fluid. A nurse in the emergency department cares for several children who all are admitted with symptoms of influenza. After routine laboratory work is obtained from the children, which child should the nurse bring to the primary care provider's attention immediately? 6-year-old child with urine specific gravity of 1.030 6-month-old infant with WBC count of 24,000/mm3 This WBC count (normal is 4,000 to 10,000/mm3) is highly elevated for a 6-month-old infant who has manifestations of influenza. A septic work up (blood, urine, and spinal fluid cultures) will need to be done immediately; therefore, the provider should be notified immediately of the infant's condition. A nurse is caring for a client who is receiving hemodialysis for the first time. Which of the following indicates to the nurse that the client is at imminent risk for developing dialysis disequilibrium syndrome (DDS)? Elevated BUN Headache DDS is a central nervous system (CNS) disorder. It is a complication that may develop in clients who are new to dialysis due to the rapid removal of solutes and changes in blood pH levels. Clients beginning hemodialysis are at greatest risk, particularly if the BUN is above 175. DDS is characterized by CNS manifestations of varying severity due primarily to cerebral edema. They include headache, nausea, disorientation, restlessness, blurred vision, and asterixis. More severely affected clients progress to confusion, seizures, coma, and death. An individual wearing a hospital-issued identification badge greets the charge nurse on the postsurgical unit and states, "I am a surgical resident assigned to this unit." The individual then asks the charge nurse for an access code to review a client's online record stating, "I'm not scheduled to attend the computer class until next week." Which of the following actions should the nurse take? Explain that it is against policy to share access codes and refer the resident to his supervisor. Explain that it is against policy to share access codes and refer the resident to his supervisor. Access codes and passwords should never be shared. Likewise, allowing access to the system for an individual who does not have their own access code is also not permitted. An integral part of computer training is learning about client data security, confidentiality, and signing documents that attest to your intention to follow these federal guidelines. The resident should be politely referred to his supervisor to obtain the information needed or to make arrangements to be trained sooner if necessary. A nurse is developing a teaching plan for a client diagnosed with type 2 diabetes mellitus. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following is an appropriate nursing response? "Let's discuss this with your physician; it may not be necessary." "You don't have to give up pasta, just adjust the amount you eat." The American Diabetes Association (ADA) recommends that carbohydrate restriction be individualized for each client as needed. A careful assessment of the client's usual dietary practices and modifications is an important part of teaching the client with diabetes to manage this disease and to ensure long-term success with the ADA diet. A client presents to the emergency department following a motor vehicle crash. She reports pain in her left leg, and the nurse notes that the left leg has manifestations of a fracture including bruising, swelling, and displacement of the bones. What action should the nurse take first? Ask the provider to prescribe an x-ray of the leg. Check neurovascular status distal to the injury. This action includes checking the circulation, sensation, and movement distal to (below) the level of the injury. If the nurse notes a weak or absent pulse distal to the injury, the limb's circulation is compromised, and immediate action is critical. This is the nurse's highest priority at this time. A nurse is talking with an unmarried couple who have come to the family planning clinic for advice. Which of the following is an appropriate response regarding the risks associated with an intrauterine device (IUD)? "If you experience any weight changes, you will need to be refitted for your IUD." "There is an increased risk for ectopic pregnancy when using an IUD." An IUD is a family planning device that is inserted through the cervix into the uterus to prevent pregnancy. The IUD works by changing the lining of the uterus and fallopian tubes, making it more difficult for fertilization to occur in the uterus. Consequently, a known complication when using the IUD is an increased risk for ectopic pregnancy. A client receiving chemotherapy has developed neutropenia. Which statement by the client indicates to the nurse that the client needs further instructions? "I make sure I always keep an antibacterial hand gel in my purse." "I'm planning a large gathering of friends and family for the holidays." A client with neutropenia must be careful to avoid exposure to infection, so this is a statement that warrants more teaching. A client experiencing neutropenia should avoid large crowds of people because a large gathering increases the client's risk for exposure to infection. TEST-TAKING STRATEGY: This question asks which statement indicates that the client needs FURTHER teaching, thus the CORRECT answer is an INCORRECT statement. A nurse is providing discharge instructions to a client who is prescribed metoprolol (Toprol-XL). Which of the following instructions should the nurse include? (Select all that apply.) Do not suddenly stop taking this medication. Take radial pulse daily is correct. The client should take a radial pulse daily and report a heart rate less than 60/min. Chew sugarless gum to relieve dry mouth is correct. Chewing sugarless gum or sucking on sugarless candy can help relieve dry mouth caused by metoprolol. Do not suddenly stop taking this medication is correct. There is an increased risk of angina, hypertension, and possible myocardial infarction when metoprolol, a beta blocker, is discontinued suddenly. If the provider discontinues the medication it should be gradually reduced over 1 to 2 weeks to prevent worsening of manifestations. A home care nurse is discussing fire safety with a homebound client. The nurse identifies which of the following safety measure to help protect the client in case of a fire? Use a night light in the bedroom. Keep a phone close to the bed. Most fires happen during the night. Placing a phone close to the bed enables the client to call the fire department quickly. The client should bring the phone (if portable) with him if he tries to exit the house. The client should be familiar with the exits, have working smoke alarms, and have a flashlight near the bed. Due to staffing shortages, an adult medical-surgical nurse is asked to work on a pediatric unit. The nurse has limited experience with pediatric clients. Which of the following actions should the charge nurse take? Provide constant supervision for the adult
medical-surgical nurse. Assign a unit nurse to act as a resource for the adult medical-surgical nurse. Assigning a nurse who usually works on the pediatric unit to work with the adult medical-surgical nurse will provide consistent support. The nurse is caring for a toddler who is hospitalized for Pneumocystis carinii pneumonia. The child is taking zidovudine (AZT). Which laboratory tests should the nurse monitor related to this medication? BUN and creatinine Hgb and Hct Zidovudine may cause severe anemia, so it is important to monitor the CBC, which includes the Hgb and Hct, closely for at least the first 2 weeks. As anemia may occur up to 2 to 4 weeks after beginning AZT therapy, the Hgb and Hct are monitored regularly for the first 2 months and then periodically after that. A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and expecting twins. The client reports feeling "lightheaded." Which position should the nurse assist the client into at this time? Lateral Lateral The lateral, or side-lying position (especially left side-lying), provides for the best uteroplacental blood flow. This is the most appropriate position for improving both maternal and fetal circulation in the pregnant client who is feeling faint. A nurse caring for a client with hypocalcemia should expect to see which of the following on the client's ECG? Flattened T-wave Prolonged QT interval Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, abdominal cramps, prolonged QT intervals, and hypotension. Causes include decreased parathyroid function, chronic renal disease, massive blood transfusions, and diarrhea. After an exploratory laparotomy, a client is admitted to the medical surgical unit with an indwelling urinary catheter and a Jackson Pratt (JP) drainage tube. Which finding should indicate to the nurse that the client may be experiencing a postoperative complication? Pain scale score of 5 out of 10 Pulse oximetry of 85% Clients who are recovering from abdominal surgery should have an oxygen saturation of 90 to 100%. A client with an oxygen saturation of 85% is poorly oxygenated. An older adult client is having trouble sleeping and comes to the primary care provider's office for evaluation. Which of the following statements should the nurse recognize as a potential rationale for the sleeping difficulties? "I take a warm shower when getting ready to go to bed." "I frequently have a cup of coffee with my dessert before going to bed." Beverages with caffeine should be avoided in the evening as it may cause stimulation to the CNS and result in sleep disturbances. A nurse working at a senior center notes that a client who is in the early stages of Alzheimer's disease has been having problems with orientation. Which of the following actions should the nurse take to improve the client's level of orientation? Encourage the client to participate in the group activities. Post a large calendar on the bulletin board. Posting a large calendar in a central location will assist this client with orientation. A provider prescribes sertraline (Zoloft) for a client. The client asks the nurse if he should continue to take St. John's Wort for depression. The nurse should advise the client to do which of the following?
Take the medication and herbal supplement together. Discontinue the herbal supplement while taking the medication. When taken with the antidepressant sertraline (Zoloft), St. John's Wort, an herbal supplement used in the treatment of mild to moderate depression, may cause an additive effect that could lead to serotonin syndrome. They should not be used concurrently. A nurse is caring for a group of clients in a long-term care setting. One of the clients is found walking in the hallway, bumping into walls, and unresponsive to his name. Which of the following actions should the nurse take first? Obtain a baseline assessment of the client. Accompany the client back to his room. The highest priority is safety. The nurse ensures safety by accompanying the client back to his room. Assessment is also essential because the client's incoordination may indicate impairment of the client's balance and level of consciousness, which may be a manifestation of an emerging complication. An adolescent client who has had no prenatal care is admitted in labor and gives birth to a stillborn preterm fetus. The client is crying and says to the nurse, "Why did this happen to me?" Which of the following responses is appropriate from the nurse at this time? "I understand how you feel."
"I am so sorry that this has happened." This statement is an example of a therapeutic response that shows empathy for the client's feelings. It is an open-ended statement that allows the client to continue to express her own feelings. A nurse participating in a community health fair is giving general information to clients who have an elevated reading during a blood pressure screening. While explaining the meaning of the results to a client, the nurse should provide the client with written information including the numeric value of the client's blood pressure. provide the client with written information including the numeric value of the client's blood pressure. When a client has an elevated reading at a hypertension screening, the nurse should encourage the client to see the provider for further evaluation. To help facilitate this process, the nurse should give the client a written record of the blood pressure result obtained at the screening so that the client can share it with the provider. A nurse is caring for an infant with a cleft palate. The parents ask the nurse when it will be repaired. The nurse replies that the palate is generally repaired between 12 and 18 months of age to prevent the child from experiencing which of the following? Repeated ear infections Difficulty with language acquisition An infant with a cleft palate may have difficulty acquiring language for two reasons. First, repeated middle ear infections are associated with transient hearing loss that can become permanent. In addition, the palate is used in vocalizing sounds, and the infant may develop poor speech habits. A nurse at an extended care facility hears an assistive personnel (AP) talking with an older adult client with dementia who has periods of confusion. Which of the following statements made by the AP should indicate to the nurse that the AP needs additional teaching about working with clients who have dementia? "We will be serving breakfast in 10 minutes. I will stay
here while you get ready." "You are running late. Let me do your hair for you and brush your teeth." When a client with dementia has periods of confusion, the nurse should allow the client additional time, as needed, to complete activities of daily living and other tasks that the client is able to perform independently. Insisting on completing the task for the client, or attempting to "hurry" the client, may make the client with dementia agitated. Rather, the nurse should encourage independence and provide assistance only if requested or required. In addition, there is no information in the case scenario to indicate that the client is, in fact, "running late." A nurse is planning care for a client admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse expects the treatment for this client to include increased fluids with hypertonic sodium chloride and fludrocortisone (Florinef). fluid restriction plus hypertonic sodium chloride and furosemide (Lasix). SIADH is a disorder of water intoxication caused by the inappropriate, continuous secretion of ADH by the posterior pituitary gland, causing hypervolemia and hyponatremia. Treatment of SIADH may include fluid restriction, sodium replacement with small amounts of sodium chloride, and IV furosemide (Lasix). A nurse is caring for a client who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect this client to have? Urine specific gravity of 1.026 Hematocrit of 55% An elevated hematocrit indicates hypovolemia. Other signs of hypovolemia are a weak pulse, hypotension, decreased central venous pressure, decreased cardiac output, elevated BUN and serum osmolality, increased urine specific gravity and osmolality, and decreased urine output. The disaster plan for a hospital has been initiated following a community flood. Which of the following actions is the responsibility of the nurse during the disaster? Turn client televisions in order for them to be kept informed of the disaster. Identify the stable clients in the intensive care unit (ICU) who can be transferred to the medical-surgical floor. Transferring the stable clients from the ICU to the medical-surgical floor allows for more intensive care beds to be used in the event that the clients from the external disaster (flood region) are deemed critically ill. As part of the disaster plan, the charge nurse will compile a list of clients who require a level of care that is consistent with the level of care that can be provided on a medical-surgical unit. A nurse is caring for a child with celiac disease. Which of the following nursing assessments is consistent with celiac disease? Elevated sweat chloride Foul-smelling stool Foul, fatty stools (steatorrhea) are a manifestation of celiac disease, a malabsorption syndrome. A nurse educator is facilitating a group discussion with preschool teachers about child abuse, and is discussing different examples of when teachers should suspect abuse. Which example should the nurse educator use to best illustrate a suspicious finding? Bruising of both knees with sutures on one Arm cast for spiral fracture of the forearm Spiral fractures can only occur from twisting of an appendage, in this case the arm. They are treated by casting the involved limb from the joint above to the joint below the fracture to limit mobility and allow healing. In most instances, spiral fractures of the arm are cited as a example of an abusive injury in children, adults, and older adults. A client diagnosed with multidrug resistant tuberculosis (MDR TB) has been prescribed ethambutol (Myambutol). The nurse plans to instruct the client that it is likely he will experience large purple bruises on the legs. loss of red/green color discrimination. Ethambutol (Myambutol) is an antitubercular drug that impairs ribonucleic acid synthesis. A common adverse reaction associated with the use of ethambutol is the loss of red/green color discrimination. A nurse is administering a transfusion of packed RBCs. Which of the following actions should the nurse take first if a transfusion reaction is suspected? Notify the primary care provider. Stop the infusion. The greatest risk to the client is a life-threatening event such as circulatory collapse. Therefore, the first action the nurse should take is to stop the infusion to prevent any further administration of blood. A new computerized charting system is going to be implemented in a health care organization. This change has been initiated by the organization's leadership and not the nurse managers. Before implementing the new system, the nurse manager should first discuss with the charge nurses their responsibility in implementing the change. announce the change in a staff meeting, allowing time for staff comments. It is important that the staff get important information related to changes in the system that impact their daily job performance directly from the manager. Using the nursing process as a priority setting framework, the nurse manager should first collect more data by allowing time for staff comment. This will allow the nurse to take further steps when implementing the new system. A primary care provider prescribes 10 units of insulin glargine (Lantus) and 4 units of NPH insulin (Humulin N) to be given subcutaneously at 1700. The nurse should plan to draw up each insulin dose into a separate insulin syringe and then combine the doses into one tuberculin syringe to inject simultaneously. draw the insulin glargine (Lantus) into an insulin syringe first, and then draw up the NPH insulin into the same syringe. draw the NPH insulin into an insulin syringe first, and then draw up the insulin glargine (Lantus) into the same syringe. draw the insulin glargine (Lantus) into one insulin syringe and the NPH insulin into a different insulin syringe and inject separately. draw the insulin glargine (Lantus) into one insulin syringe and the NPH insulin into a different insulin syringe and inject separately. Insulin glargine (Lantus) cannot be mixed with any other insulin. A nurse is caring for a client who has been hospitalized due to methicillin-resistant Staphylococcus aureus (MRSA) in the sputum. The dietary assistant asks the nurse what precautions are necessary to enter the client's room with the lunch tray. Which instructions should the nurse provide to the dietary assistant? Don a gown before entering the room and remove it before exiting. Don gloves when entering the room and use hand sanitizer when exiting. Clients with MRSA are on contact precautions. In addition to the use of standard precautions and appropriate hand hygiene, contact precautions require that any staff who will have contact with the client's environment must don gloves prior to entering the room. Additional precautions, such as a gown, are required for contact with the client; a mask and goggles could be required if secretions from the infected area could spray into the face. Delivering the tray would require contact with the environment, therefore gloves are required. A nurse is admitting a client to the medical unit and asks if the client has an advance directive. The client states "I have a document with me that names someone who can make health care decisions for me if I am not able." The client is referring to which of the following documents? Informed consent form Medical power of attorney document This type of advance directive names a surrogate who can make health care decisions for the client if he is unable to do so. This document may also be called a health care proxy.
In planning care for a child with severe reactive airway disease, the nurse knows that when chronic steroid use is indicated, inhaled steroids are preferred over oral steroids for which of the following reasons? Inhaled steroids are less likely to cause thrush. Oral steroids can slow linear growth in children. Chronic use of oral steroids in children can result in decreased linear growth. Inhaled steroids are also preferred because they deliver the anti-inflammatory agent directly to the local target area (the client's airways) without the risks of side effects associated with oral administration of steroids, such as immunosuppression and adrenal suppression. When assessing a child with lymphocytic leukemia who is being treated with vincristine (Oncovin), the nurse should give the highest priority to which of the following reports? Paraesthesia Paraesthesia The greatest risk to the client is neurotoxicity. Vincristine, a cell-cycle specific chemotherapy agent, interrupts cellular reproduction at mitosis. One of its side effects is neurotoxicity. An early finding with neurotoxicity is paresthesia, or numbing, of the peripheral extremities. As the neurotoxicity progresses, the client may develop autonomic and central nervous system dysfunction. If paresthesia occurs, the child's provider must be notified immediately, since a change in the dosage or therapy may be indicated. A client with extensive deep partial and full thickness burns has been prescribed a topical antimicrobial drug. The nurse understands that the goal of this therapy is to reduce bacterial growth. bacterial growth. The use of topical antimicrobial drugs (particularly broad-spectrum antimicrobials) is an important intervention to help prevent bacteria from entering the body when the protective covering of skin is impaired, as with burns. A topical antimicrobial is generally used on deep partial-thickness (2nd-degree) and full-thickness (3rd-degree) burn wounds to provide a protective barrier, along with the dressing, between bacteria and the exposed body tissues. A client diagnosed with acute systemic lupus erythematosus (SLE) is to begin treatment for systemic manifestations. The nurse should recognize that the preferred classification of medications to be used is corticosteroids. corticosteroids. Corticosteroids, such as prednisone (Deltasone), are the treatment of choice for systemic manifestations of SLE because of their rapid anti-inflammatory action. A nurse is caring for an unaccompanied infant who is brought to the emergency department following a multiple car crash. During assessment, the nurse notes that the infant's posterior fontanel is closed, and the anterior fontanel is soft and flat. The infant has six teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever a new person enters the room and is asking for "mama" and "dada." Which of the following is an appropriate age assessment for this child? 12 months 12 months The nurse knows that the infant must be less than 18 months old due to the anterior fontanel still being open and at approximately 12 months due to the presence of six teeth. The infant's skills - sitting unsupported (8 months), drinking well from a cup (9 months), stranger anxiety (8 months), and ability to say two words (12 months) help the nurse to estimate the infant's age as 12 months. A nurse on an oncology unit receives a report about the postoperative clients assigned to the nurse's team. Which client should the nurse see first? Postoperative day 1: Chest tube placement following lobectomy for small-cell carcinoma. Finding: Chest tube with 20 to 50 mL/hr of bright red bloody drainage Postoperative day 2: Colectomy with creation of an ostomy due to colon cancer. Finding: Ostomy bag full of bright red bloody drainage Postoperative day 2: Excision of abdominal mass with placement of a portable wound suction. Finding: Device filled with serosanguineous drainage approximately 150 mL/8 hr Postoperative day 1: Excision of bladder wall tumor and prostate. Finding: Continuous bladder irrigation reveals cherry-colored urine of 300 mL/hr Postoperative day 2: Colectomy with creation of an ostomy due to colon cancer. Finding: Ostomy bag full of bright red bloody drainage An ostomy bag full of blood is an ominous finding at any time. It indicates that the client's bowel is hemorrhaging and must be reported to the client's surgeon immediately. The client may require fluid replacement, transfusion, and additional surgery to repair the bleeding vessel. Four clients are brought to the emergency department after sustaining injuries at a bar. They all have an odor of alcohol on their breath, facial lacerations, and bruising of the head and extremities. The triage nurse makes the following additional observations: Client 1: Lethargic. Awakens to name but unable to answer questions regarding date or place. Client 2: Slurred speech. Refuses to answer questions "until a doctor looks at my broken arm." Client 3: Alert and oriented to person, place, and time. Reports nausea and is vomiting. Client 4: Belligerent and uncooperative. Responds to all questions and requests with profanity. Which client should the nurse admit first? Client 1 1 While acute alcohol intoxication may cause lethargy, the nurse should not assume that all of this client's behavior is related to the client's apparent alcohol ingestion. This client's situation includes the potential for a head injury due to facial lacerations and bruising. The nurse must consider that his lethargy and inability to answer questions could indicate a decreased level of consciousness related to acute head trauma. This client is at greatest physiological risk and must be admitted first. A nurse is caring for a school age child who has received a fiberglass cast following a lower extremity fracture. Which instructions should the nurse give the child and his parents about caring for the casted extremity in the first 48 hr? "Use only a toothbrush to scratch under the cast if your skin itches." "Apply ice to the cast at the level of the injury to help prevent swelling." Immediately following the injury, and for at least the first 48 hr, ice should be applied to the affected limb. This will help to prevent edema and pain, which could lead to impaired circulation. A nurse is caring for a client with chronic atrial fibrillation who takes warfarin (Coumadin). The client has early manifestations of Alzheimer's disease. The client's spouse asks the nurse if the client would benefit from taking ginkgo biloba. Which of the following is an appropriate response? "It is likely that ginkgo biloba may interfere with the effectiveness of his other medications." "It is likely that ginkgo biloba may interfere with the effectiveness of his other medications." Overall, the research has shown that ginkgo biloba may be effective in delaying the mental deterioration of Alzheimer's disease if taken in the early stages. However, ginkgo biloba is likely to alter the effectiveness of warfarin. A client comes to the emergency department reporting fever and severe upper left quadrant abdominal pain. The primary care provider suspects pancreatitis. Based on this information, the nurse expects to see an elevation in the client's serum amylase and lipase. amylase and lipase. With pancreatitis, laboratory results typically show elevated serum amylase and lipase up to two or three times the expected values. Liver enzymes may also be elevated, depending on the cause of pancreatitis. Serum glucose may also be elevated (hyperglycemia) due to inflammation of the pancreas A client admitted with borderline personality disorder is expressing concern about requiring a prolonged hospitalization. What is the therapeutic statement the nurse could make when interacting with this client? "Most clients are only hospitalized for about a week." "Tell me what concerns you the most about being hospitalized." Clients with borderline personality disorder have a hard time identifying their feelings. This response allows the client to focus on her concerns regarding hospitalization. It is a form of open-ended therapeutic communication. A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from the bed to a wheelchair. Which action taken by the AP indicates to the nurse an understanding of the proper technique to use for this type of transfer? Locks the brakes on the bed and the wheelchair before moving the client Locks the brakes on the bed and the wheelchair before moving the client Prior to starting the transfer, the AP should ensure that both the wheelchair and the bed are stationary and will not shift when the client moves into the chair. Therefore, locking the brakes on the bed and the wheelchair is an important action. A nurse is caring for a gravida 3 para 3 client who has had a precipitous delivery. During the fourth stage of labor, which nursing assessment must be performed every 10 to 15 min to prevent the most common complication due to this type of delivery? Monitor the level of consciousness. Palpate the fundus. A precipitous delivery is one in which the client delivered suddenly or excessively fast. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhaging. Although fundal assessment is always appropriate following delivery, this situation requires a more frequent examination of the fundus, as well as the amount of lochia. A nurse is caring for a client who is scheduled for discharge this morning and does not speak English. The client's child arrives accompanied by a neighbor to pick up the client. Both the child and neighbor speak the client's native language and English fluently. Which of the following actions should the nurse take when providing discharge instructions? Have a hospital staff member who speaks the client's language translate. Obtain the services of a translator. Medical information should be communicated by a qualified medical interpreter who speaks the client's native language. Federal law provides that the hospital is required to provide a qualified medical interpreter to translate the client's health care information into the client's native language. A charge nurse on a pediatric floor receives the results from the morning laboratory work. Which of the following client results will require the nurse call to the primary care provider first? A client who has tetralogy of Fallot and a hematocrit of 56% A client who has diabetic ketoacidosis (DKA) and a blood glucose of 375 mg/dL The normal range for a fasting blood glucose is 70 to 100 mg/dL. When treating a client in DKA, the initial goal of therapy is to get the blood glucose level less than 200 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV drip, and the glucose should be monitored hourly. The nurse needs to notify the client's primary care provider immediately of this very elevated level so that the necessary adjustments in the insulin drip dosage can be made. A nurse is preparing to care for a client in balanced skeletal traction with a femur fracture. Which of the following is an appropriate nursing intervention for this client? Offering the client a diet high in fluid and fiber Offering the client a diet high in fluid and fiber An immobilized client is at risk for constipation. The nurse should encourage a diet high in fluid and fiber to promote gastrointestinal function. A nurse is assessing a client who is prescribed rosiglitazone (Avandia). For which of the following should the nurse monitor? Fever Swollen ankles Rosiglitazone is prescribed, along with diet and exercise, to treat type 2 diabetes. Rosiglitazone can lead to fluid retention, exacerbation of heart failure, and an increased incidence of angina and myocardial infarction. A nurse is caring for a postoperative client following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). The nurse knows that the oxygen delivery system appropriate for the client is a simple face mask. nasal cannula. A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client with COPD who requires a precise percentage of inspired oxygen. A client who has been treated for a transient ischemic attack (TIA) is being discharged. The nurse's discharge teaching plan related to this admission should reinforce the importance of monitoring blood glucose using a glucometer. blood pressure at regular intervals. TIAs are caused by a temporary disturbance of blood supply to the brain, resulting in brief neurologic dysfunction. One third of clients who have had a TIA later have recurrent TIAs, and another one third have cerebrovascular accidents (CVA) that results in permanent nerve cell loss. The most common causes of TIAs is atherosclerotic plaque in the carotid arteries and hypertension. Consequently, managing hypertension is important in reducing the risk of CVA. A clinic nurse is caring for an older adult client with an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse explains that whistling in hearing aids is often caused by low battery power. excessive wax in the ear canal. Whistling from the hearing aid can be caused by a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, or a malfunction. Ear molds should be cleaned regularly, turned off and removed at night, and protected from water and direct heat. A nurse is helping plan a health fair for adults in the community. One booth will focus on primary and secondary prevention actions for colorectal cancer. The nurse should include information on the prevention and treatment of constipation. importance of colonoscopy screening starting at age 50. Screening exams for colorectal cancer are considered secondary prevention (early detection of disease). While it is recommended that some high-risk clients have a colonoscopy before age 50, most clients should have a baseline colonoscopy done at age 50. A nurse is providing teaching to a client who is prescribed albuterol (Proventil) via a metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take which of the following actions next? (Move the following steps into the box on the right, placing them in the selected order of performance. All steps must be used.) The client should hold the mouth piece 1/2 to 2 inches from his mouth, tilt his head back slightly and then open his mouth. Next, he should press the inhaler while taking a deep breath to facilitate delivery of the medication to the air passages. After holding his breath for 10 seconds, the client should resume normal breathing. During a change of shift, a nurse is reviewing the medication administration records (MAR) for her assigned clients. The nurse notes that a prescribed dose of a medication is above the recommended safe range, and the dose was administered on the previous shift by a nurse. Which of the following actions should the nurse take? Call the previous nurse to verify that the dose was given. Call the prescriber to get the dose clarified. The nurse needs to clarify the prescribed dose to determine what the next action will be. A client comes to the emergency department with deep, rapid respirations. Arterial blood gas analysis includes these values: pH 7.25, PCO2 40, and HCO3- 18. The nurse reports to the provider that the client is experiencing respiratory alkalosis.
metabolic acidosis. When evaluating arterial blood gas reports, the nurse first checks the acid-base balance. Since the pH (7.25) is acidic (expected range = 7.35 to 7.45) the client is acidotic. Next the nurse determines the cause. If the cause is respiratory, the pH and PCO2 values deviate in opposite directions. Since the PCO2 (40) is acceptable (expected range = 35 to 45) despite the low pH, the cause must be metabolic. Therefore, the nurse correctly reports to the provider that the client is experiencing metabolic acidosis. After 30 min of rambling about the "ozone layer" and being "doomed to die," a client begins pacing in an increasingly agitated manner. What should the nurse do first? Obtain a prescription for PRN medication for
agitation. Remain with the client and attempt to reduce the environmental stimuli. The nurse should remain with the client, even if that requires walking alongside the client. Also, attempts should be made to reduce the client's external stimuli. A newly licensed nurse is caring for a child who is brought to the emergency department with bruises that the nurse believes are due to child abuse. What should be the nurse's action at this time? Ask the child who is responsible for the bruises. Notify the charge nurse. The nurse has noted that the bruises are suspicious. The proper action at this point is to follow the chain of command to ensure that the incident is reported to the authorities for investigation. A client who is regularly exposed to sunlight comes to the clinic to have several skin lesions evaluated. Which assessment finding should alert the nurse to the possibility of malignant melanoma? A pearly papule that is 0.5 cm in size with raised, indistinct borders on the upper right shoulder An irregularly shaped brown lesion with light blue areas on the neck Malignant melanoma, the leading cause of death from skin cancer, is a neoplasm derived from dermal or epidermal cells. Exposure to sunlight increases the risk, with fair-skinned people at greatest risk. Malignant melanoma commonly starts in exposed skin areas like the back, scalp, face, and neck, and metastasizes readily to other areas. Manifestations include a change in the color, size, or shape of a skin lesion, with irregular borders in hues of tan, black, or blue. A nurse is caring for a client who is mechanically ventilated due to acute respiratory failure. At 1600, the client had a heart rate of 80/min and a respiratory rate of 20/min, with an oxygen saturation (SaO2) of 98%. At 1800, the client has a heart rate of 120/min, a respiratory rate of 32/min, and a SaO2 of 87%. The nurse should provide 100% oxygen by
bag-valve-mask ventilation. auscultate the client's anterior and posterior lung fields. When a client is intubated and ventilator-dependent, oxygen saturation levels (SaO2) are a crucial factor in evaluating respiratory status. Note that the client was stable at 1600, with an acceptable SaO2 at 98% and respirations of 20/min; however, 2 hr later, the SaO2 has dropped to an unacceptably low 87% with an associated increase in respirations to 32/min. There are many potential reasons for these findings, so the first step is to complete a respiratory assessment, including auscultation of all lung fields. A client is in the dayroom when another client asks if two items of clothing match. The client with schizophrenia replies, "A match. I like matches. They are the givers of light, the light of the world. God will light the world if you let Him. Let your light shine in." Which of the following is the client demonstrating? Clang association Loose association This client is demonstrating loose association, a pattern of disordered language that represents disordered thought. A nurse is caring for a client with a history of an above-knee amputation and chronic phantom pain. Which of the following medication prescriptions should the nurse question? Meperidine HCL (Demerol) Meperidine HCL (Demerol) The nurse should question the use of meperidine HCL in the client with chronic pain. Chronic pain should not be managed with an opioid analgesic due to the risk of dependence and tolerance. Also, meperidine should not be used long-term due to the build up of a toxic metabolite that occurs when the medication is metabolized. An 18 month old infant admitted with Pneumocystis carinii pneumonia has enzyme linked immunosorbent assay (ELISA) testing and is diagnosed as being human immunodeficiency virus (HIV) positive. In planning care, the nurse should be aware that the infant's mother is also HIV positive. the infant's mother is also HIV positive. Transmission from an HIV-infected mother to an infant can occur during pregnancy, delivery, or through breastfeeding. An 18-month-old infant would be unlikely to have contracted HIV via any of the other known high-risk transmission behaviors such as sexual contact or IV drug use. Acquisition of HIV via contaminated blood products is also very unlikely for this infant (although not impossible) because of improved accuracy of testing for the presence of HIV antibodies in all donated blood since 1985. A client being treated for antisocial personality disorder is becoming increasingly loud and belligerent on the mental health unit. Which approach should the nurse use to manage this client's potentially violent behavior? Confront the client for breaking the rules. Use clear, calm statements and set limits on the behavior. In order to remain in control of the situation, the nurse should use clear, calm statements when the client is highly anxious. Limits should be set for the client who exhibits potentially violent behavior. A disabled client is taking phenelzine (Nardil) for depression. The nurse is teaching the client's new home health aide about the client's diet restrictions due to the medication. The nurse evaluates that the teaching has been effective when the home health aid selects which of the following for the client's lunch? Bologna sandwich on wheat bread and orange slices Chicken salad and carrot sticks Phenelzine is a monoamine oxidase inhibitor (MAOI). Clients taking MAOIs must avoid foods with tyramine due to a dangerous food-drug interaction. Foods high in tyramine include those that are processed and aged, such as lunch meats and cheeses. This menu selection does not contain food high in tyramine; therefore, it is the best choice. A nurse is caring for a 4 year old child who is admitted to the pediatric unit through the emergency department and will be having a procedure in the morning. The child has been crying throughout the night and experiencing night terrors despite the parent's presence at the bedside. The nurse should understand that engaging the child in therapeutic play may provide which of the following benefits?
Decreases the child's fear of the dark Allows the child to manipulate play medical equipment A major function of play in play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express his fear of the unfamiliar medical equipment used in the hospital. The nurse encourages the child to touch the equipment to decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people. A charge nurse in the labor and delivery suite is coordinating the care of four clients. When the reporting nurses bring the charge nurse assessments, which client must the charge nurse see first? Client in active labor with late decelerations on the monitor strip Client in active labor with late decelerations on the monitor strip Late decelerations are nonreassuring patterns that reflect impaired placental exchange or placental insufficiency. Interventions include improving placental blood flow and fetal oxygenation with such actions as changing the mother's position, giving the mother oxygen, increasing the mother's IV fluids, and possibly even an immediate caesarean birth. This is the client who must be assessed by the charge nurse immediately. A nurse is instructing a client on postoperative care related to a surgical procedure that will occur later in the day. The client states that no one has spoken to him about this before. Which of the following actions should the nurse take? Continue the teaching, but check afterward with the surgeon
related to informed consent. Stop the teaching and check with the surgeon related to informed consent. The client's statement indicates that informed consent has not been obtained. Therefore, the nurse should stop the teaching and contact the surgeon. A nurse is preparing to administer medications to an unconscious client. The nurse should bring the medication administration record (MAR) to the client's bedside and check the client's name and medical record number on the MAR against the room and bed number. compare the medical record number and name on the MAR with the client's identification band. The Joint Commission requires the use of two client identifiers when administering medications. It is correct for the nurse to compare the medical record number and name on the MAR with the client's identification band. Which of the following actions should a nurse take after discontinuing IV therapy for a client with a platelet count of 50,000/mm3? Monitor the client's vital signs frequently. Apply pressure to the catheter removal site for 5 min. The expected platelet (thrombocyte) count ranges from 150,000 to 450,000/mm3. Any value below 100,000/mm3 is considered thrombocytopenia, a problem that puts the client at increased risk for bleeding. By applying pressure to the site for at least 5 min, the nurse promotes coagulation and prevents additional blood loss. A nurse is caring for a child who has epistaxis. Which of the following actions would be the most appropriate for the nurse to take? Administer aspirin for pain. Apply a cold cloth to the bridge of the nose. Applying a cold cloth to the bridge of the nose causes vasoconstriction, which decreases the bleeding. A nurse manager notes conflicts between nurses on different shifts. These problems are likely due to several factors, including generational differences, experience, and the expectations of care on each shift. Which of the following strategies should the nurse use to resolve these conflicts? Have the
charge nurses for each shift get together and discuss the issues between shifts. Set up a series of meetings for all staff members to attend to discuss issues. The nurse manager realizes that conflict resolution requires bringing the groups together to communicate common issues. Inviting all staff members to participate allows this to happen. A hospital receives a bomb threat and the charge nurse has to coordinate the evacuation of the clients. Which of the following actions should the nurse take when implementing the evacuation process? Call in the
clients' family members to provide additional help in moving the clients. Instruct clients who are able to ambulate to leave. Clients who are able to ambulate should be asked to leave first because this is the fastest way to start the evacuation process. Clients on neuroleptic antipsychotic medications are at a higher risk for developing agranulocytosis. What client data should the nurse review for the earliest indication of this problem? Urinalysis Temperature Agranulocytosis is a blood dyscrasia. It is the depletion of WBCs, which makes the client more susceptible to infection. An assessment of the client's temperature will provide easy, noninvasive baseline data to determine if laboratory work, such as a WBC count, should be requested. A nurse is providing teaching to a client who is prescribed insulin for a new diagnosis of diabetes mellitus. The nurse should explain the need for subcutaneous injections of insulin by responding that insulin is a hormone that cannot be converted to a pill form. is destroyed by the digestive enzymes in the stomach if taken orally. Insulin must be given by a parenteral route because it is destroyed by the digestive enzymes of the stomach. Taken orally, it would be deactivated before it could be absorbed. A nurse is assigned to care for several postoperative clients. The nurse identifies a client as having a high risk for delayed wound healing if the client has hypertension treated with nifedipine (Procardia). adrenal insufficiency treated with prednisone (Deltasone). Prednisone is a potent glucocorticoid (steroid) that is associated with delayed wound healing. In addition, the client with adrenal insufficiency will have a poor stress response, therefore requiring high steroid doses to adapt to the stress of surgery. A nurse is providing teaching to parents of a child who is prescribed lamotrigine (Lamictal) for a seizure disorder. The nurse should instruct the parents to notify the primary care provider immediately if the child develops which of the following? Headache Rash A rash is the first indication of both Stevens-Johnson syndrome and toxic epidermal necrolysis, which can occur typically in the first 2 to 8 weeks of treatment with lamotrigine. The greatest risk to the client is a life-threatening adverse reaction to lamotrigine that can result in permanent disability or death. A female client with a history of recurrent cystitis asks the nurse about preventing future episodes. Which client statement describes a self care activity that the nurse should discourage? "I drink at least 2 liters of fluid per day." "I prefer tub baths to showering." Cystitis is an inflammation of the bladder lining that commonly occurs with a urinary tract infection (UTI). Women at risk for UTIs should avoid tub baths as they are associated with an increased risk for infection. This is a self-care activity the nurse should discourage. TEST-TAKING STRATEGY: This question asks which activity the nurse should DISCOURAGE, thus the CORRECT answer is an INCORRECT activity. A community health nurse is planning the day's schedule for visiting four high risk neonates discharged yesterday. Which of the following neonates should the nurse plan to visit first? 1 week old who needs a repeat phenylketonuria (PKU) screening test 4 day old with an elevated bilirubin level who is prescribed phototherapy An elevated bilirubin level can lead to kernicterus (bilirubin encephalopathy), a form of brain damage associated with newborn hyperbilirubinemia and jaundice. This neonate must be seen first so that the prescribed phototherapy can be initiated as soon as possible. If initiated early, the neonate may be successfully treated at home with exposure to sunlight, avoiding the need for hospitalization. A nurse in a substance abuse program is interacting with a client. The client is a nurse who has entered into the program as requirement of the state's board of nursing. Which statement by the client indicates to the nurse that the client is using intellectualization as a way of coping with the anxiety of admission? "I was just using the medication to help me out during a rough time in my life, that's all. I can stop whenever I want." "In my experience, problems with substances can have a variety of predisposing factors." Intellectualization is an attempt to use intellectual processes to avoid expressing emotions associated with stressful situations. It is a common defense mechanism used by professionals in the medical field as a way of coping with their anxiety related to either their own diagnoses or hospitalizations. A nurse is caring for a client diagnosed with hyperthyroidism. When developing a teaching plan, it is important for the nurse to encourage the client to reduce her hours of sleep. increase nutritional intake with meals. Clients with elevated thyroid hormone levels have increased protein, lipid, and carbohydrate metabolism, resulting in the loss of protein stores and a negative nitrogen balance. Even with an increased appetite, it is often difficult to meet energy demands, and weight loss is common. Muscle weakness and wasting can develop without adequate caloric and protein intake. A family member of a client receiving hospice services asks the hospice nurse for assistance. The family member states that the client has insomnia almost nightly. The nurse assesses the client and documents the following: "Vital signs are stable, takes a short nap once a day as needed, walks around the neighborhood once a day if feeling ok, likes to watch television (TV) in bed during the day, goes to bed at 10 pm every night, drinks hot herbal tea before going to bed, and gets up to go to the bathroom once during the night." Which of the following mostly likely contributes to the client's insomnia? The client watches TV in the bed during the day. The client watches TV in the bed during the day. General sleep strategies include establishing a regular sleep schedule and staying out of bed during the day, except for naps. A high carbohydrate, low protein diet is prescribed for a client who has chronic renal failure. The nurse explains to the client that the carbohydrates in this diet will help prevent ketosis. prevent ketosis. Clients in chronic renal failure have diets restricted in protein, sodium, potassium, magnesium, phosphorus, and saturated fats. Carbohydrates provide the client with adequate calories to meet metabolic and energy needs while preventing the development of ketosis. Carbohydrates also have a protein-sparing effect that makes protein available for growth and tissue building. A nurse is assessing a client who is taking varenicline (Chantix) for smoking cessation. Which of the following client reports is the highest priority finding? Irritability Irritability The greatest risk to the client is the development of CNS side effects that can progress to depression and suicide. Therefore, the highest priority finding is irritability. A nurse is teaching a client who is a paraplegic to perform intermittent urinary self catheterization at home after discharge. Which statement by the client demonstrates to the nurse that the client understands the procedure? "I will not use the Valsalva maneuver while performing self-catheterization." "I will perform intermittent self-catheterization every 4 to 6 hours." The standard interval for intermittent catheterization is every 4 to 6 hr . Although some adult clients may wait up to 8 hr, that greatly increases the risk for urinary tract infection. A nurse is planning care for an older adult client. An increase in which of the following is a normal physiological change associated with aging? Vital capacity Adipose tissue Physiological changes occur with aging in all organ systems. Tissue composition changes the nurse should be aware of include an increase in adipose tissue, a decrease in lean body mass, and a decrease in total body water. Because of these normal alterations, medication dosages may need to be reduced in the older adult client. For example, an increase in adipose tissue may prolong the half-life of lipid-soluble medications. A nurse is caring for a client who is at 38 weeks of gestation and in the active phase of the first stage of labor. The client's electronic fetal monitoring reveals two early decelerations in the last five contractions. Which of the following is an appropriate nursing intervention? Increase the IV solution rate. Alter the client's position to a lateral position. An early deceleration is a common, normal variation in the fetal heart rate. It is caused by pressure on the fetal head from the walls of the birth canal. This may be relieved by changing the maternal position. Lateral, or side-lying positioning provides for the best uteroplacental blood flow. A nurse is taking a history from a client with presbyopia. With which of the following should the nurse expect the client to have difficulty? Finding the bathroom in the dark Reading the newspaper In presbyopia, the lens is unable to change shape to focus on objects close up. Presbyopia occurs most often with aging, beginning in the forties, and is due to the decreased flexibility of the lens. A client with a history of chronic renal failure (CRF) has routine laboratory tests done with the following results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and albumin 3.0 g/dL. Which result should the nurse report to the client's primary care provider immediately? Hypocalcemia Hyperkalemia Hyperkalemia (elevated potassium) is common among clients with CRF. The other values are outside of the expected range but are expected with CRF. However, even for a client with CRF, this potassium level is associated with life-threatening cardiac dysrhythmias.
At a maternal health clinic, a nurse talks with several prenatal clients on the phone. Which client report does the nurse realize is a normal physiologic adaptation to pregnancy? Spotting with urination Breast tenderness Breast tenderness is commonly experienced during both the first and third trimesters of pregnancy. The nurse explains to the client that this is a normal adaptation to pregnancy and should also teach the client to wear a well-fitting, supportive bra to alleviate the tenderness A client comes to the emergency department in severe respiratory distress with a knife protruding from his left chest. The nurse finds that the client has tachycardia, hypotension, and has a tracheal shift to the right. The nurse should prepare the client for tracheostomy placement. chest tube insertion. The client's manifestations indicate pneumothorax due to the open chest wound. The provider must insert a chest tube immediately and connect it to a water-seal drainage system. A nurse is caring for a client with hypothyroidism who is taking levothyroxine sodium (Synthroid). The nurse teaches the client to report which adverse effect of this medication to the provider immediately? Weight gain Chest pain Chest pain may result if a client takes too much levothyroxine. It is important to increase the dosage gradually as needed to prevent rapid changes in cardiac output that can cause tachycardia and angina, especially for clients with longstanding hypothyroidism or cardiovascular disorders. A nurse is teaching the parents of an infant about treatment options for profound sensorineural hearing loss. The nurse explains that cochlear implants work by which of the following? Direct stimulation of auditory nerve endings Direct stimulation of auditory nerve endings Cochlear implants work by directly stimulating nerve endings in the cochlea. A nurse is talking with the parent of a 4 month old infant about normal growth and development. Which comment made by the parent should indicate to the nurse a need for further teaching? "I need to remind my older kids to keep small objects out of the baby's reach." "My baby loves to play with the musical mobile in the crib." Crib mobiles should be removed from the crib at 4 months. Infants at this age are beginning to reach for objects and pull on them. The crib mobile could fall and become a choking or strangulation hazard. A client recently received a Mantoux skin test. After 48 hr , the test was evaluated by the nurse and reveals 10 mm of induration with slight redness. This indicates to the nurse that the client has active tuberculosis (TB). client has been exposed to tuberculosis (TB). A Mantoux test is done to determine if a client has been exposed to TB. Forty-eight to 72 hr after the Mantoux is performed, the client will need to return to the provider to have the results read. This involves a brief examination of the test site. The nurse will look at the test site and palpate the area to determine if the test site is raised and feels hard to the touch (induration) and will record the results in millimeters to represent the size of the raised bump. Redness does not count toward reading the test as negative or positive. A nurse responds to a call from the nursing assistant that a client has had a seizure and is unconscious. What is the nurse's priority at this time? Notify the client's primary care provider. Check airway patency. The nurse's highest priority in this situation is to establish and maintain the client's airway to prevent respiratory arrest and/or hypoxia. A nurse has taught the parent of a child diagnosed with type 1 diabetes mellitus how to manage the child's condition during illness, such as colds or flu. The nurse evaluates that the child's parent understands the teaching when the parent states, "On sick days I will reduce my child's food intake to prevent nausea and vomiting." increase the frequency of checking my child's blood glucose." Blood glucose should be monitored every 3 hr during an illness because it will often rise, even if food intake decreases. Which statement made by an assistive personnel (AP) to a nurse indicates that the AP needs more education about the use of side rails as a safety device? "All four side rails cannot be left raised at all times unless there is a prescription from the provider for client restraints." "If the client is confused, I'm going to raise all four side rails, so that the client doesn't hurt himself." Raising all four side rails can put the client at greater risk for injury. If the client becomes confused and tries to climb over the side rails, it could result in a much more serious fall. Therefore, one side rail at the bottom of the bed should remain down. TEST-TAKING STRATEGY: With a negative-format question like this one, the CORRECT answer is an INCORRECT statement. A nurse is caring for a client with schizophrenia in an inpatient mental health facility. The client asks the nurse, "Can I vote in the upcoming presidential election?" Which of the following is an appropriate response? "No, clients with mental health disorders requiring hospitalization cannot vote." "Yes, you can vote. Can I assist you with obtaining an absentee ballot?" Clients that are hospitalized in an inpatient mental health facility may vote, but they frequently need assistance to vote with an absentee ballot. Clients with mental health disorders have all the legal rights of any other United States citizen, unless the client is under a specific court order (or other legal ruling) to the contrary. A nurse admits an child with a urinary tract infection (UTI) who has a history of myelomeningocele. After completion of the admission history, which action should the nurse take? Label the client's identification band with a "latex allergy" alert. Label the client's identification band with a "latex allergy" alert. Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are external to the spinal bones and contained in a cerebrospinal fluid-filled sac at birth. The nurse is aware that clients with neural tube defects are at an increased risk for latex allergy; therefore, these clients are placed on latex alert as a matter of caution. Exposure to common medical products containing latex, such as latex gloves, must be avoided. A nurse is providing discharge teaching to parents whose infant has had a ventriculoperitoneal shunt placed. The nurse evaluates that teaching was effective when the parent states which of the following? "We will check the abdomen daily for signs of fluid accumulation." "A new shunt will probably be needed in a couple of years." When the ventriculoperitoneal shunt is inserted, the surgeon will leave the distal tubing longer than necessary and coiled in the peritoneum to allow for growth. Even so, by about the preschool period, the child will outgrow the tubing length and require a revision of the original shunt. Another common complication is shunt malfunction, which also requires surgical revision, typically within a few years. A nurse is teaching a group of clients at an older adult center about the risk for the development of osteoporosis. Which of the following statements should the nurse include in the teaching session? "Extended periods of immobility increase your risk for osteoporosis." "Extended periods of immobility increase your risk for osteoporosis." Osteoporosis is a condition in which bones become weakened due to a loss of bone mass and a change in bone structure. Immobility can result in osteoporosis; therefore, weight-bearing exercise, such as walking, is one way for the client to prevent osteoporosis. A nurse is caring for a client taking warfarin (Coumadin). Which of the following laboratory values indicates to the nurse an effective response to the medication? Hct of 45%
INR of 3.0 Warfarin is an anticoagulant used to prevent thrombus formation in susceptible clients. The INR is used to monitor for the desired response to warfarin. A therapeutic INR for a client on warfarin is 2.5 to 3.0, but varies by diagnosis and provider preference. An INR greater than 4.0 may result in an increased risk for bleeding. A nurse at an acute care clinic is talking with a client who reports that her arthritis pain is increasing each day. The client wants to discuss nonpharmacological approaches that would help relieve her. Which intervention should the nurse suggest? Increasing dietary intake of omega-3 fatty acids Increasing dietary intake of omega-3 fatty acids Taking omega-3 fatty acids has been found to be effective in reducing inflammation. It may also help prevent cardiovascular disease. Omega-3 fatty acids can be found in fish oil and can be taken as a dietary supplement. A nurse is preparing to administer a feeding via a gastrostomy tube to a client recovering from a cerebrovascular accident. The prescription is for tube feedings to be administered every 4 hr. Which action should the nurse take prior to initiating the feeding? Warm the feeding in the microwave. Elevate the head of the bed. A common reason that clients recovering from brain injury require gastrostomy tube feedings is that they are unable to swallow due to aphagia and cannot adequately protect their airway from aspiration due to an impaired gag reflex. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, it is important to take actions to prevent aspiration, such as elevating the head of the bed, prior to initiating the feeding. Which of the following herbal supplements can interact adversely with warfarin?Common supplements that can interact with warfarin include:. Dong quai.. Garlic.. Ginkgo biloba.. Ginseng.. Green tea.. St. John's wort.. Vitamin E.. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?Prothrombin time (PT) — The clotting test used to measure the effect of warfarin is the prothrombin time (called pro time, or PT).
What is patient anticoagulant therapy?Anticoagulants are medicines that help prevent blood clots. They're given to people at a high risk of getting clots, to reduce their chances of developing serious conditions such as strokes and heart attacks. A blood clot is a seal created by the blood to stop bleeding from wounds.
Which dietary instruction should the nurse provide the client taking hydrochlorothiazide?These changes include eating a diet that is low in fat and salt, maintaining a healthy weight, exercising at least 30 minutes most days, not smoking, and using alcohol in moderation.
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A nurse is teaching a client who is to start taking warfarin about herbal supplements
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