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38 Cards in this Set

  • Front
  • Back

A 35-year-old client who is 28 weeks pregnant is admitted for testing. After reading the nursing notes, which rationale best explains why a pregnant client should lie on her left side when resting or sleeping in the later stages of pregnancy?


a) To facilitate digestion.


b) To prevent development of fetal anomalies.


c) To prevent compression of the vena cava.


d) To facilitate bladder emptying.

c) To prevent compression of the vena cava.




The weight of the pregnant uterus is sufficiently heavy to compress the vena cava, which could impair blood flow to the uterus, possibly decreasing oxygen to the fetus. The client may experience supine hypotension syndrome (faintness, diaphoresis, and hypotension) from the pressure on the inferior vena cava. The side-lying position puts the weight of the fetus on the bed, not on the woman. The side-lying position has not been shown to prevent fetal anomalies, nor does it facilitate bladder emptying or digestion.

Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain?


a) Clean briskly around the site with alcohol.


b) Wear sterile gloves and a mask.


c) Remove the drain before cleaning the skin.


d) Clean from the center outward in a circular motion.

d) Clean from the center outward in a circular motion.




The nurse should move from the center outward in ever-larger circles when cleaning around a wound drain because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and, because it evaporates, has no lasting effect on bacteria. The nurse should wear sterile gloves to prevent contamination, but need not wear a mask.

When admitting an elderly client for nausea and vomiting that has lasted for 3 days, the nurse should assess for which of the following clinical findings?


a) Hypertension.


b) Bradycardia.


c) Polyuria.


d) Poor skin turgor.

d) Poor skin turgor.




In a client with persistent nausea and vomiting, the nurse should anticipate that the client may be dehydrated and exhibit signs of a fluid volume deficit, such as poor skin turgor. Other typical assessment findings include lethargy, dry mucous membranes, tachycardia, weight loss, and decreased urine output. Blood pressure is usually within normal limits in the case of a mild to moderate fluid volume deficit because of the compensatory mechanisms of sympathetic nervous system stimulation of the heart (causing tachycardia) and peripheral vasoconstriction.

The client with chronic renal failure tells the nurse he takes magnesium hydroxide at home for constipation. The nurse suggests that the client switch to psyllium hydrophilic mucilloid because:


a) Magnesium hydroxide is high in sodium.


b) Magnesium hydroxide can cause magnesium intoxication.


c) Magnesium hydroxide is too harsh on the bowel.


d) Psyllium hydrophilic mucilloid is more palatable.


b) Magnesium hydroxide can cause magnesium intoxication.




Magnesium is normally excreted by the kidneys. When the kidneys fail, magnesium can accumulate and cause severe neurologic problems. Magnesium hydroxide is harsher than psyllium hydrophilic mucilloid, but magnesium toxicity is a more serious problem. A client may find both magnesium hydroxide and psyllium hydrophilic mucilloid unpalatable. Magnesium hydroxide is not high in sodium.

After teaching the parents about the cause of ringworm of the scalp (tinea capitis), which statement by a parent indicates successful teaching?


a) "It's a fungal infection of the scalp."


b) "It's caused by infestation with a mite."


c) "It results from overexposure to the sun."


d) "It's an allergic reaction."


a) "It's a fungal infection of the scalp."




Ringworm of the scalp is caused by a fungus of the dermatophyte group of the species. Overexposure to the sun would result in sunburn. Mites, such as chiggers or ticks, produce bites on the skin, resulting in inflammation. An allergic reaction commonly is manifested by hives, rash, or anaphylaxis.

The nurse is reflecting on the evaluation step of the nursing process. Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply.


a) Edema of the extremities, labored respirations, color normal


b) Lung sounds clear bilaterally with non-labored respirations noted


c) Disoriented; oxygen saturation levels at 85%; coughing large amount thick, white sputum; dyspnea on exertion


d) Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min


e) Respirations at 26 breaths/min, circumoral cyanosis present, orthopneic


b) Lung sounds clear bilaterally with non-labored respirations noted


d) Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min




A decrease in anxiety with an increase in oxygen saturation and clear lung sounds with non-labored respirations show documentation that breathing has improved. The other answers indicate abnormal data of the respiratory status.

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in his cast care?


a) "Keep your right leg elevated above heart level."


b) "A foul smell from the cast is normal."


c) "Use a knitting needle to scratch itches inside the cast."


d) "Cover the cast with a blanket until the cast dries."


a) "Keep your right leg elevated above heart level."




The nurse should instruct the client to elevate the leg to promote venous return and prevent edema. The cast shouldn't be covered while drying. Covering the cast will cause heat buildup and prevent air circulation. The client should be instructed not to insert foreign objects into the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

A client with burns to 40% of the body arrives at the emergency room. Which prescriptions by the primary healthcare provider should the nurse anticipate? Select all that apply.


a) Administration of lactated Ringer's (LR) solution intravenously


b) Monitoring the client’s body temperature


c) Administration of 100% humidified oxygen


d) Education about the importance of good nutrition


e) Insertion of a nasogastric tube


a) Administration of lactated Ringer's (LR) solution intravenously

b) Monitoring the client’s body temperature


c) Administration of 100% humidified oxygen


e) Insertion of a nasogastric tube




A client arriving to the emergency room with burns is in the emergent/resuscitative phase of managing a burn injury. The nurse should expect the primary healthcare provider to prescribe insertion of a nasogastric tube to decompress the stomach and prevent vomiting. Administration of 100% humidified oxygen and monitoring the client’s body temperature are also expected. Fluid resuscitation for clients with burn injuries greater than 20% is necessary to support circulatory function and tissue perfusion. Administration of LR intravenously is the preferred fluid. The nurse would not provide education about nutrition during the emergent phase.

Which goal would be appropriate for a client with viral hepatitis? The client will:


a) restrict activity to within the home to prevent disease transmission.


b) verbalize the importance of reporting bleeding gums or bloody stools.


c) limit use of alcohol to two to three drinks per week.


d) demonstrate a decrease in fluid retention related to ascites.


b) verbalize the importance of reporting bleeding gums or bloody stools.




The client should be able to verbalize the importance of reporting any bleeding tendencies that could be the result of a prolonged prothrombin time. Ascites is not typically a clinical manifestation of hepatitis; it is associated with cirrhosis. Alcohol use should be eliminated for at least 1 year after the diagnosis of hepatitis to allow the liver time to fully recover. There is no need for a client to be restricted to the home because hepatitis is not spread through casual contact between individuals.

A client with chronic obstructive pulmonary disease (COPD) has developed tachypnea, dyspnea, and oxygen saturation (SaO2) of 90%. Which of the following actions by the nurse is most appropriate?


a) Place the client in the Trendelenburg position


b) Place the client on bed rest


c) Assist the client to sit in a chair and lean slightly forward with hands on the knees


d) Position the client in a low Fowler’s position with the knees flexed


c) Assist the client to sit in a chair and lean slightly forward with hands on the knees




Dyspnea is the primary disabling symptom of COPD and the most common. Persistent labored breathing is triggered by increased ventilation secondary to increased work of breathing. Dyspnea also has psychophysiologic components, triggered by such factors as anxiety and fear causing clients to avoid exercise and abandon activities, leading to a downward spiral of disability. To help manage dyspnea, teach clients activities that reduce or control it such as sitting up in the "tripod" position where the client sits or stands leaning forward with the arms supported, forces the diaphragm down and forward, and stabilizes the chest while reducing the work of breathing. COPD clients require exercise, better exercise capacity decreases dyspnea and improves quality of life. Continued bed rest is not recommended. If the client is in bed, the head should bed elevated to high Fowler's position and their arms should be supported on pillows or over the bed side table resting the elbows on a surface. This reduces competing demands of the arm, chest, and neck muscles needed for breathing. The Trendelenburg position is used for treatment of severe hypotension.

Immediately after a lumbar laminectomy, the nurse administers ondansetron hydrochloride to the client as prescribed. The nurse determines that the drug is effective when which sign is controlled?


a) nausea


b) dry mouth


c) shivering


d) muscle spasms


a) nausea




Ondansetron hydrochloride is a selective serotonin receptor antagonist that acts centrally to control the client’s nausea in the postoperative phase. It does not control muscle spasms, shivering, or dry mouth.

A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to:


a) participate in a game of charades.


b) perform an aerobic exercise.


c) fold towels and pillowcases.


d) play cards with another client.


c) fold towels and pillowcases.




Folding towels and pillowcases is a simple activity that redirects the client's attention. Also, because this activity is familiar, the client is likely to perform it successfully. Cards, charades, and aerobic exercise are too complicated for a confused client.

The nurse is aware that clients who are Christian Scientists may not approve of


a) Circumcisions


b) Expensive treatments


c) Contraception


d) Immunizations


d) Immunizations




Some groups, such as Christian Scientists and Amish, have been legally exempted from immunizations; however, many medical decisions are reviewed on a case-by-case basis depending on the client’s age and imminence of death.

The mother of a 17-year-old girl with Down syndrome tells the nurse that her daughter recently stated that she has a boyfriend. The mother is concerned that her daughter might become pregnant. Which is the most appropriate suggestion by the nurse?


a) "I understand your concern; you may want to enroll your daughter in an abstinence program."


b) "Women with Down syndrome are infertile, so you do not need to worry about her getting pregnant."


c) "This may be difficult, but you may want to suggest that your daughter break off the relationship."


d) "I understand your concern; you may want to start your daughter on long-acting contraception."


d) "I understand your concern; you may want to start your daughter on long-acting contraception."




Children with Down syndrome range from severely intellectual disability to low average intelligence, Thus the adolescent’s ability to make informed choices regarding sexual activity is limited. Long-acting contraception, such as an intrauterine device or a progestin implant, greatly reduces the risk of unwanted pregnancy. Most women with Down syndrome are fertile; however, children born to women with Down syndrome often have congenital defects. An abstinence program may not be effective due to the intellectual level of children with Down syndrome. Suggesting that the adolescent break off the relationship does not ensure that she will.

The parents of a 20-year-old female client diagnosed with paranoid schizophrenia admitted 4 days ago are attending a family psychoeducation group in the hospital. Which statement by the mother indicates that she understands her daughter’s illness and management?


a) "I know that visits from her friends at home should be discouraged for a while."


b) "Tasks as simple as getting out of bed and showering in the morning may be difficult for her."


c) "She will not experience a relapse as long as she takes her prescribed medication."


d) "I know that I will have to do everything for my daughter when she comes home."


b) "Tasks as simple as getting out of bed and showering in the morning may be difficult for her."




Clients with paranoid schizophrenia experience alterations in thought resulting in introspection, confusion, and distraction from external reality. Simple tasks that require concentration and effort, including activities involving self-care, may be difficult for the client, especially during the acute phase of the illness. However, the mother should not need to do everything for her daughter. Rather, the mother should encourage the daughter to do things for herself with guidance. Visits from friends should be discussed with the client, and the client should be encouraged to visit with friends to minimize the risk of social isolation. Although relapse typically occurs with medication noncompliance, vulnerability to stress, a low threshold for stress, the number of stresses, and the client’s lack of adaptive coping behaviors contribute to relapse

Experimental and epidemiologic evidence suggests that a high-fat diet increases the risk of several cancers. Which of the following cancers is linked to a high-fat diet?


a) Lung.


b) Liver.


c) Colon.


d) Ovarian.


c) Colon.




Evidence suggests that a high-fat diet increases the risk of several cancers, including breast, colon, and prostate cancers. Ovarian, lung, and liver cancers have not been linked to a high-fat diet.

A client asks the nurse how frequently she should have a mammogram. The nurse assesses that there is no family history of breast cancer and no risk factors with this particular client. Which statement, if made by the client, shows an understanding of the nurse’s teaching regarding the frequency of mammograms?


a) "I should have a mammogram twice yearly until age 50, then only yearly."


b) "I should have a mammogram only if I find a lump after self-breast examination."


c) "I should have a mammogram once a year at age 40, then annually."


d) "I should have a mammogram every year beginning at age 40."


d) "I should have a mammogram every year beginning at age 40."




Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks exist, such as family history, genetic tendency, or past breast cancer, more frequent examinations may be necessary.

A client taking risperidone 2 mg orally twice a day informs the nurse that she will be getting married in 3 months to another client she met at the outpatient clinic. During the client interview, the nurse should ask the client further about:


a) Her fiancé’s medication compliance.


b) Living arrangements.


c) Money management.


d) Plans to become pregnant.


d) Plans to become pregnant.




The nurse should determine if the client intends to become pregnant. Most antipsychotic medications are contraindicated during pregnancy because of potential injury to the fetus. The fiancé’s medication compliance is not a concern as it relates to the possible pregnancy for the woman who is taking risperidone. Plans for money management will not influence the risk of injury to the fetus should the woman become pregnant. Living arrangements are not an issue for this client.

A client takes prednisone for an acute exacerbation of rheumatoid arthritis. Which of the following statements indicates the client understands how to take the prednisone?


a) "I can stop taking the prednisone as soon as my joints feel better."


b) "It is best if I take this medication with some food."


c) "It is important for me to increase my sodium intake while I am taking this medication."


d) "I should not be concerned if I lose a little weight while I take the prednisone."


b) "It is best if I take this medication with some food."




Prednisone is a gastrointestinal irritant that is best taken with food. The client should not abruptly stop taking the prednisone when her joints feel better. Rather, the drug must be tapered slowly. Abrupt withdrawal can precipitate a return of the symptoms. Sodium intake should be reduced, not increased. The client will most likely retain fluids and demonstrate some weight gain.

When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol:


a) is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II.


b) blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction.


c) is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure.


d) increases norepinephrine secretion and thus decreases blood pressure and heart rate.


b) blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction.




Propranolol is a beta-adrenergic blocking agent. Actions of propranolol include reducing heart rate, decreasing myocardial contractility, and slowing conduction. Propranolol does not increase norepinephrine secretion, cause vasodilation, or block conversion of angiotensin I to angiotensin II.

A client with a history of bladder retention hasn't voided for 8 hours. A nurse concerned that the client is retaining urine notifies the physician. He orders a bladder ultrasonic scan and placement of an indwelling catheter if the residual urine is greater than 350 ml. The nurse knows that using the bladder ultrasonic scan to measure residual urine instead of placing a straight catheter reduces the risk of:


a) microorganism transfer.


b) client discomfort.


c) prostate irritation.


d) incorrect urine output values.


a) microorganism transfer.




Bladder ultrasonic scanning, a noninvasive way of calculating the amount of urine in the bladder, reduces the risk of transferring microorganisms into the bladder. Use of a straight catheter to measure residual urine increases the transfer of microorganisms into the bladder, and increases, rather than reduces, client discomfort. A bladder ultrasonic scan doesn't reduce the risk of prostate irritation or incorrect urine output values.

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?


a) Blood urea nitrogen (BUN) level of 22 mg/dl (1.2 mmol/L)


b) Urine output of 250 ml/24 hours


c) Serum creatinine level of 1.2 mg/dl (0.1 mmol/L)


d) Temperature of 100.2° F (37.8° C)


b) Urine output of 250 ml/24 hours




ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is characterized by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder.

Which of the following is a risk factor for toxic shock syndrome (TSS)?


a) Avoiding use of deodorized tampons.


b) Using only tampons at night.


c) Alternating tampons with sanitary pads.


d) Changing tampons every 3 hours.


b) Using only tampons at night.




Risk factors for TSS include the use of tampons at night, when the tampon would be in place for 7 to 9 hours. TSS can occur in other situations, but it is commonly associated with women during menses, particularly women who use tampons. The longer the tampon is left in place, the greater the risk for TSS. Changing tampons every 3 hours or more frequently, avoiding use of deodorized tampons, and alternating tampons with sanitary pads are actions that decrease the risk of TSS.

A client with Crohn's disease is scheduled for a barium enema. What should the plan of care include today to prepare for the test tomorrow?


a) Serve the client a regular diet.


b) Order a high-fiber diet.


c) Encourage plenty of fluids.


d) Avoid dairy products.


c) Encourage plenty of fluids.




The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise?


a) Tetany


b) Cerebral edema


c) Hypovolemic shock


d) Severe hyperkalemia


b) Cerebral edema




Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn't alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn't occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.

A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's:


a) blood pressure.


b) temperature.


c) hemoglobin level.


d) heart rate.


a) blood pressure.






With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.

The nurse is caring for a neonate diagnosed with early onset sepsis and is being treated with intravenous antibiotics. Which instructions will the nurse include in the parents’ teaching plan?


a) Wear a mask when holding the neonate.


b) Wash hands thoroughly before touching the neonate.


c) Wear protective gear near the isolation incubator.


d) Visit but do not touch the neonate.


b) Wash hands thoroughly before touching the neonate.




The parents of a neonate with an infection should be allowed to participate in daily care as long as they use good handwashing technique. This includes touching and holding the neonate. It is not necessary for parents to wearing protective gear new the isolette. Restricting parental visits has not been shown to have any effect on the infection rate and may have detrimental effects on the neonate’s psychological development. Normally, the neonate does not need to be isolated. It is not necessary for the parents to wear a mask while holding the neonate. The neonate is not contagious and is receiving treatment for the infection.

Which of the following measures should the nurse perform for a child who is receiving chemotherapy and allopurinol?


a) Giving foods that are high in potassium.


b) Omitting carbonated fluids.


c) Limiting foods that are high in natural sugar.


d) Encouraging a high fluid intake.


d) Encouraging a high fluid intake.




Destruction of malignant cells during chemotherapy produces large amounts of uric acid. The child’s kidneys may not be able to eliminate the uric acid, and tubular obstruction from the crystals could result in renal failure and uremia. Allopurinol interrupts the process of purine degradation to reduce uric acid buildup. The child should be encouraged to increase fluid intake to further assist in eliminating uric acid. Carbonated fluids need not be omitted when allopurinol is administered. An intake of foods high in potassium is not necessary, nor is limiting foods high in natural sugar.

When obtaining a history from the parents of a child diagnosed with diarrhea due to Salmonella, the nurse should ask the parents if the child has been exposed to which possible source of infection?


a) nonrefrigerated custard


b) unwashed fruit


c) undercooked eggs


d) a pet canary


c) undercooked eggs




Diarrhea related to Salmonella bacilli is commonly spread by raw or undercooked fowl and eggs, pet turtles, and kittens. Food poisoning caused by Staphylococcus species is commonly spread by inadequately cooked or refrigerated custards, cream fillings, or mayonnaise. Psittacosis, a respiratory illness, may be spread by canaries. Contaminated, unwashed fruit is associated with typhoid fever (caused by Salmonella typhi), a disorder rarely seen in the United States and Canada.

A parent of a 9-year-old child who is scheduled to have surgery expresses concern about the potential for a postoperative infection. Which of the following information would be most important for the nurse to tell the parent?


a) "Cover your mouth and nose when you cough or sneeze in the room."


b) "Wear an isolation gown when entering the room."


c) "All visitors should wash their hands before they leave or enter the room."


d) "Do not bring fresh flowers or fruit to the room after surgery."


c) "All visitors should wash their hands before they leave or enter the room."




Hand washing upon entry and when leaving the client’s room should be stressed to visitors to prevent the spread of disease. During the postoperative period, visitors could inadvertently bring in infectious agents to the client. Telling the family to cover their mouths and noses when coughing and sneezing does not decrease postoperative infection risks as much as hand washing would impact the client. Fresh flowers and fruit are restricted for neutropenia clients. Isolation gowns would not be necessary in a noninfected postoperative client.

A young woman has been stalked and then beaten by an ex-boyfriend. Treatment of her injuries is complete, and she is ready for discharge. What should the nurse do to ensure the woman’s safety and security prior to discharge? Select all that apply.


a) Obtain consent to send her emergency department records to her family health care provider (HCP).


b) Determine if the client knows the location of the ex-boyfriend.


c) Ensure that she has a safe place to stay after discharge.


d) Ask if she plans to see the ex-boyfriend again.


e) Provide information on resources and a safety plan.


b) Determine if the client knows the location of the ex-boyfriend.

c) Ensure that she has a safe place to stay after discharge.


d) Ask if she plans to see the ex-boyfriend again.


e) Provide information on resources and a safety plan.




The crucial interventions involve safety and support. Asking for consent is a health privacy issue, not a safety issue, and is not essential to the discharge process.

When reporting to the outpatient cancer center for his first chemotherapy treatment, a client appears anxious and apprehensive. Which statement by the nurse may help allay the client's anxiety?


a) "As a precaution, we wear gowns, goggles, and gloves to administer the medication."


b) "You look anxious, don't worry you will get used to this place."


c) "We wear gowns and gloves to administer chemotherapy drugs because they're very dangerous."


d) "You may have a seat right over here."


a) "As a precaution, we wear gowns, goggles, and gloves to administer the medication."




Telling the client about the personal protective equipment worn to administer the chemotherapy drugs educates the client about the administration process and helps allay his anxiety. Telling the client to have a seat, saying that chemotherapy drugs are dangerous, and telling the client not to worry dismiss the client's feelings of anxiety.

A 14-year-old with rheumatic fever who is on bed rest is receiving an I.V. infusion of dextrose 5% in water administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which of the following times? Select all that apply.


a) At the beginning of each shift.


b) When the child is sleeping.


c) When the child moves in the bed.


d) When the child returns from X-ray.


e) When the infusion is started.


a) At the beginning of each shift.


d) When the child returns from X-ray.


e) When the infusion is started.




The alarm settings on infusion pumps should be verified at the time the infusion is started, at the beginning of each shift, and when the client is moved. The child can move in bed or sleep, but if the alarm is triggered, the nurse should verify the settings.

A nurse is working with a client who abuses alcohol. Which fact should the nurse communicate to the client?


a) Abstinence is the basis for successful treatment.


b) For treatment to be successful, family members must participate.


c) An alcoholic may enjoy an occasional social drink.


d) Daily attendance at Alcoholics Anonymous (AA) meetings will cure alcoholism.


a) Abstinence is the basis for successful treatment.




Attendance at AA helps some individuals maintain strict abstinence from alcohol, which is the foundation of any treatment for alcoholism. Participation in treatment by the family is beneficial to both the client and the family but isn't essential. Abstinence requires refraining from social drinking.

The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The nurse knows that the client understands the discharge plan when the client:


a) selects a low-cholesterol diet to control coronary artery disease.


b) verbalizes safety precautions needed to prevent pacemaker malfunction.


c) states a need for bed rest for 1 week after discharge.


d) explains signs and symptoms of myocardial infarction (MI).


b) verbalizes safety precautions needed to prevent pacemaker malfunction.




Education is a major component of the discharge plan for a client with an artificial pacemaker. The client with a permanent pacemaker needs to be able to state specific information about safety precautions, such as to refrain from lifting more than 3 lb (1.35 kg) or stretching and bending. The client should know how to count the pulse and do so daily or as instructed by the health care provider (HCP). The client will not necessarily be placed on a low cholesterol diet. The client should resume activities, and does not need to remain on bed rest. The client should know signs and symptoms of a MI, but is not at risk because of the pacemaker.

When asked about her stresses before admission, an anxious client stares blankly at the nurse and mutters unintelligibly. Which description of the client's behaviors should the nurse document in the client's medical record?


a) "Client cannot answer any questions asked at this time."


b) "Client responded to questions with a blank look and incomprehensible mumble."


c) "Client is uncooperative during admission procedure, refusing to answer any questions."


d) "Client stared at wall when asked questions and was disoriented and incoherent."




b) "Client responded to questions with a blank look and incomprehensible mumble."




The nurse must be objective in documenting the client’s behavior, recording exactly what the client did or did not say or do in a particular situation. Recording that the client could not answer any questions, was uncooperative and refused to answer questions, or was disoriented and incoherent is not described and is a subjective interpretation on the nurse’s part.

While the nurse is conducting a teaching session on breast-feeding, a client asks why she should put her newborn to the breast within the first 30 minutes of birth. The nurse's best response will be:


a) "The neonate will be responsive and eager to suck at this time."


b) "Breast-feeding will prevent the newborn from heat loss."


c) "Breast-feeding will inhibit prolactin production."


d) "Your breasts will be firm and filled with colostrum at this time."


a) "The neonate will be responsive and eager to suck at this time."




During the first 30 minutes or so after birth, the healthy, full-term neonate is highly responsive and has a strong desire to suck. Many neonates breast-feed shortly after birth; all make licking or nuzzling motions, helping to stimulate the mother's prolactin production and enhance maternal-neonate bonding. Also, the client's breasts may be soft and easily manipulated at this time, promoting proper attachment of the neonate. Although the breasts contain colostrum at this time, they aren't firm. Typically, the neonate falls asleep 2 to 3 hours after birth.

Which of the following interventions would be most appropriate for the nurse to recommend to a client to decrease discomfort from hemorrhoids?


a) Decrease fiber in the diet.


b) Decrease physical activity.


c) Take laxatives to promote bowel movements.


d) Use warm sitz baths.


d) Use warm sitz baths.




Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids. Fiber in the diet should be increased to promote regular bowel movements. Laxatives are irritating and should be avoided. Decreasing physical activity will not decrease discomfort.