Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
151 Cards in this Set
- Front
- Back
- 3rd side (hint)
|
The young adult is involved in a motorcycle accident and is broughtto the emergency department. The health care provider diagnoses a closed headinjury with suspected subdural hematoma. Although reporting a severe headache,the client is alert and answers questions appropriately. The nurse shouldquestion which order? |
1. "Promethazine 25 mg IM 3 h."2. "Morphine sulfate 10 mg IM q3 4h."3. "Docusate sodium 50 mg PO bid."4. "Ranitidine 50 mg IVPB q12h."
|
Strategy: "Question which of the following orders" indicates an incorrectorder. (1) H1 receptor blocker, used as an antiemetic (2) correct—narcoticanalgesic, causes CNS and respiratory depression, contraindicated in headinjury because it masks signs of increased intracranial pressure (3) stool softener, used for an immobilized patient (4) H2 histamine antagonist, reduces acid productionin stomach, prevents stress ulcers |
|
|
The nurse returns to the desk and finds four phone message to return.Which message should the nurse return first? |
1. The client in the first trimester of pregnancy reports heartburn.2. The client reports heartburn that radiates tothe jaw.3. The client reports hot flashes and difficulty sleeping.4. The client reports knee pain after playing basketball. |
Strategy: Determine the least stable client. (1) caused by reflux of gastric contents into esophagus, treatment issmall, frequent meals, don't consume fluids with food, don't wear tight clothing (2) correct—indicateschest pain, needs to seek medical attention immediately (3) caused by menopause, treat with hormone replacement therapy (HRT) (4) should treat with rest and ice |
|
|
A client is admitted to the surgical unit with a diagnosis of rule out(R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NGtube as ordered. It is best for the nurse to place the client in which position? |
1. Head of bed elevated 30–45°.2. Head of bed elevated 60–90°.3. Side-lying with head elevated 15°.4. Lying flat with head turned to the left side. |
Strategy: Remember the positioning strategy. (1) head of bed not elevated enough (2) correct—facilitatesswallowing and movement of tube through gastrointestinal tract (3) not the best position (4) not the best position |
|
|
The nurse monitors the fluid status of an older client receiving IVfluids following surgery. Which symptom suggests to the nurse that the clienthas fluid volume overload? |
1. Temperature 101°F (38.3°C), BP 96/60, pulse 96 andthready.2. Cool skin, respiratory crackles, pulse 86 andbounding.3. Reports a headache, abdominal pain, and lethargy.4. Urinary output 700 ml/24 h, CVP of 5, and nystagmus.
|
Strategy: (1) indicates dehydration (2) correct—will seebounding pulse, elevated BP, distended neck veins, edema, headache, polyuria,diarrhea, liver enlargement (3) symptoms could be from causes other than volume overload (4) slightly reduced output, CVP would be elevated, normal CVP 3 to12 mm/H2O, involuntary eye movements not seen |
|
|
A woman has been recently diagnosed with systemic lupus (SLE) and shareswith the nurse, "I am thinking about getting pregnant, but I don't know howI will be able to tolerate a pregnancy because I have lupus." Which responseby the nurse is best? |
1. "Most women find that they feel better when they are pregnant."2. "How long have you been in remission?"3. "Women with lupus frequently have slightly longer gestations."4. "It is best to become pregnant within the first 6 months ofdiagnosis." |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. (1) maternal morbidity and mortality are increased with SLE (2) correct—should bein remission for at least 5 months prior to conceiving (3) gestation not affected by SLE (4) recommended that a woman wait 2 years following diagnosis beforeconceiving |
|
|
The multidisciplinary team decides to implement behavior modificationwith a client. Which nursing action is of primary importanceduring this time? |
1. Confirm that all staff members understand andcomply with the treatment plan.2. Establish mutually agreed-upon, realistic goals.3. Ensure that the potent reinforcers (rewards) are importantto the client.4. Establish a fixed interval schedule for reinforcement. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—to implementa behavior modification plan successfully, all staff members need to be includedin program development, and time must be allowed for discussion of concernsfrom each nursing staff member; consistency and follow-through is importantto prevent or diminish the level of manipulation by the staff or client duringimplementation of this program (2) not of primary importance in designing an effective behavior modificationprogram (3) not of primary importance in designing an effective behavior modificationprogram (4) not of primary importance in designing an effective behavior modificationprogram |
|
|
The client received six units of regular insulin 3 hours ago. The nurseis most concerned if which findingis observed? |
1. Kussmaul respirations and diaphoresis.2. Anorexia and lethargy.3. Diaphoresis and trembling.4. Headache and polyuria. |
Strategy: "MOST concerned" indicates a complication. (1) Kussmaul respirations are signs of hyperglycemia (2) not indicative of hypoglycemia (3) correct—regularinsulin peaks in 2 to 4 hours; indicates hypoglycemia; give skim milk (4) not indicative of hypoglycemia |
|
|
The nursing assistive personnel (NAP) reports to the nurse that theclient who is 1 day postoperative after an angioplasty refuses to eat andstates, "I just don't feel good." Which action by the nurse is best? |
1. Talk with the client about how the client isfeeling.2. Instruct the NAP to sit with the client while the client eats.3. Contacts the health care provider to obtain an order for anantacid.4. Evaluate the most recent vital signs recorded in the chart. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. Is the assessment appropriate? Yes. (1) correct—assessmentrequired; before the nurse can choose interventions what exactly is keepingthe client from eating needs to be known (2) assess cause of problem before implementing (3) assess cause of problem before implementing (4) would be assessed after talking with the client |
|
|
The nurse prepares a client for a cesarean birth. The client tellsthe nurse about having a "shot" before major surgery several years ago andasks if a similar one will be given before this one. What is the nurse's bestunderstanding? |
1. The medication given before a cesarean has a lower overalldose of medication than is given before general surgery.2. The medication given before a cesarean has lower amounts ofsedatives and hypnotics than are given before general surgery.3. The medication given before a cesarean containslower amounts of narcotics than are given before general surgery.4. The medication given before a cesarean contains medicationssimilar in type and dosages to those given before general surgery |
Strategy: Think about the action of the medications. (1) decreased dosage of narcotics are used (2) dosages of sedatives and hypnotics will be similar (3) correct—decreasedso that less narcotic crosses the placental barrier, causing respiratory depressionin the infant (4) The medication given before a cesarean contains medications similarin type and dosages to those given before general surgery |
|
|
The nurse cares for a client placed in balanced suspension tractionwith a Thomas splint and Pearson attachment because of a fractured right femur.The nurse notes that the client's left leg is externally rotated. The nurseshould take which action? |
1. Place a trochanter roll on the outer aspectof the thigh.2. Perform resistive range of motion of the left leg.3. Adduct and internally rotate the left leg.4. Instruct the client to maintain the left leg in a neutralposition. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—holds hipin neutral position and leg in normal alignment, entire weight of leg cannotbe held by props placed below knee (2) exercise would not prevent future external rotation of the leg (3) adduction (add to midline of body) does not change external rotation,internal rotation is not beneficial, normal alignment is required (4) leg will externally rotate unless propped in proper alignment |
|
|
The nurse prepares a 5-year-old child for surgery. The nurse notes thatthe child's parents are divorced and have joint legal custody. The informedconsent for surgery has been signed by one parent. Which action by the nurseis best?
|
1. Notify the health care provider.2. Inform surgery.3. Contact the other parent to obtain consent.4. Continue the child's preoperative preparation.
|
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) no reason to notify the health care provider (2) no reason to call the OR (3) consent from either divorced parent is sufficient (4) correct—parent orlegal guardian required to give informed consent prior to surgical procedure |
|
|
1. Notify the health care provider.2. Inform surgery.3. Contact the other parent to obtain consent.4. Continue the child's preoperative preparation. |
1. Reassess in 5 minutes.2. Check the client's visual acuity.3. Lower the head of the client's bed.4. Contact the health care provider. |
Strategy: Answers are a mix of assessments and implementations. Is thisa situation that requires assessment or validation? No. Determine the outcomeof the implementations. (1) assessment; situation does not require validation (2) assessment; has symptoms of increased intracranial pressure (ICP) (3) implementation; would increase the ICP (4) correct—implementation;fixed and dilated pupil represents a neurological emergency |
|
|
The parent brings the 2-year-old to the office. Which symptom suggeststo the nurse that the child has strabismus? |
1. The child places head close to the table when drawing.2. The child rubs eyes frequently.3. The child closes one eye to see a poster onthe wall.4. The child is unable to see objects in the periphery of visualfield. |
Strategy: Think about each answer choice. (1) suggestive of refractive error, myopia (nearsightedness), able tosee objects at close range (2) suggestive of refractive error (3) correct—visual axesare not parallel, so the brain receives two images (4) suggestive of cataracts or problem with peripheral vision |
|
|
The nurse administers morphine 6 mg IV push to a client for postoperativepain. Following administration of the drug, the nurse observes the following:BP 100/68, pulse 68, respirations 8, client sleeping quietly. Which actionis most appropriate? |
1. Allow the client to sleep undisturbed.2. Administer oxygen via face mask or nasal prongs.3. Administer naloxone.4. Place epinephrine 1:1,000 at the bedside. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) should be given naloxone for low respiratory rate (2) problem is low respirations; this may be administered after medication (3) correct—IV naloxoneshould be given to reverse respiratory depression; respiratory rate of 8is too low and necessitates a nursing action (4) unnecessary |
|
|
The school nurse instructs a group of preschool parents about poisonprevention in the home. Which statement, if made by a parent to the nurse,indicates further teaching is necessary? |
1. "The poison control center number is stored on all the phonesin our house."2. "I should induce vomiting if my child swallowslighter fluid."3. "If I carry medication in with me, it should be in a child-proofcontainer."4. "Proper storage is the key to poison prevention in the home." |
Strategy: "Further teaching is necessary" indicates an incorrect statement. (1) Appropriate action; terminate exposure to the poison and then contactpoison control for further instructions (2) correct—vomitingcontraindicated when child ingests hydrocarbons because of danger of aspiration (3) 'poison-proofs' the medication (4) store in locked cabinets |
|
|
The nurse cares for a manic client in the seclusion room, and it istime for lunch. It is most appropriatefor the nurse to take which action? |
1. Take the client to the dining room with 1:1 supervision.2. Inform the client that dining room privileges will be givenfor controlled behavior.3. Hold the meal until the client is able to come out of seclusion.4. Serve the meal to the client in the seclusionroom. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) should remain in the seclusion room (2) should have meal at regular time (3) should have meal at regular time (4) correct—should eatat regular time; remain in the seclusion room for client's safety |
|
|
Which nursing action has the highest priority for a teenager admittedwith burns to 50% of the body? |
1. Counseling regarding problems of body image.2. Maintaining airborne precautions.3. Maintaining aseptic technique during procedures.4. Encouraging peers to visit on a regular basis. |
Strategy: Think "Maslow." (1) psychosocial, not highest priority (2) physical, use standard precautions (3) correct—safety isa priority for the client who is at high risk for infection (4) psychosocial, important for an adolescent but is not highest priority |
|
|
The home health care nurse cares for the client diagnosed with type1 diabetes. The client is maintained on a regimen of NPH and regular insulinand a 1,800-calorie diabetic diet with normal blood sugar levels. Morningself-monitored blood sugar (SMBG) readings the past 2 days were 205 and 233mg/dL(11.4 and 12.9 mmol/L) . The nurse expects the health care provider totake which action? |
1. Reduce the client's diet to 1,500 calorie ADA. 2. Order three additional units of NPH insulinat 22:00 3. Order an additional 10 units of regular insulin at 20:004. Eliminate the client's bedtime snack. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) diet should not be reduced (2) correct—dawn phenomena,treatment is to adjust evening diet, bedtime snack, insulin dose, and exerciseto prevent early morning hyperglycemia (3) peaks in 4 to 6 hours, would not prevent dawn phenomena (4) would adjust snack, not eliminate it |
|
|
After sustaining a closed head injury and numerous lacerations and abrasionsto the face and neck, a 5-year-old is admitted to the emergency room. Theclient is unconscious and has minimal response to noxious stimuli. Which assessment,if observed by the nurse 3 hours after admission, should be reported to thehealth care provider? |
1. The client has slight edema of the eyelids.2. There is clear fluid draining from the client'sright ear.3. There is some bleeding from the client's lacerations.4. The client withdraws in response to painful stimuli.
|
Strategy: Think about how each answer choice relates to a head injury. (1) not priority (2) correct—indicatesa rupture of meninges and presents a potential complication of meningitis (3) not priority (4) is not a change in assessment |
|
|
The psychiatric nurse is assigned to conduct an admission nursing historyon a new client. Which finding should the history include? |
1. The nurse's opinion regarding the mental and emotional statusof the client.2. Data addressing the client's emotional state.3. Data addressing a biopsychosocial approach,including a family system assessment.4. Specific data detailing the client's mental status. |
(1) depends on opinions that are not based on a complete assessment (2) limits the degree of information that is obtained from the client (3) correct—completenursing history includes biopsychosocial data; client's psychosocial and physicalstatus are evaluated along with an assessment of the client's family systemand social support network; evaluation of the client's cognitive ability isimportant during the physiological status assessment (4) is necessary information about mental status but is also an incompleteassessment |
|
|
Prochlorperazine maleate 10 mg IM is ordered for a client. The clientis also to receive butorphanol 2 mg IM. Before administering these medications,the nurse should take which action? |
1. Obtain respirations and temperature.2. Dilute with 9 ml of NS.3. Draw the medications in separate syringes.4. Verify the route of administration. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) should monitor blood pressure and heart rate for orthostatic hypotension;respiration and temperature are not as high a priority (2) inappropriate (3) correct—Prochlorperazinemaleate should be considered incompatible in a syringe with all other medications (4) unnecessary |
|
|
The nurse cares for clients in the student health center. A client confidesto the nurse that their significant other tested positive for hepatitis B.Which response by the nurse is best? |
1. "That must have been a real shock to you."2. "You should be tested for hepatitis B."3. "You'll receive the hepatitis B immune globulin (HBIG)."4. "Have you had unprotected sex with your significantother?" |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) nurse is interjecting own feelings (2) will require testing; not best response initially (3) implementation; receive HBIG for postexposure prophylaxis; may alsoreceive HBV vaccine (4) correct—assessment;transmitted through parenteral drug abuse and sexual contact; determine exposurebefore implementing |
|
|
A young adult client constantly seeks attention from the nurses, stompingaway from the nurses' station and pouting when requests are refused. Whichresponse by the nurse is most appropriate? |
1. Encourage the client to establish trust with one staff personwith whom therapeutic interventions should occur.2. Give the client unsolicited attention when theclient is exhibiting acceptable behaviors.3. Ignore the client when the client exhibits attention-seekingbehavior.4. Rotate the staff so that the client will learn to relate tomore than one nurse. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) staff should use a consistent undivided approach (2) correct—reward non–attention-seekingbehaviors by giving the client unsolicited attention (3) remain nonjudgmental, carry out limit-setting (4) staff should use a consistent undivided approach |
|
|
After abdominal surgery, a client has a nasogastric tube attached tolow suctioning. The client becomes nauseated, and the nurse observes a decreasein the flow of gastric secretions. Which nursing intervention is most appropriate? |
1. Irrigate the nasogastric tube with distilled water.2. Aspirate the gastric contents with a syringe.3. Administer an antiemetic medicine.4. Insert a new nasogastric tube. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) tube would be irrigated with normal saline after the position ofthe tube was evaluated (2) correct—to confirmplacement, nurse should aspirate and test the pH of the aspirate; resultsshould be 0 to 4 (3) does not assess status of nasogastric tube (4) does not assess status of nasogastric tube |
|
|
A middle-aged client with two children, has a mastectomy for breastcancer. The client returns to the clinic one month later for routine follow-upcare. The nurse asks the client how things are going. Which response bythe client to the nurse indicates a normal reaction to the surgery?
|
1. "I have been helping my family deal with their feelings aboutthe surgery."2. "I have been having difficulty coping with thesurgery and cry frequently."3. "I have been unable to leave the house or talk to my friendsabout the surgery."4. "I am doing just great since the surgery and have gone backto work at my job."
|
Strategy: Think about each answer choice. Does it describe an expectedresponse to a crisis situation? (1) will not be able to help others this soon after surgery (2) correct—normal reaction1 month later (3) excessive, abnormal reaction (4) indicates integration, too early for this stage |
|
|
The nurse cares for clients in outpatient surgery. The parent of a 4-year-oldasks the nurse how to prepare the child for eye surgery. Which statement bythe nurse is best? |
1. "Draw a picture of the eye to explain what will happen."2. "Tell your child that the procedure will take 1 hour."3. "Use dolls or puppets to explain how to getready for surgery."4. "Read an age-appropriate illustrated book about eye surgeryto your child." |
Strategy: Think about growth and development. (1) appropriate for school-aged child (2) preschooler can't relate to the concept of 1 hour (3) correct—use puppetor doll to show where procedure is performed; explain procedure in simpleterms and what the child will see, hear, taste, smell, and feel (4) appropriate for school-aged child |
|
|
A client at 32 weeks gestation is seen in the outpatient clinic. Whichfinding, if assessed by the nurse, indicates a possible complication? |
1. The client's urine test is positive for glucoseand acetone.2. The client has 1+ pedal edema in both feet at the end of theday.3. The client reports an increase in vaginal discharge.4. The client says that she feels pressure against her diaphragmwhen the baby moves. |
Strategy: Determine how each answer choice relates to pregnancy. (1) correct—abnormalfinding, could indicate gestational diabetes (GDM), hazard of placental insufficiency (2) not unusual, caused by pressure of enlarging uterus on veins returningblood from lower extremities (3) common near term with increased vascularity of vagina and perineum,only abnormal if bloody, foul-smelling, or abnormally colored (4) not unusual, due to pressure of enlarging uterus |
|
|
A nurse cares for a client diagnosed with metastatic ovarian canceradmitted for nausea and vomiting. The health care provider orders parenteralnutrition (PN), a nutritional consult, and diet recall. Which is the best indication that the client's nutritionalstatus has improved after 4 days? |
1. The client eats most of the food served to her. 2. The client has gained 1 pound since admission. 3. The client's albumin level is 4.0 g/dL(40 g/L).4. The client's hemoglobin is 8.5 g/dL(85 g/L). |
Strategy: Determine how each answer choice relates to nutritional status. (1) appetite is not the best indicator (2) weight gain may be fluid retention (ascites) (3) correct—albuminlevels are best indicators of long-term nutritional status (4) low levels are caused by chemotherapy or cancer, not a good indicatorbecause it takes long time to increase levels |
|
|
The nurse cares for clients on a medical/surgical unit. The nurse determinesseveral situations need to be addressed. In which order will the nurse addressthe situations?
|
|
Strategy: Identify the least stable clients to see first and the moststable to see last.1) Important to assess client to determine amount and cause of bleeding.2) Important issue that needs to be addressed after tending to the clientwho is bleeding.3) Last client issue to address or can be delegated to another staffmember.4) Clients take priority over personnel issues |
|
|
A woman is admitted to the labor and delivery unit in a sickle cellcrisis. Which action is the highest priority? |
1. Administer oxygen.2. Turn her to the right side.3. Provide adequate hydration.4. Start antibiotics. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) not a priority (2) not a priority (3) correct—adequatehydration is a priority for any client with sickle cell crisis (4) not a priority |
|
|
The client diagnosed with a peptic ulcer has a partial gastrectomy andvagotomy (Billroth I). In planning the discharge teaching, which statementis the priority to caution the client about? |
1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simplesugars and liquids. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) client should recline for 30 minutes after eating (2) fluids should be given between meals (3) intake of carbohydrates should be reduced along with highly spicedfoods (4) correct—basic guidelinesto teach a postgastrectomy client are measures to prevent dumping syndrome,which include: lying down for 30 minutes after meals, drinking fluids betweenmeals, and reducing intake of carbohydrates |
|
|
The nurse is assigned to work with the parents of a child diagnosedwith mental disabilities. Which should the nurse include in the care planfor the parents? |
1. Interpret the grieving process for the parents.2. Discuss the reality of institutional placement.3. Assist the parents in making decisions and long-term plansfor the child.4. Perform a family assessment to assist in theplanning of intervention. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. (1) inappropriate before the assessment; action can be taken only whenthe circumstances are known (2) inappropriate before the assessment; action can be taken only whenthe circumstances are known (3) inappropriate before the assessment; action can be taken only whenthe circumstances are known (4) correct—assessment;this will help the nurse to know where the family is in regard to grieving,coping, etc. |
|
|
The nurse should explain to the client that glipizide is effective forwhich client diagnosed with diabetes?
|
1. The client who can no longer produce any insulin.2. The client who produces minimal amounts of insulin.3. The client who is unable to administer injections.4. The client who has a sustained decreased blood glucose.
|
Strategy: Think about each answer choice. (1) client diagnosed with type 1 diabetes is unable to produce insulin (2) CORRECT - oral hypoglycemicagents are administered to clients diagnosed with type 2 diabetes who areable to produce minimal amounts of insulin (3) clients diagnosed with type 1 diabetes who cannot administer injectionsneed alternate plans to be made to receive the injections from a family member (4) glipizide is administered for an increase in blood glucose |
|
|
The client at 38 weeks gestation comes to the emergency room reportingvaginal bleeding. Which statement, if made by the client, suggests to thenurse that placenta previa is the cause of the bleeding? |
1. "I feel fine, but the bleeding scares me."2. "I've been more nauseated during the past few weeks."3. "The bleeding started after I carried four bags of groceries."4. "I've been having severe abdominal cramps." |
Strategy: All answers are assessments. Think about what each phraseis describing and how it relates to a placenta previa. (1) correct—placentaprevia is characterized by painless vaginal bleeding (2) nausea not a symptom of placenta previa (3) bleeding is not necessarily related to activity (4) pain not characteristic of placenta previa |
|
|
The nurse cares for an elderly client diagnosed with Parkinson's disease.Which goal is MOST realistic andappropriate in planning care for this client? |
1. Return the client to usual activities of daily living.2. Maintain optimal function within the client'slimitations.3. Prepare the client for a peaceful and dignified death.4. Arrest progression of the disease process in the client. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) unrealistic (2) correct—irreversibledisease that leads to permanent physical limitations (3) unnecessary; disease usually is not terminal (4) unrealistic; disease is progressive, cannot be arrested |
|
|
When a nurse is using restraints for an agitated/aggressive client,which item should not influence the nurse's actions during this intervention? |
1. The restraints/seclusion policies set forth by the institution.2. The client's competence.3. The client's voluntary/involuntary status.4. The client's nursing care plan. |
Strategy: Think about each answer choice. (1) nurse should follow the policies of the institution (2) must get written permission from the client for restraints; if clienthas been judged incompetent, permission is obtained from the legal guardian (3) correct—the needfor restraints is based on client's behavioral status and condition, not theclient's voluntary/involuntary status (4) must first try less restrictive means to control client before usingrestraints |
|
|
The school-aged child injured their right knee yesterday. The child'sright knee is painful, swollen, and bruised. The nurse learns from the parentthe child has hemophilia A. The nurse determines which medication is best for this child? |
1. Oxycodone terephthalate.2. Ibuprofen.3. Enteric-coated aspirin.4. Codeine phosphate. |
Strategy: Think about the action of each medication. (1) contains aspirin, contraindicated for persons with bleeding disorders (2) increases bleeding time by decreasing platelet aggregation, contraindicatedfor persons with bleeding disorders (3) increases bleeding time by decreasing platelet aggregation, contraindicatedfor persons with bleeding disorders (4) correct—analgesicused for moderate to severe pain |
|
|
The parents of a 1-month-old infant bring their infant to the clinicfor evaluation of possible developmental dysplasia of the right hip. The nurseshould observe for which assessment? |
1. Limited adduction of the right leg.2. Uneven gluteal fold and thigh creases.3. Increase in length of the right limb.4. Internal rotation of the right leg. |
Strategy: Think about each answer choice. (1) will see limited abduction (2) correct—folds andcreases will be longer and deeper on affected side (3) will be decrease in limb length (4) may or may not see internal rotation |
|
|
The nurse prepares to administer terbutaline to a client in labor. Priorto administration of the medication, the nurse assesses the client's pulseto be 144. Which action should the nurse take first? |
1. Withhold the medication.2. Decrease the dose by half.3. Administer the medication.4. Wait 15 minutes, and then recheck the rate. |
Strategy: Answers are a mix of assessments and implementations. Is thisa situation that requires validation? No. Determine the outcome of each answerchoice. (1) correct—maternaltachycardia is a side effect of terbutaline; other maternal side effects includenervousness, tremors, headache, and possible pulmonary edema; fetal side effectsinclude tachycardia and hypoglycemia; terbutaline is usually preferred overritodrine because it has minimal effects on blood pressure (2) should never change a prescribed dosage of medication (3) should not be given with a high pulse rate (4) assessment; maternal tachycardia is a side effect of terbutaline;medication should be withheld |
|
|
The nurse supervises the staff providing care for the 18-month-old hospitalizedwith hepatitis A. The nurse determines that the staff's care is appropriateif which action is observed?
|
1. The child is placed in a private room.2. The staff removes a toy from the child's bed and takes itto the nurse's station.3. The staff offers the child french fries and a vanilla milkshakefor a midafternoon snack.4. The staff uses standard precautions.
|
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—contactprecautions required for diapered or incontinent clients (2) do not remove toys from room, possibly contaminated (3) diet should be high in carbohydrates and protein and low in fat (4) contact precautions required in addition to standard precautions |
|
|
The nurse prepares to administer an injection of haloperidol decanoateto a client. Which action by the nurse is most appropriate? |
1. Massage the injection site.2. Give deep IM in a large muscle mass.3. Use a 2 inch 25 gauge needle.4. Administer the medication in divided doses. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) should not be done because medication is very irritating to subcutaneoustissue (2) correct—medicationis very irritating to subcutaneous tissue (3) should use a 2 inch 21 gauge needle (4) should administer in single dose; client should lie in recumbentposition for one-half hour after administration of IM haloperidol decanoate |
|
|
The nurse monitors a client's EKG strip and notes coupled prematureventricular contractions greater than 10 per minute. The nurse should expectto administer which medication? |
1. Atropine sulfate IV.2. Isoproterenol IV.3. Verapamil IV.4. Lidocaine hydrochloride IV. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) antidysrhythmic, used for bradycardia (2) antidysrhythmic, used for heart block, ventricular dysrhythmias (3) antihypertensive, calcium-channel blocker (4) correct—lidocaineis the drug of choice for frequent premature ventricular contractions (PVC)occurring in excess of 6 to 10 per minute; for coupled PVCs or for a consecutiveseries of PVCs that may result in ventricular tachycardia |
|
|
The home care nurse visits the client with newly diagnosed type 1 diabetes.The health care provider's orders include 1,200-calorie ADA diet, 15 unitsof NPH insulin before breakfast, and check blood sugar qid. When the nursevisits the client at 17:00, the nurse observes the client perform a bloodsugar analysis. The result is 50 mg/dL (2.8 mmol/L). The nurse should observefor which information? |
1. Symptoms of hypoglycemia, normal blood sugar70–110 mg/dL(3.9 - 6.1 mmol/L)2. Symptoms of hyperglycemia, blood sugar above 110 mg/dL(6.1mmol/L)3. Alert and cooperative, blood pressure and pulse within normallimits. 4. Shortness of breath, distended neck veins, and a boundingpulse of 96. |
Strategy: Determine the cause of each answer choice. (1) correct—symptomsof hypoglycemia, normal blood sugar 70–110 mg/dL (2) symptoms of hyperglycemia, blood sugar above 110 mg/dL (3) normal appearance and vital signs (4) symptoms of fluid overload caused by heart failure, rapid infusionof IV fluids |
|
|
What is the nurse's initial priority whenmanaging a physically assaultive client? |
1. Restrict the client to the room.2. Place the client under one-to-one supervision.3. Restore the client's self-control and preventfurther loss of control.4. Clear the immediate area of other clients to prevent harm. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) time out or room restriction might be a useful strategy before theclient becomes assaultive; once client is assaultive, he/she may continuethis behavior in his/her room without any redirection and support (2) may not stop assaultive behavior (3) correct—most importantpriority in the nursing management of an assaultive client is to maintainmilieu safety by restoring the client's self-control; a quick assessment ofsituation, psychological intervention, chemical intervention, and possiblyphysical control are important when managing the physically assaultive client (4) is helpful but may not be realistic if the situation escalates quickly |
|
|
The nurse observes an LPN/LVN perform a wet-to-dry dressing change ona 2-inch abdominal incision. Which behavior, if performed by the LPN/LVN,indicates an understanding of proper technique? |
1. A clean cotton ball is used to cleanse from the top of theincision to the bottom of the incision using long strokes.2. The incision is packed with sterile gauze, and then sterilesaline is poured over the dressing. 3. Wet gauze is packed into the incision withoutoverlapping it onto the skin. 4. The old dressing is saturated with sterile saline before itis removed. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) should clean from the center of wound to the outside using sterileequipment (2) dressings should be soaked before application (3) correct—if wet dressingtouches skin, it could cause skin breakdown (4) should be removed dry so that wound debris and necrotic tissue areremoved with old dressing |
|
|
The nurse assesses the development of a 3-month-old child in the well-childclinic. Which behavior, if observed by the nurse, is unexpected?
|
1. The child holds the head erect when sitting on the examinationtable. 2. The child tries to grasp a toy just out of reach.3. The child turns the head to try to locate a sound.4. The child smiles spontaneously when the parent is seen. |
Strategy: Picture the infant. (1) expected at 3 months (2) correct—unexpecteduntil 6 months of age (3) expected at 3 months of age (4) expected at 3 months of age |
|
|
The older client is seen in the outpatient clinic for treatment of anacute attack of gout. Which nursing intervention is most beneficialin decreasing the client's pain during ambulation? |
1. Perform passive range-of-motion exercises before walking.2. Encourage partial weight bearing while ambulating.3. Immobilize the extremity between activities.4. Restrict the amount of time and the distance the man walks. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) would aggravate pain (2) correct—would relieveweight, pressure, and stress on affected leg, may use walker (3) would increase stiffness (4) immobility would aggravate pain and inflammation |
|
|
Which observation best indicatesto the nurse that the client diagnosed with a spinal cord injury resultingin paraplegia, can adequately carry out activities of daily living at homeafter discharge? |
1. The client shaves and brushes the teeth.2. The client transfers into and out of his wheelchair.3. The client maneuvers the wheelchair without difficulty.4. The client prepares well-balanced meals. |
Strategy: Think about the outcome of each answer. (1) paraplegic has full use of upper body, so this activity presentsno problem (2) correct—essentialif client is to perform ADLs (3) done with the arms and presents no real problem (4) is a necessary requisite for living alone and performing ADLs butis not directly hindered by paraplegia |
|
|
During a first aid class, the nurse instructs clients on the emergencycare of partial thickness burns. The nurse identifies which intervention forpartial thickness burns of the chest and arms BEST prevents infection? |
1. Wash the burn with an antiseptic soap and water.2. Remove clothing, and wrap the victim in a cleansheet.3. Leave the blisters intact and apply an ointment.4. Take no action until the victim arrives in a burn unit. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) soaps and ointments should not be applied to second-degree burnsin an emergency situation (2) correct—after fireis out, remove clothing and cover victim with a clean sheet (3) soaps and ointments should not be applied to second-degree burnsin an emergency situation (4) does not prevent infection |
|
|
The 2-month-old with a temperature of 102°F (39°C) is broughtto the emergency department by the parent. The parent tells the nurse, "Mybaby had a DTaP injection 1 week ago. Is this fever related to the immunization?"The nurse's response should be based on which fact? |
1. If a fever does occur in a child after a DTaP, it usuallyoccurs within the first 2 hours. 2. An elevated temperature is very rarely seen in a child aftera DTaP immunization. 3. If there is a fever after a DTaP, it is usuallylow-grade and appears within the first 48 hours.4. The child's high fever is a direct response to the DTaP immunizationand should be treated. |
Strategy: Think about each answer choice. (1) inaccurate; low-grade fever is expected within 24 to 48 hours (2) inaccurate; low-grade fever is expected within 24 to 48 hours (3) correct—low-gradefever and irritability frequent response to immunization (4) symptoms should be reported to physician, antipyretic usually prescribed |
|
|
A client takes perphenazine by mouth for 2 days and now displays thesesymptoms: head turned to the side, neck arched at an angle, and stiffnessand muscle spasms in the neck. The nurse expects to give which PRN medication? |
1. Promazine.2. Biperiden.3. Thiothixene.4. Haloperidol. |
Strategy: Think about each answer choice. (1) antipsychotic medication, would not relieve the side effects (2) correct—antiparkinsonianagent, used to counteract extrapyramidal side effects the client is experiencing (3) antipsychotic medication, would not relieve the side effects (4) antipsychotic medication, would not relieve the side effects |
|
|
The home care nurse instructs a client recently diagnosed with tuberculosis.It is MOST important for the nurseto include which as a part of the teaching plan? |
1. The client should cover the mouth and nose when coughing orsneezing during the first 2 weeks of treatment.2. It is necessary for the client to wear a mask at all timesto prevent transmission of the disease.3. The family should support the client to help reduce feelingsof low self-esteem and isolation.4. The client will be required to take prescribedmedication for 6 to 9 months. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) on airborne precautions during hospitalization; can send home withfamily because they are already exposed (2) not required (3) important, but not as important as taking medication (4) correct—necessaryto take medication for 6 to 9 months |
|
|
Which assessment findings indicate to the nurse the need for more sedationfor a client withdrawing from alcohol dependence? |
1. Steadily increasing vital signs.2. Mild tremors and irritability.3. Decreased respirations and disorientation.4. Stomach distress and inability to sleep. |
Strategy: Determine the cause of each answer choice and how it relatesto alcohol withdrawal. (1) correct—indicationthat the client is approaching delirium tremens, which can be avoided withadditional sedation (2) describes normal mild withdrawal symptoms (3) would contraindicate giving more sedation (4) describes expected symptoms of alcohol withdrawal, which will subsideas the alcohol is excreted from the body |
|
|
The nurse in the outpatient clinic instructs the parent of a school-agedchild diagnosed with asthma how to prevent future asthmatic attacks. The nurseis most concerned if the parentmakes which statement? |
1. "My child plays the tuba in the grade school band."2. "My child loves to help my spouse rake leaves."3. "My child participates in after-school activities 3 days aweek."4. "My child walks 1 mile to school every day with friends." |
Strategy: Think about what the words mean. (1) involves forced expiration; would not cause problems with asthma (2) correct—main causeof asthma is inhaled allergens (animal dander, mold, pollen, dust), wouldexpose child to pollen and dust from leaves (3) school activities should be encouraged to help development (4) walking is good exercise; running could be a problem if he has exercise-inducedasthma |
|
|
The nurse cares for a postcholecystectomy client who had the T-tuberemoved this morning. Two hours after removal of the T-tube, the nurse notesthat the 4 × 4 dressing covering the stab site is saturated with dark,greenish-yellow drainage. It is most appropriatefor the nurse to take which action? |
1. Remove the dressing, and replace it with a moreabsorbent dressing.2. Collect a culture and sensitivity specimen of the drainage.3. Observe the wound for dehiscence.4. Reinforce the dressing with an 8 × 10 dressing. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? No. Determine the outcome of each implementation. (1) correct—expectedthat a stab wound will continue to drain until the wound seals; nurse shouldkeep wound clean and dry (2) drainage described is bile, which is expected; no indication ofinfection (3) doesn't usually occur (4) reinforcing dressing might cause infection; change dressing to keepsite clean and dry |
|
|
Which action does the nurse identify as most likely to help the familyof an emotionally disturbed client manage behaviors at home after dischargefrom inpatient treatment? |
1. Refer the family to Alliance for the MentallyIll meetings for educational programs and support groups.2. Provide the family with pamphlets that describe the desiredaction and side effects of medications the client is taking.3. Tell the family that it is not their fault that the clientbehaves inappropriately.4. Involve the family in the assessment of the client when theclient is first admitted to the hospital. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—this groupprovides ongoing support and educational information; people who attend havecommon needs and goals focused on managing the clients' behavior at home (2) would be helpful but will not have the ongoing impact of the supportgroup (3) would be helpful but will not have the ongoing impact of the supportgroup (4) would be helpful but will not have the ongoing impact of the supportgroup |
|
|
A child returns to the recovery room after a bronchoscopy. The nurseshould place the client in which position? |
1. Semi-Fowler's position. 2. Prone with the head turned to the side.3. Head of the bed elevated 45° with the neck extended.4. Supine with the head in the midline position. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—check vitalsigns every 15 minutes until stable, assess for respiratory difficulty (stridorand dyspnea resulting from laryngeal edema or laryngospasm) (2) would limit respiratory excursion and assessment of breathing (3) extension of neck could obstruct airway because tongue falls inback of mouth (4) not best position after procedure |
|
|
Which is a correctly stated nursing diagnosis for a client with an abruptioplacenta? |
1. Infection related to obstetrical trauma.2. Potential for fetal injury related to abruptio placenta.3. Potential alteration in tissue perfusion related to depletionof fibrinogen.4. Fluid volume deficit related to bleeding. |
Strategy: Think about each answer choice. (1) inaccurate for the situation (2) incorrectly stated (3) incorrectly stated (4) correct—abruptioplacenta is premature separation of a normally implanted placenta leadingto hemorrhage; fluid volume deficit is a major nursing concern with theseclients |
|
|
An elderly client returns to the room after an open reduction and internalfixation of the left femoral head after a fracture. It is most importantfor the nursing care plan to include which intervention? |
1. High-protein, low-residue diet.2. Position client on unaffected side.3. Exercise the client’s arms and legs.4. Encourage the client to cough and deep breathe. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) diet should be high residue to prevent constipation due to inactivity (2) may be positioned on affected side after incision heals (3) foot flexion exercises should be done every hour to prevent complications (4) correct—preventsrespiratory complications due to immobility following surgery |
|
|
The nursing team includes two RNs, one LPN/LVN, and one nursing assistivepersonnel (NAP). The nurse considers the assignments appropriate if the NAPis assigned to care for which client? |
1. A client diagnosed with Alzheimer's requiringassistance with feeding.2. A client diagnosed with osteoporosis reporting burning onurination.3. A client diagnosed with scleroderma receiving a tube feeding.4. A client diagnosed with cancer who has Cheyne-Stokes respirations. |
Strategy: Assign to nursing assistants clients with standard, unchangingprocedures. (1) correct—standard,unchanging procedure (2) requires assessment; should assign to an RN (3) stable client with expected outcome; should assign to an LPN/LVN (4) unstable client, requires assessment and nursing judgment; shouldassign to an RN |
|
|
The client is admitted with a diagnosis of subdural hematoma and cerebraledema after a motorcycle accident. Which symptoms should the nurse expectto see initially? |
1. Decreasing level of consciousness.2. Fine tremors of the extremities.3. Decerebrate posturing.4. Ipsilateral pupil dilation.5. Headache.6. Tonic/Clonic seizures. |
Strategy: Think of head injury and intracranial pressure symptoms. 1) CORRECT— As pressureincreases, the level of consciousness decreases. 2) Not related to increased intracranial pressure. 3) Late sign of brainstem damage. 4) CORRECT— This ispupil dilation on same side as the hematoma. 5) CORRECT— Headacheis the first symptom. 6) Late sign of increased intracranial pressure. |
|
|
The nurse performs an assessment of an 8-year-old child diagnosed withscoliosis. Which observation is expected with scoliosis? |
1. The child's thoracic area is asymmetrical.2. The child walks with a waddling gait.3. The child's lower legs are edematous.4. The child has a protruding sternum. |
Strategy: Determine the significance of each answer choice and how itrelates to scoliosis. (1) correct—thoracicarea becomes noticeably distorted (2) seen with hip dislocation (3) seen with circulatory or inflammatory processes (4) seen with pigeon breast, or pectus carinatum |
|
|
The client in the ICU is given procainamide HCl slowly by IV push. Thenurse should withhold the next dose if which is observed? |
1. Presence of premature ventricular contractions.2. Occurrence of severe hypotension.3. Recurring paroxysmal atrial tachycardia.4. A sedimentation rate of 10. |
Strategy: Determine the cause of each answer choice and how it relatesto Pronestyl. (1) procainamide is given to treat premature ventricular contractionsor atrial tachycardia (2) correct—severe hypotensionor bradycardia are signs of an adverse reaction to this medication (3) procainamide is given to treat premature ventricular contractionsor atrial tachycardia (4) lab value is within normal limits |
|
|
The client diagnosed with AIDS is seen in the emergency room with reportingmouth pain, difficulty swallowing, and a white discharge in the back of thethroat. The nurse expects the health care provider to order which medication? |
1. Metronidazole 7.5 mg/kg q6h. 2. Ketoconazole 200 mg daily.3. Trimethoprim-sulfamethoxazole 800 mg PO q12h. 4. Rifampin PO 10 mg/kg daily. |
Strategy: The topic of the question is unstated. (1) anti-infective, used in treatment of intestinal amebiasis, trichomoniasis,inflammatory bowel disease (2) correct—drug ofchoice for treatment of candidiasis (3) treatment for PCP; symptoms of dyspnea, tachypnea, persistent drycough, fever, fatigue (4) treatment for tuberculosis; symptoms of fever, chills, night sweats,weight loss, anorexia |
|
|
A client is transferred to a psychiatric crisis unit with a diagnosisof a dissociative disorder. The nurse identifies which comment by the clientas most indicative of this disorder? |
1. "I keep having recurring nightmares."2. "I have a headache, and my stomach has bothered me for a week."3. "I always check the door locks three times before I leavehome."4. "I don't know who I am, and I don't know whereI live." |
Strategy: Think about each answer choice. (1) posttraumatic stress disorder (PTSD) is characterized by anxietyand stress symptoms that occur after an intense traumatic event; characteristicsymptoms are hypervigilance, insomnia, and recurring nightmares (2) somatoform disorder (or hypochondria) is concerned with physicaland emotional health, accompanied by various bodily complaints for which thereis no physical basis (3) reflects the compulsive checking behavior of the anxiety associatedwith obsessive-compulsive disorder (4) correct—dissociativedisorders characterized by either a sudden or a gradual disruption in theintegrative functions of identity, memory, or consciousness; disruption maybe transient or may become a well-established pattern; development of thesedisorders is often associated with exposure to a traumatic event |
|
|
The nurse learns that the client has a history of heart failure (HF),is on a low-sodium diet, and is taking chlorothiazide 500 mg. Diagnostic testsindicate sodium 127 mEq/L(127 mmol/L), potassium 3.8 mEq/L(3.8 mmol/L), glucose110 mg/dL(6.1 mmol/L), and normal chest x-ray. It is most importantfor the nurse to assess for which signs? |
1. Sticky mucous membranes; decreased urinary output; and firm,rubbery tissues.2. Cool, moist skin; fine hand tremors; and mental confusion.3. Headache, apprehension, and lethargy.4. Shortness of breath, chest pain, and anxiety. |
Strategy: Determine the significance of each answer choice. (1) symptoms of hypernatremia, along with restlessness, weakness, coma,tachycardia, flushed skin, oliguria, fever (2) symptoms of hypoglycemia, normal blood sugar 70–110 mg/dL (3) correct—symptomsof hyponatremia along with muscle twitching, convulsions, diarrhea, fingerprintingof skin (4) symptoms of CHF, chest x-ray clear, no other information provided |
|
|
The nurse cares for a client following an appendectomy. The client takesa deep breath, coughs, and then winces in pain. Which statement, if made bythe nurse to the client, is best? |
1. "Take three deep breaths, hold your incision,and then cough."2. "That was good. Do that again and soon it won't hurt as much."3. "It won't hurt as much if you hold your incision when youcough."4. "Take another deep breath, hold it, and then cough deeply." |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—most effectiveway of deep breathing and coughing, dilates airway and expands lung surfacearea (2) should splint incision before coughing to reduce discomfort andincrease efficiency (3) partial answer, should take three deep breaths before coughing (4) implies coughing routine is adequate, incision needs to be splinted |
|
|
The nurse in a psychiatric emergency room cares for the client who isa victim of rape. Which is the initial priorityof the nurse? |
1. Encourage the client to verbalize feelings.2. Assess for physical trauma.3. Provide privacy for the client during the interview.4. Help the client identify and mobilize resources and supportsystems. |
Strategy: Think "Maslow." (1) psychosocial, priority is physical injury (2) correct—physical,victim may have physical trauma and concealed injuries; assessment is of utmostimportance so that the client's physiologic integrity is maintained (3) psychosocial, done concurrently as the nurse is assessing for physicalinjury (4) psychosocial, priority is physical injury |
|
|
The client returns to the room following a myelogram. The nursing careplan should include which interventions? |
1. Encourage oral fluid intake.2. Maintain the prone position for 12 hours.3. Lie flat for several hours.4. Monitor vital and neurological signs.5. Encourage the client to ambulate after the procedure.6. Evaluate the client's distal pulses on the affected side. |
Strategy: Mixture of actions and assessments.1) CORRECT— Implementation;fluids should be encouraged to facilitate dye excretion and to maintain normalspinal fluid.2) Implementation; clients are not placed in the prone position.3) CORRECT— Implementation;helps prevent headaches.4) CORRECT— Assessment;identify abnormalities early.5) Implementation; bed rest is maintained for several hours after thetest.6) Assessment; an extremity was not used for injection of the dye. |
|
|
The nurse in the well-baby clinic observes a group of children. Thenurse notes that one child is able to sit unsupported, play "peek-a-boo" withthe nurse and is starting to say "mama" and "dada". The nurse determines theinfant’s behaviors are consistent with which age? |
The nurse in the well-baby clinic observes a group of children. Thenurse notes that one child is able to sit unsupported, play "peek-a-boo" withthe nurse and is starting to say "mama" and "dada". The nurse determines theinfant’s behaviors are consistent with which age? |
Strategy: Picture each infant. (1) unable to sit unsupported until 8 months (2) unable to sit unsupported until 8 months (3) correct—can pullself up and assume a sitting position at 8 months, can say few words (4) would be able to say three to five words in addition to dada and mama |
|
|
The nurse in the outpatient clinic instructs a client diagnosed witha sprained right ankle to walk with a cane. What behavior, if demonstratedby the client, indicates to the nurse that teaching is effective? |
1. The client advances the cane 18 inches in front of the footwith each step.2. The client holds the cane in the left hand. 3. The client advances the right leg, then the left leg, andthen the cane. 4. The client holds the cane with elbows flexed 60°. |
Strategy: "Teaching is effective" indicates a correct behavior. (1) should advance cane 6–10 inches with body weight on both legs (2) correct—should holdcane on strong side, widens base of support, reduces stress on affected side (3) should advance cane, weaker leg, stronger leg (4) should flex no more than 30° |
|
|
The nurse performs triage on a group of clients in the emergency department.Which client should the nurse see first? |
1. A 12-year-old oozing blood from a laceration of the left thumbdue to cut on a rusty metal can.2. A 19-year-old with a fever of 103.8°F (39.8°C)who is able to identify a sibling but not the place and time.3. A 49-year-old with a compound fracture of the right leg reportingsevere pain.4. A 65-year-old with a flushed face, dry mucous membranes, anda blood sugar of 470 mg/dL. |
Strategy: Identify the least stable client. (1) no indication of hemorrhage, will require a tetanus shot (2) correct—disoriented,requires immediate assessment to determine underlying cause (3) splint; cover wound with sterile dressing; check temperature, color,sensation; give narcotic (4) hyperglycemic, give IV fluid, regular insulin |
|
|
The client develops right-sided heart failure. The nurse expects toobserve which symptoms? |
1. Increased respiration with exertion.2. Peripheral edema and anorexia.3. Polycythemia4. Cough producing large amount of thick, yellow mucus.5. Twitching of extremities.6. Distended neck veins. |
Strategy: All assessments, do they relate to heart failure? 1) Common assessment finding of the client with chronic lung disease. 2) CORRECT— Edema causedby decreased heart pumping action and accumulation of fluid; malaise causinganorexia. 3) CORRECT— IncreasedRBC as compensation for decreased oxygenation. 4) Describes a complication of pneumonia. 5) Not related to heart failure. 6) CORRECT— Relatedto heart failure. |
|
|
The client takes gemfibrozil. It is most important for the nurse tomonitor which laboratory value? |
1. Serum creatine.2. Erythrocyte sedimentation rate (ESR).3. Aspartate aminotransferase (AST).4. Arterial blood gases (ABG). |
Strategy: Recall what each lab function is measuring and determine howit relates to gemfibrozil (Lopid). (1) indicates kidney function, normal 0.6 to 1.2 mg/dL (2) indicates inflammation, normal 0 to 20 mm/h (3) correct—indicatesliver function, normal 8–20 units/L; lipid-lowering agent used withpatients with high serum triglyceride levels, side effects include abdominalpain, cholelithiasis; take 30 minutes before breakfast and supper (4) indicates acid/base balance |
|
|
The health care provider orders ranitidine hydrochloride 150 mg PO dailyfor the client. The nurse should advise the client the best time to take themedication is when? |
1. Prior to breakfast.2. With dinner.3. With food.4. At hour of sleep. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) absorption is not affected by food (2) absorption is not affected by food (3) absorption is not affected by food (4) correct—best resultswhen taking once a day |
|
|
After a client has a positive Chlamydiatrachomatis culture, the client and partner return for counseling.It is most important for the nurseto ask which question? |
1. "What contacts do you need to identify?"2. "What do you know about how chlamydia is transmitted?"3. "What questions do you have about the culture?"4. "What allergies do you have to medications?" |
Strategy: "MOST important" indicates that this is a priority question. (1) may be part of follow-up (2) correct—means oftransmission of chlamydia may or may not have been made clear to both partners;nurse should assess this first; is a sexually transmitted infection (3) most cultures used today have few false positives (4) would be done later in the nursing assessment |
|
|
A client diagnosed with bipolar disorder receives haloperidol 2 mg POtid. The client tells the nurse, "Milk is coming out of my breasts." Whichresponse by the nurse is BEST? |
1. "You are seeing things that aren't real."2. "Why don't we go make some fudge?"3. "You are experiencing a side effect of haloperidol."4. "I'll contact your health care provider to change your medication." |
Strategy: The topic of the question is unstated. (1) hallucinations usually not seen with patients with bipolar disorder;seen with psychotic disorders (2) assumption that patient just wants attention (3) correct—side effectsinclude galactorrhea (excessive or spontaneous flow of milk), lactation, gynecomastia(excessive growth of male mammary glands) (4) indicates a side effect, not effectiveness of medication |
|
|
An elderly client returns from surgery after a hysterectomy due to cancer,and there is an order for antiembolism stockings. Which information shouldthe nurse include when instructing the client about wearing the support stockings? |
1. "Wear the stockings when your legs cramp."2. "Wear the stockings during your hospitalization."3. "Put the stockings on prior to going to bed."4. "Put the stockings on after you get out of bed in the morning." |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) antiembolism stockings should be worn to prevent any discomfortand to increase the blood flow (2) correct—stockingsshould be worn the entire time that client is in the hospital; should be removedfor baths and replaced after the skin is dry, and before the client gets outof bed (3) stockings should be worn during the day and when client is nonambulatory (4) stockings should be applied before getting out of bed |
|
|
The client is scheduled for a left lower lobectomy. The health careprovider orders diazepam 2 mg IM for anxiety. The nurse determines the medicationis appropriate if the client displays which symptoms? |
1. Agitation and decreased level of consciousness.2. Lethargy and decreased respiratory rate.3. Restlessness and increased heart rate.4. Hostility and increased blood pressure. |
Strategy: Determine if the answer choice relates to Valium. (1) more indicative of preoperative complications, should be reportedbefore medications are given (2) more indicative of preoperative complications, should be reportedbefore medications are given (3) correct—observationmost indicative for antianxiety drugs is restlessness and increase in heartrate due to circulating catecholamines (fight or flight) (4) hostility may be treated best by ventilating feelings |
|
|
A client diagnosed with multiple sclerosis (MS) is at 39 weeks gestation.The client is admitted to the labor and delivery unit in active labor. Theclient's vital signs are BP 127/72; pulse 72 bpm; cervix is 4 cm dilated;FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipatethe need for which intervention? |
1. Prepare to administer IV oxytocin to the client.2. A reduction in the amount of pain medicationadministered.3. Check the client's blood pressure every 5 minutes.4. Prepare an isolette for the infant. |
Strategy: Answers are a mix of assessments and implementations. Doesthe assessment make sense? No. Determine the outcome of each intervention. (1) uterine contractions not affected by MS (2) correct—less painmedication is required because of overall decrease in pain perception dueto MS (3) no reason to assess this frequently (4) baby's outcome not affected by MS |
|
|
The clinic nurse performs diet teaching for an older client with acutegout. The nurse should teach the client to limit the intake of which foods? |
1. Red meat and shellfish.2. Cottage cheese and ice cream.3. Fruit juices and milk.4. Fresh fruits and uncooked vegetables. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—should beon low-purine diet, should avoid red and organ meats, shellfish, oily fishwith bones (2) calcium-rich foods are not limited with gout (3) no restriction with gout (4) high-roughage foods are not limited with gout |
|
|
The nurse assists with a bone marrow aspiration. Which action shouldthe nurse take? |
1. Drop additional sterile supplies onto a steriletray.2. Unwrap all sterile packs for the procedure in case they areneeded.3. Reach over the tray, and remove contaminated supplies.4. Place the bottle of sterile liquid on the sterile field sothat it does not splash. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—sterilearticles should be dropped at a reasonable distance from the edge of the sterilearea (2) sterile packs should be opened only as needed (3) never reach an unsterile arm over a sterile field (4) outside of a bottle containing sterile liquid is not consideredto be sterile |
|
|
An older client undergoes the second exchange of intermittent peritonealdialysis (IPD). Which action requires an intervention by the nurse? |
1. The client reports pain during the inflow of the dialysate.2. The client reports constipation.3. The dialysate outflow is cloudy.4. There is blood-tinged fluid around the intra-abdominal catheter. |
Strategy: "Requires an intervention" indicates you are looking for acomplication. (1) common report, moderate pain is frequently experienced as fluidis instilled during first few exchanges (2) common report due to inactivity, decreased nutrition, use of medications;high-fiber diet and stool softeners help prevent (3) correct—indicatesperitonitis, also will see nausea and vomiting, anorexia, abdominal pain,tenderness, rigidity (4) caused by subcutaneous bleeding, common during first few exchanges |
|
|
The nurse observes care given to the client experiencing severe to paniclevels of anxiety. The nurse should intervene in which situation? |
1. The staff maintains a calm manner when interacting with theclient.2. The staff attends to client's physical needs as necessary.3. The staff helps the client identify thoughtsor feelings that occurred prior to the onset of the anxiety.4. The staff assesses the client's need for medication or seclusionif other interventions have failed to reduce anxiety. |
Strategy: "Nurse would intervene" indicates that you are looking foran inappropriate response. (1) appropriate nursing action for this level of anxiety (2) appropriate nursing action for this level of anxiety (3) correct—at thislevel of anxiety, client is unable to process thoughts and feelings for problemsolving (4) appropriate nursing action for this level of anxiety |
|
|
The 4-month-old child is admitted with a tentative diagnosis of meningitis.To confirm the diagnosis, a lumbar puncture (LP) is ordered. While assistingthe health care provider with the procedure, it is most importantfor the nurse to take which action? |
1. Appropriately restrain the child.2. Instruct the parents about the procedure.3. Provide support to the child.4. Elevate the head of the bed. |
Strategy: Think "Maslow." (1) correct—primaryobjective is to prevent trauma to child during the procedure; child must berestrained (2) not as high a priority as preventing injury to the child (3) should be done before and/or after the procedure (4) elevating the head of the bed for a 4-month-old will not exposethe spinal column |
|
|
The 48-year-old client is seen in the outpatient clinic reporting irregularmenses. The client's history indicates an onset of menses at age 14, para2 gravida 2, and regular periods every 28 to 30 days. The client is divorcedand works full time as a bank teller. The nurse identifies which as the most probable cause of the client's symptoms? |
1. Emotional trauma and stress.2. Onset of menopause.3. Presence of uterine fibroids.4. Possible tubal pregnancy. |
Strategy: "MOST probable" indicates discrimination is required to answerthe question. (1) not enough information given in question to assume that symptomsare caused by stress (2) correct—ovarianfunction gradually decreases and then stops, usually 45 to 50 years old (3) benign tumors arising from muscle tissue of uterus, menorrhagia(excessive bleeding) most common symptom along with backache, constipation,dysmenorrhea (4) usually see history of missed periods or spotting with abdominalpain |
|
|
The nurse cares for a child several hours after the application of ahip spica cast. The parent turns on the call light and says the child haspain in the left foot. Which action should the nurse take first? |
1. Elevate the left leg on two pillows.2. Palpate the cast for warmth and wetness.3. Administer pain medication as ordered.4. Check the blanching sign on both feet. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. (1) implementation; done to prevent swelling and venous congestion,not helpful to reduce pain due to circulatory impairment (2) assessment; not helpful to reduce pain due to circulatory impairment,should not palpate wet cast, would result in depressions causing pressure (3) implementation; pain important diagnostic symptom, should not besuppressed or masked (4) correct—assessment;pain main symptom of circulatory impairment from cast; pressing nail of greattoe indicates circulatory function, compare speed with which color returnswith result on the opposite side; sluggish return indicates circulatory impairment,too rapid return indicates venous congestion |
|
|
The nurse cares for clients in the skilled nursing facility. In whichorder will the nurse see the clients? |
|
Strategy: Which client has the most life-threatening problem? 1) First: Duration of warfarin is 2 to 5 days, client at risk for arepeat stroke. 2) Second: Anticoagulant takes priority, client still receiving painmedication but must be address because change in medication intensity. 3) Third: Painful urination, may indicate infection; not as urgent asprevious two. 4) Anticoagulant takes priority; immunization is last priority of theseclients. |
|
|
An extremely agitated client receives haloperidol IM every 30 minuteswhile in the psychiatric emergency room. It is most importantfor the nurse to take which action? |
1. Monitor blood pressure every 30 minutes.2. Remain at the client's side to provide reassurance.3. Tell the client the name of the medication and its effects.4. Assess for anticholinergic effects of the medication. |
Strategy: Answers are a mix of assessments and implementations. Is thisa situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) correct—assessment;monitoring vital signs is of utmost importance to ensure client safety andphysiological integrity; rapid neuroleptization is a pharmacological interventionused to rapidly diminish severe symptoms that accompany acute psychosis; alpha-adrenergicblockade of peripheral vascular system lowers BP and causes postural hypotension (2) implementation; should be done but is not highest priority (3) implementation; should be done but is not highest priority (4) assessment; circulatory system takes priority |
|
|
The newborn infant of an HIV-positive mother is admitted to the nursery.The nurse should include which intervention in the plan of care? |
1. Standard precautions.2. Testing for HIV.3. Transfer to an acute care nursery facility.4. Place the infant in isolation. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—providesimmediate protective care for the staff members (2) might be employed, safety is the priority (3) might be employed, is not a priority (4) isolation not required; infant may be in normal nursery |
|
|
The nurse cares for a client receiving IV antibiotics for 4 days. Whichsymptom should cause the nurse to be concerned about postinfusion phlebitis? |
1. Tenderness at the IV site.2. Increased swelling at the insertion site.3. Reddened area or red streaks at the site.4. Leaking of fluid around the IV catheter.
|
Strategy: Determine the significance of each assessment and how it relatesto phlebitis. (1) tenderness at the IV site is common (2) increased swelling at the insertion site may indicate infiltration (3) correct—characterizedby inflammation and reddened areas around site and up length of vein (4) not indicative of phlebitis |
|
|
The nurse counsels an elderly client who comes to the outpatient clinicfor a routine examination. The history indicates the client takes a laxativetablet twice a day and a laxative suppository once a day. The nurse shouldsuspect which about the client? |
1. The client has an anal fixation resulting from recent lossof a spouse. 2. The client is depressed because of alterations in intestinalabsorption and excretion.3. The client is experiencing excessive concernwith body function because of physical changes.4. The client has regressed because of a fear of losing the abilityto have bowel movements. |
Strategy: Think about each answer choice. (1) makes judgment without information (2) constipation common finding in elderly; no information about depression (3) correct—physicalchanges occur in late adulthood causing changes in body image; constipationfrequent problem of elderly, but reaction by this client is excessive (4) no information provided about regression |
|
|
The nurse performs discharge teaching for a client diagnosed with Addison'sdisease. It is most important forthe nurse to instruct the client about which information? |
1. Signs and symptoms of infection.2. Fluid and electrolyte balance.3. Seizure precautions.4. Steroid replacement. |
Strategy: Determine the outcome of each answer choice. Is it desired? (1) not most important (2) not most important (3) not most important (4) correct—steroidreplacement is the most important information the client needs to know |
|
|
The client has a history of oliguria, hypertension, and peripheral edema.Current lab values are BUN 25 (8.9 mmol/L) and K+ 4.0mEq/L (4.0 mmol/L). The nurse should restrict which foods in the client’sdiet? |
1. Protein.2. Fats.3. Carbohydrates.4. Magnesium. |
Strategy: Determine which system is involved and then determine whichnutrients require restriction. (1) correct—decreasedproduction of urea nitrogen can be achieved by restricting protein; metabolicwastes cannot be excreted by the kidneys (2) decreases the nonprotein nitrogen production; these foods are encouraged (3) decreases the nonprotein nitrogen production; these foods are encouraged (4) should not be restricted |
|
|
After a client develops left-sided hemiparesis from a stroke, the nursenotes a decrease in muscle tone. The nurse determines which nursing diagnosisis the priority? |
1. Impaired Mobility related to paralysis.2. Impaired Skin Integrity related to decreasein tissue oxygenation.3. Impaired Skin Integrity related to immobility.4. Impaired Verbal Communication related to decrease in thoughtprocesses. |
Strategy: Think about each answer choice. (1) not a priority (2) correct—leadingcause of skin breakdown is a decrease in tissue perfusion (3) not a priority (4) would be more relevant to right-sided hemiparesis |
|
|
The nurse cares for clients in the pediatric clinic. A mother reportsthat her infant's smile is "crooked". The nurse should assess which cranialnerve? |
1. III.2. V.3. VII.4. XI. |
Strategy: Think about each answer choice. (1) oculomotor; provides innervation for extraocular movement (2) trigeminal; provides sensation to facial muscles (3) correct—facial;provides motor activity to the facial muscles (4) spinal accessory; provides innervation to the trapezius and sternocleidomastoidmuscles |
|
|
An adolescent client is ordered to take tetracycline HCL 250 mg PO bid.Which instruction should be given to the client by the nurse? |
1. "Take the medication on a full stomach or with a glass ofmilk."2. "Wear sunscreen and a hat when outdoors."3. "Continue taking the medication until you feel better."4. "Avoid the use of soaps or detergents for 2 weeks." |
Strategy: Think about each answer choice. (1) should be taken on an empty stomach (2) correct—photosensitivityoccurs with the use of this medication (3) should be taken as directed (4) unnecessary |
|
|
The client who is positive for human immunodeficiency virus (HIV) isto be discharged and will be taking zidovudine at home. Which action by thenurse is best? |
1. Review the importance of adhering to a 4-hour schedule.2. Advise the client to buy a timed pill dispenser.3. Write the schedule of when the medicine shouldbe taken.4. Encourage self-medication prior to discharge. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) less helpful in the overall teaching-learning process (2) less helpful in the overall teaching-learning process (3) correct—plannedand written schedule of administration is more effective for adherence totime frames (4) less helpful in the overall teaching-learning process |
|
|
The nurse cares for the client on the nursing unit. Which finding doesthe nurse recognize as a positive response to fluoxetine HCl? |
1. The nurse notes hand tremors and leg twitching.2. The client states is able to sleep for longer periods of time.3. The client has an increased energy level andparticipates in unit activities.4. The nurse observes that the client is hypervigilant and scansthe environment. |
Strategy: Think about each answer choice. (1) can be side effect of the medication (2) not an effect of fluoxetine HCL, can actually inhibit sleep; isuseful with clients who experience increased sleeping and psychomotor retardationand lethargy (3) correct—fluoxetineHC is an "energizing" antidepressant; as client begins to demonstrate a positiveresponse, he has an increased energy level, is able to participate more inmilieu (4) can be side effect of medication |
|
|
The nurse supervises the staff caring for four clients receiving bloodtransfusions. In which order should the nurse visit each client? |
|
Strategy: Identify the most critical type of transfusion reaction. 1) First: Acute hemolytic reaction; most dangerous type of transfusionreaction, symptoms include nausea, vomiting, pain in lower back, hematuria;treatment is to stop blood, obtain urine specimen, and maintain blood volumeand kidney perfusion. 2) Second: Circulatory overload; treatment is to adjust rate of infusion,position in an upright position, and administer oxygen and possibly diuretics. 3) Third: Allergic reaction; symptoms include urticaria, pruritus, fever;treatment is to stop blood, give antihistamine, and restart transfusion slowly. 4) Fourth: Febrile reaction; symptoms include fever, chills, nausea,headache; treatment is to stop blood and administer antipyretics |
|
|
The nurse plans care for a client on bed rest. To promote evening restand sleep for this client, it is most importantfor the nurse to take which action? |
1. Provide privacy.2. Give back rubs at bedtime.3. Assist with a bath every day.4. Encourage daytime activities. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) excessive privacy can limit sensory input (2) will help client to relax but is not most important (3) should encourage client to do as much of his care as he can to maintainindependence (4) correct—providesrelief from tension, ensures client naps less during the day, helps clientrelax |
|
|
Which nursing intervention is a priority in preventing complicationsafter a cesarean birth? |
1. Turn, cough, and deep breathe.2. Limit fluid intake.3. Supply a high-carbohydrate diet.4. Evaluate skin integrity |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—representspreventive care for respiratory congestion resulting from anesthesia and shallowrespirations due to the abdominal incision (2) fluids should be encouraged (3) will not prevent complications (4) does not address a common complication |
|
|
The nurse cares for a client just returning to the postsurgical unitfollowing abdominal surgery for cancer of the colon. It is most appropriatefor the nurse to take which action? |
1. Determine the stage of loss and grief.2. Analyze the quality and quantity of pain.3. Instruct the client to cough and deep breathe.4. Ask the client to lift the head off the pillow. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. Remember Maslow. (1) physical needs take priority (2) not most important (3) implementation; should first assess (4) correct—should assesswhether there are any remaining effects of neuromuscular blocking agents;may block ability to breathe deeply |
|
|
The client is treated for sexual abuse by one parent. What does thenurse anticipate as an initial positive client outcome of treatment? |
1. Acknowledges willing participation in an incestuous relationship.2. Re-establishes a trusting relationship with his/her otherparent.3. Verbalizes that they are not responsible forthe sexual abuse.4. Describes feelings of anxiety when speaking about sexual abuse. |
Strategy: Think about each answer choice. (1) continues the myth of "badness" and that he/she deserved the abuseand actively consented to it (2) outcome that would be positive but usually is not an initial resultof treatment (3) correct—victim needsassistance to challenge "belief of victims," which includes "I am bad anddeserve the abuse" (4) expected long term outcome |
|
|
The client is returned to the room after a subtotal thyroidectomy fortreatment of hyperthyroidism. Which item, if found by the nurse at the client'sbedside, is nonessential? |
1. Potassium chloride for IV administration.2. Calcium gluconate for IV administration.3. Tracheostomy setup.4. Suction equipment. |
Strategy: Answers are all implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—hypokalemiais not expected after this surgery (2) used to treat tetany resulting from possible damage to parathyroidglands (3) essential equipment to provide for airway (4) needed to maintain a patent airway |
|
|
The nurse knows that the client diagnosed with medication-induced Cushing'ssyndrome should first be instructedabout which outcome? |
1. Compression fractures from increased calcium excretion.2. Decreased resistance to stress.3. Scheduled gradual withdrawal of the medication.4. Changes in secondary sex characteristics. |
Strategy: Think about each answer choice. (1) problems associated with Cushing's syndrome but are not the firstpriority (2) problems associated with Cushing's syndrome but are not the firstpriority (3) correct—if steroidsare withdrawn suddenly, the client may die of acute adrenal insufficiency (4) not seen with this medication |
|
|
Which is a correct instruction by the nurse to the parent of a 4-year-oldclient regarding collecting a specimen to be tested for pinworms? |
1. Collect the specimen 30 minutes after the child falls asleepat night.2. Save a portion of the child's first stool of the day and takeit to the clinic immediately.3. Collect the specimen in the early morning witha piece of Scotch tape touched to the child's anus.4. Feed the child a high-fat meal, and then save the first stoolfollowing the meal. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) specimen should be collected early in the morning after the childawakens (2) unnecessary; pinworms are not routinely found in the stool (3) correct—pinwormscrawl outside the anus early in the morning to lay their eggs (4) inappropriate for this situation |
|
|
The client is being discharged with sublingual nitroglycerin. Whichinformation should the nurse give to the client? |
1. Take the medication 5 minutes after the pain has started.2. Stop taking the medication if a stinging sensation is absent.3. Take the medication on an empty stomach.4. Avoid abrupt changes in posture. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) should be taken immediately when pain is felt (2) presence or absence of a stinging sensation is not indicative ofthe effect of the drug (3) should be taken when pain is experienced (4) correct—nitroglycerincan cause hypotension; client should avoid changing positions quickly to decreasethe chances of falling |
|
|
The nurse makes nursing assignments for the burn unit. Which is the most appropriate assignment for a client witha positive cytomegalovirus (CMV) titer? |
1. Instruct the client to wear a mask when outside the room.2. Wear eyewear when emptying a urinary drainagebag.3. Place the client in a private room.4. Keep the client's door shut at all times. |
Strategy: Determine what type of precautions are required. 1) positive CMV titer does not require airborne precautions 2) correct— positiveCMV titer requires standard precautions; eyewear worn whenever there is riskof splash or splatter 3) no need for private room 4) standard precautions only indicated |
|
|
A 13-year-old male diagnosed with muscular dystrophy (MD) develops nocturia.The client wants to know about external catheters. The nurse should base theresponse on which statement? |
1. The catheter can be removed during the day.2. External catheters are uncomfortable.3. The catheter would drain into a bag at the bedside or on thewheelchair.4. The external condom catheter is easy to apply. |
Strategy: Think about each answer choice. (1) correct—being freefrom any drain bags during the day would appeal to a 13-year-old (2) is negative (3) would be embarrassing to a 13-year-old (4) it would be impossible for a teen with muscular weakness to puton an external catheter |
|
|
A client is seen in the clinic for treatment of chronic back pain. Theclient tells the clinic nurse that at home an ointment, prepared from severaldifferent herbs, is applied to the lower back to relieve the pain. The clientasks the nurse, "Should I continue using it?" Which response by the nursewould be best? |
1. "No. It might do you more harm than good."2. "Yes. Continue using it, but I don't see how it could helpyour condition."3. "You may think it works, but I don't believe home remedieswork."4. "Pain can be relieved in several ways. Consultyour health care provider regarding this home remedy." |
Strategy: Remember therapeutic communication. (1) closed statement (2) closed statement; casts doubt on efficiency of alternative therapy (3) focus should be on client, not on nurse's beliefs (4) correct—herbal medicationcan interact with other medication |
|
|
Which technique is correct for the nurse to use when changing a largeabdominal dressing on an incision with a Penrose drain? |
1. Remove the dressing layers one at a time.2. Clean the wound with povidone-iodine solution and hydrogenperoxide.3. Clean the drain area first.4. If the dressing adheres to the wound, pull gently and firmly. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired?(1) correct—to avoiddislodging drain, remove the dressing layers one at a time(2) do not clean a wound with both povidone-iodine solution and hydrogenperoxide(3) cleansing of the wound is from the center outward to the edges andfrom the top to the bottom(4) incorrect; may dislodge drain |
|
|
Which assessment does the nurse expect to make regarding the developmentalstage of a 40-year-old male? |
1. Cognitive skills are starting to decline.2. A balance is found among work, family, and social life.3. Bone mass begins to increase at this age.4. The client starts to measure life accomplishmentsagainst goals. |
Strategy: Think about each answer choice. (1) does not occur (2) occurs earlier in development (3) at age 40, bone mass begins to decrease (4) correct—may precipitatea mid–life crisis |
|
|
The nurse instructs a client diagnosed with multiple sclerosis to performintermittent self-catheterization at home. The nurse should include whichinstructions? |
1. Use a new, sterile catheter each time the client performsa catheterization.2. Store the catheter in a plastic food-storagebag.3. Perform the catheterization procedure every 8 hours.4. Limit oral fluids to reduce the number of times a catheterizationis needed.
|
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) should use clean (not sterile) technique, used for clients withlower motor neuron disorders resulting in flaccid bladder (2) correct—will reducethe risk of contamination; sterile storage not necessary (3) usually done every 2 to 3 hours initially, and then increased toevery 4 to 6 hours (4) should encourage fluids |
|
|
The nurse completes client assignments for the day. The nurse shouldassign an LPN/LVN to which client? |
1. A client who had a total hip replacement andrequires assistance with ambulation.2. A client with type I diabetes mellitus who has bilateral 4+pitting edema of the feet.3. A client with cholelithiasis scheduled for a cholecystectomyand receiving IV morphine.4. A client 6 hours postoperative after cystoscopy to removea mass in the bladder. |
Strategy: The LPN/LVN is assigned to stable clients with expected outcomes. (1) correct—stable clientwith expected outcome (2) requires the assessment skills of the RN (3) requires assessment and teaching (4) requires assessment skills of RN |
|
|
The client is admitted to the outpatient unit in the cancer center forchemotherapy. The client is lethargic, weak, and pale. During chemotherapy,which nursing intervention is most important? |
1. Establish emotional support.2. Position for physical comfort.3. Maintain droplet precautions.4. Perform hand washing prior to care. |
Strategy: Think "Maslow." (1) appropriate but not a priority (2) appropriate but not a priority (3) unnecessary during chemotherapy (4) correct—chemotherapycan lead to immunosuppression, which predisposes client to infection; handwashing is one of most effective means of decreasing infection transmission |
|
|
The nurse cares for clients on the medical/surgical unit. The nurseidentifies which client is most atrisk for developing herpes zoster? |
1. A 19-year-old with a broken tibia in Buck's traction.2. A 50-year-old with a diabetic foot ulcer.3. A 62-year-old heart transplant with suspectedrejection.4. An 84-year-old with chronic obstructive pulmonary disease. |
Strategy: (1) has an acute trauma, is not immunocompromised (2) has a bacterial infection, is not immunocompromised (3) correct—immunocompromiseddue to immune suppression therapy; clients with compromised immune systemat risk for reactivation of the varicella zoster virus (4) has chronic disease, is not immunocompromised |
|
|
The nurse cares for a young adult admitted to the hospital with a severehead injury. How should the nurse position the client? |
1. With the client’s neck in a midline positionand the head of the bed elevated 30°.2. Side-lying with the client’s head extended and the bedflat. 3. In high Fowler's position with the client’s head maintainedin a neutral position. 4. In semi-Fowler's position with the client’s head turnedto the side. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—decreasesintracranial pressure (2) decreases venous blood return (3) too elevated, would increase intracranial pressure (4) head should be maintained in neutral position |
|
|
The client at the health clinic asks the nurse if a "flu shot" shouldbe obtained. Which factors, if learned by the nurse from the client's healthhistory, would be reasons for the client to receive the influenza vaccine? |
1. The client is 69 years old.2. The client plays poker with a group every week.3. The client volunteers at a preschool.4. The client lives with two large dogs.5. The client and sibling share an apartment.6. The client had bronchitis twice last year. |
Strategy: Think about each answer choice, how does it apply to needingan influenza vaccine 1) CORRECT— recommendedfor people over 65. 2) CORRECT— recommendedfor exposure to general puplic 3) CORRECT— recommendedfor people who come in contact with young children 4) not at risk for getting the influenza from a dog 5) not a risk factor for exposure 6) CORRECT— recommendedfor people with chronic respiratory or cardiovascular disease |
|
|
The nurse cares for clients in the pediatric clinic. The parent of a5-year-old child calls the nurse to say that after administering cough syrupcontaining dextromethorphan to the child, the child becomes very excitableand restless. Which action by the nurse is most appropriate?
|
1. Report the child's behavior to the health careprovider for a possible change in medication.2. Instruct the parent to administer half the ordered amountin all future doses to limit this behavioral response.3. Instruct the parent to give the child a glass of warm milkto dilute any medication left in the stomach.4. Chart the child's response to the medication, and alert thestaff about the parent's phone call.
|
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—althoughthis type of response to antitussive is not uncommon in young children, itis undesirable and must be reported to the health care provider so that achange in drug therapy can be initiated (2) is not within the realm of the nurse's scope of practice; healthcare provider must order dose changes (3) inappropriate (4) response must be charted, and the child's intolerance to the drugdocumented and reported to other nurses; this is not enough, health care providermust be alerted so that preventive action can be taken |
|
|
A young adult asks the nurse in the AIDS clinic what to do for the multiplesmall, painless purplish-brown spots on the right leg and ankle. The nurseshould instruct the client to take which action? |
1. Clean the spots carefully with soap and warm water twice aweek, and cover them with a sterile dressing.2. Clean the lesions twice a day with a diluted solution of povidone-iodine,and leave them open to the air.3. Shower daily using a mild soap from a pump dispenser,and pat the skin dry.4. Soak in a warm tub three times a day, and rub the spots witha washcloth. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) if lesions are open and draining, they must be cleaned and dresseddaily to prevent secondary infection (2) treatment for herpes simplex virus abscess, not Kaposi's sarcoma (3) correct—importantto keep the skin clean and prevent secondary skin infection (4) increases risk of secondary skin infection |
|
|
The nurse knows which observation is indicative of chronic cocaine use? |
1. Nasal septum disruption.2. Lack of coordination.3. Constricted pupils.4. Craving for sweets and carbohydrates. |
Strategy: Determine how each answer choice relates to cocaine. (1) correct—chronicinhalation creates sores, burns, disruption of mucous membranes, and holesin the nasal septum (2) barbiturate abusers typically suffer from lack of coordination (3) narcotic abusers demonstrate constricted pupils (4) clients who abuse marijuana, hashish, and/or THC experience cravingsfor sweets and carbohydrates |
|
|
Which statement should the nurse make to a client who is going to self-administercontinuous ambulatory peritoneal dialysis (CAPD) at home? |
1. "Check your weight at the same time daily."2. "Maintain clean technique at all times during the procedure."3. "Milk the catheter to encourage extra fluid to be removedfrom the abdomen."4. "Eat a well-balanced, low-protein diet." |
Strategy: Answers are a mix of assessments and implementations. Is assessmentrequired? Yes. Is the assessment appropriate? Yes. (1) correct—assessment;daily weight necessary with peritoneum empty to assess fluid volume status,guidelines for weight gain/loss set by health care provider (2) implementation; strict aseptic technique required to prevent contamination,sterile = aseptic, clean = antiseptic (3) implementation; don't milk catheter, drainage by gravity only (4) implementation; encouraged to eat a high-protein diet because ofprotein loss with CAPD |
|
|
Which nursing intervention is most importantfor a client diagnosed with rheumatoid arthritis? |
1. Provide support to flexed joints with pillows and pads.2. Position the client on the abdomen several times a day.3. Massage the inflamed joints with creams and oils.4. Assist the client with heat application andROM exercises. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) would result in contractures due to the strength of flexor muscles (2) should encourage range of motion in all joints, not just hip flexors (3) massaging inflamed joints will add to inflammation and pain (4) correct—reducesswelling, increases circulation, diminishes stiffness while preserving jointmobility |
|
|
A nonstress test is scheduled for the client at 34 weeks gestation whodeveloped hypertension, periorbital edema, and proteinuria. Which nursingaction should be included in order to best preparethe client for the diagnostic test? |
1. Start an intravenous line for an oxytocin infusion.2. Obtain a signed consent prior to the procedure.3. Instruct client to push a button when she feelsfetal movement.4. Attach a spiral electrode to the fetal head. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) would be appropriate for an oxytocin (stress) test (2) is incorrect because this is noninvasive (3) correct—nonstresstest is a noninvasive test to evaluate the response of the fetal heart rateto the stress of fetal movement; response will be reflected on the fetal monitor (4) prepares for internal fetal monitoring |
|
|
A client is in cardiogenic shock after a myocardial infarction (MI).Which is a correctly stated nursing diagnosis for the client? |
1. Activity intolerance: related to impaired oxygen transport.2. Decreased Cardiac Tissue Perfusion relatedto decreased heart-pumping action.3. Altered cardiac output related to cardiac ischemia.4. Deficient Fluid Volume related to decreased fluid intake. |
Strategy: Think about each answer choice. (1) not best (2) correct—correctlystated, appropriate nursing diagnosis (3) altered cardiac output is not a commonly accepted nursing diagnosis (4) not appropriate for this client |
|
|
The client exhibits symptoms of myxedema. The nursing assessment shouldreveal which information? |
1. Increased pulse rate.2. Decreased temperature.3. Fine tremors.4. Increased radioactive iodine uptake level. |
Strategy: Determine how each answer choice relates to myxedema. (1) pulse will decrease (2) correct—with myxedemathere is a slowing of all body functions (3) associated with hyperthyroidism (4) associated with hyperthyroidism |
|
|
The health care provider orders sucralfate 1 g PO bid for a client takingdigoxin 0.25 mg daily. The client asks the nurse if both pills can be takentogether at breakfast so that the client doesn't forget to take them. Thenurse should advise the client to take the medications in which way? |
1. Take the sucralfate and digoxin before breakfast.2. Take the digoxin 1 hour before breakfast and the sucralfate1 hour after breakfast. 3. Take the sucralfate 1 hour before breakfastand the digoxin 1 hour after breakfast.4. Take the sucralfate and the digoxin after breakfast. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) Sucralfate forms a barrier on the gastrointestinal mucosa, woulddecrease absorption of other medications, separate by 2 hours (2) Sucralfate best results on empty stomach (3) correct—Sucralfatebest results on empty stomach, medications should be separated by 2 hoursfor maximum absorption (4) Sucralfate best results on empty stomach, medications should beseparated by 2 hours for maximum absorption |
|
|
During preadmission planning for a client scheduled for a kidney transplant,the client should be educated by the nurse regarding which information? |
1. Remind family and friends that there is restrictedvisiting for at least 72 hours postoperatively.2. Arrange all live plants received postoperatively in one sectionof the room.3. Continue intermittent peritoneal dialysis for 3 months followingsurgery.4. Limit consumption of sodium-free liquids for 1 year postoperatively. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) correct—transplantclients require protective isolation following surgery (2) can't have live plants in the room at all (3) no need for dialysis following transplant (4) need to force fluids, not restrict them |
|
|
When administering antipsychotic medications parenterally, which actionshould the nurse take first? |
1. Monitor the client's blood pressure while theclient is sitting and standing before and after each dose is given.2. Caution the client not to drink or operate machinery thatrequires mental alertness for safety.3. Have an emergency cart available in case of an adverse reaction.4. Reassure the client that side effects are only temporary. |
Strategy: Answers are a mix of assessments and implementations. Doesthe assessment make sense? Yes. (1) correct— primaryconcern with postural hypotension caused by medication and preventing an injuryfrom a fall; monitoring vital signs will provide data to address this concern;this is the immediate concern (2) a concern but not the major one at this time (3) nurse should know sign and symptoms of neuroleptic malignant syndrome(pallor, tachycardia, hypertension or hypotension, diaphoresis, fever, convulsions,loss of bladder control, respiratory distress, severe muscle stiffness, tiredness);identify it early; notify health care provider; administer emergency careas needed (4) false reassurance; nurse needs to be realistic about adverse effects |
|
|
The client receives parenteral nutrition (PN). To determine the client'stolerance of this treatment, the nurse should assess which physiological sign? |
1. A significant increase in pulse rate.2. A decrease in diastolic blood pressure.3. Temperature in excess of 98.6°F (37°C).4. Urine output of at least 30 mL/h. |
Strategy: Determine how each answer choice relates to TPN. (1) if the pulse rate increases, may indicate fluid overload (2) if the diastolic blood pressure decreases, it might indicate shockor lack of blood volume (3) temperature should remain within normal limits (4) correct—if the clientis being properly hydrated with hypertonic IV such as TPN, urine output needsto be at least 30 mL/h; other nursing action includes assessment of bloodglucose levels |
|
|
The client receives parenteral nutrition (PN). To determine the client'stolerance of this treatment, the nurse should assess which physiological sign? |
1. A significant increase in pulse rate.2. A decrease in diastolic blood pressure.3. Temperature in excess of 98.6°F (37°C).4. Urine output of at least 30 mL/h. |
Strategy: Determine how each answer choice relates to TPN. (1) if the pulse rate increases, may indicate fluid overload (2) if the diastolic blood pressure decreases, it might indicate shockor lack of blood volume (3) temperature should remain within normal limits (4) correct—if the clientis being properly hydrated with hypertonic IV such as TPN, urine output needsto be at least 30 mL/h; other nursing action includes assessment of bloodglucose levels |
|
|
The visiting nurse instructs a client how to use esophageal speech followinga total laryngectomy. Which action, if performed by the client, indicatesteaching is effective? |
1. The client swallows air and then eructates itwhile forming words with the mouth. 2. The client places a battery-powered device against the sideof the neck. 3. The client places a finger over the tracheostomy, forcingair up through the vocal cords. 4. The client covers the stoma in the tracheoesophageal fistulaand moves the lips. |
Strategy: "Teaching is effective" indicates a correct response. (1) correct—describesesophageal speech (2) describes electric larynx (3) method of speech for client with a tracheostomy (4) describes tracheoesophageal fistula (TEF) |
|
|
The nurse cares for the client who has just returned to the room aftera scleral buckling procedure. Which nursing action is most important? |
1. Remove reading material to decrease eyestrain.2. Ask the client if there is any nausea.3. Assess color of drainage from the affected eye. 4. Maintain sterility during q3h saline eye irrigations. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. Think about what the assessments mean. (1) implementation; would be ineffective (2) correct—assessment;is important to prevent nausea and vomiting, would increase intraocular pressure,could cause damage to area repaired (3) assessment; refers to an eye infection, would be important afterinitial operative day (4) implementation; eye irrigations are not commonly done followingthis procedure |
|
|
A 4-month-old infant is admitted to the pediatric intensive care unitwith a temperature of 105°F (40.5°C). The infant is irritable, andthe nurse observes nuchal rigidity. Which assessment finding indicates anincrease in intracranial pressure? |
1. Positive Babinski.2. High-pitched cry.3. Bulging posterior fontanelle.4. Pinpoint pupils.
|
Strategy: Determine if each answer relates to increased ICP. (1) normal for the first year of life (2) correct—high-pitchedcry is one of the first signs of an increase in the intracranial pressurein infants (3) fontanelle should be closed by the third month (4) with increased pressure, the pupil may respond to light slowly,rather than with the usual brisk response |
|
|
The client tells the nurse, "I have taken acetaminophen every day for5 months." The nurse is most concernedby which laboratory result? |
1. Aspartate aminotransferase (AST) 60 units/Land alanine aminotransferase (ALT) 48 units/L.2. Hemoglobin (Hgb) 16.2 g/dL (162g/L) and hematocrit (Hct) 46%(0.46).3. White blood cell count (WBC) 7,000/mm3(7x109/L).4. Blood urea nitrogen (BUN) 11 mg/dL (3.9 mmol/L). |
Strategy: Determine how each answer choice relates to acetaminophen. (1) correct—can causeliver damage, normal AST (formerly SGOT) 8 to 20 units/L, normal ALT (formerlySGPT) 8 to 20 units/L (2) normal Hgb male 13.5–17.5 g/dL, female 12–16 g/dL, normalHct male 41 to 53%, female 36 to 46% (3) normal WBC 5,000 to 10,000/mm3 (4) normal BUN 10 to 20 mg/dL (3.6 to 7.1 mmol/L) under 60 years |
|
|
The nurse teaches a well-baby class to a group of parents with toddlers.The nurse should encourage the parents to perform which intervention? |
1. Exercise their children daily.2. Use a playpen whenever possible.3. Provide a safe play area for their children.4. Teach their children noncompetitive activities. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) no specific exercise program is necessary; children of this agein good health are naturally active (2) limits a child's interaction with the outside world, should be usedjudiciously (3) correct—safety isfundamental issue with this age group; they are exploratory in their play (4) unnecessary; children learn by observing and by participating |
|
|
A 2-year-old is admitted to the pediatric unit with numerous bruises,a fractured left humerus, and several lacerations with unexplained origin.The nurse identifies which as a priority nursingaction? |
1. Report the findings to the child protectionagency.2. Share this information only with other health care professionals.3. Document this information in the chart.4. Share the information with the pediatric social worker. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) correct—any suspicionof child abuse should be reported to the child protection agency (2) does not provide or plan for protection of the child (3) does not provide or plan for protection of the child (4) does not provide or plan for protection of the child |
|
|
An elderly client is admitted to the hospital for treatment of a fracturedfemur. The client's spouse tells the nurse that the client has become veryhard of hearing. The nurse might expect the client to exhibit which characteristic? |
1. The client prefers to be left alone.2. The client appears suspicious of strangers.3. The client communicates best in writing.4. The client's speech is difficult to understand. |
Strategy: All answers are assessments. Determine how each assessmentrelates to this situation. (1) unrelated to hearing deficit (2) correct—suspiciousnessresults from interference with communication (3) writing may be difficult for client, depends on intellectual capacity (4) diminished hearing late in life does not cause speech difficulties |
|
|
The nurse cares for a client with type 1 diabetes. The client receivesnasal oxygen at 4 L/min. The student nurse reports that the client has pulledout the nasogastric tube and is picking at the bed covers. The client's BPis 150/90 and pulse is 90. Which action by the nurse is most appropriate? |
1. Obtain a pulse oximetry reading.2. Apply soft wrist restraints.3. Reorient the client to person and place.4. Determine the client's blood glucose level. |
Strategy: Answers are a mix of assessments and implementations. Doesthis situation require assessment? Yes. Is there an appropriate assessment?Yes. (1) correct—assessment;symptoms indicate reduced oxygen levels (2) implementation; must assess first to determine problem; all otherinterventions must be tried before using restraints (3) implementation; must determine the cause of the behavior beforeimplementing (4) assessment; symptoms indicate decreased oxygen levels |
|
|
To maintain client safety, the nurse should have which equipment readilyavailable when inserting an Ewald tube? |
1. Suction equipment.2. Blood pressure cuff.3. Levine tube.4. Emesis basin. |
Strategy: Think about each answer choice. (1) correct—Ewald tubeis a large, orogastric tube designed for rapid lavage; insertion often causesgagging and vomiting, suction equipment must be immediately available to reducethe risk of aspiration (2) not a high priority (3) not a high priority (4) not a high priority |
|
|
In planning anticipatory guidance for parents of a beginning school-agedchild, it is most important forthe nurse to include which information? |
1. Teach the child to read and write.2. Teach the child sex education at home.3. Give the child responsibility around the house.4. Expect stormy behavior. |
Strategy: Answers are implementations. Determine the outcome of eachanswer choice. Is it desired? (1) may require some assistance from the parents, but children thisage learn at their own rate (2) unnecessary at this early age (3) correct—giving childrenresponsibilities allows them to develop feelings of competence and self-esteemthrough their industry (4) does not occur until about age 11 |
|
|
The nurse cares for clients in the antepartal clinic. A client at 34weeks gestation comes to the clinic for treatment of a sprained ankle. Thenurse should question which order? |
1. Aspirin 650 mg PO q4h prn for pain.2. Return to the clinic in 2 weeks.3. Apply ice to sprain for 20 minutes qh for 24 hours.4. Teach client three-gait crutch walking. |
Strategy: Determine the outcome of each answer choice. Is it desired? (1) correct—aspirincan cause fetal hemorrhage; do not use during pregnancy (2) routine follow-up (3) treat sprain with rest and elevation of affected part; intermittentice compresses for 24 hours (4) appropriate gait if client unable to bear weight |
|
|
Which nursing action is important for safe administration of oxytocin? |
1. Assess respirations and urine output.2. Administer oxytocin parenterally as the primary IV.3. Have calcium gluconate available as an antidote.4. Palpate the uterus frequently. |
Strategy: Answers are a mix of assessments and implementations. Is therean appropriate assessment? Yes. (1) assessment; pertinent to the care of a client receiving magnesiumsulfate for pre-eclampsia (2) implementation; oxytocin is always given via an infusion pump andis never allowed to be the primary IV (3) implementation; pertinent to the care of a client receiving magnesiumsulfate for pre-eclampsia (4) correct—assessment;oxytocin stimulates the uterus to contract, which necessitates frequent assessmentof the uterus; prolonged tetanic contraction can lead to a ruptured uterus |
|
|
An adult client has regular insulin ordered before breakfast. The nursenotes that the client's blood glucose level is 68 mg/dL (3.8mmol/L) and theclient is nauseated. Which action should the nurse take? |
1. Immediately give the client orange juice to drink.2. Administer the insulin on time.3. Withhold the insulin, and notify the health care provider4. Return the breakfast tray to the kitchen. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired?(1) may cause vomiting(2) correct—take insulinor oral agent as ordered; encourage client to eat soft foods and liquids onbreakfast meal tray; recheck blood glucose again in 30-60 minutes; becauseillness can raise the blood glucose level with the regularly prescribed insulinregime, blood glucose and/or urine ketones should be monitored every 3 to4 hours; sip 8 to 12 ounces of liquid per hour to decrease the possibilityof dehydration; substitute easily digested soft foods or liquids if solidsare not tolerated(3) blood glucose increases during illness; even though client can'teat, administer insulin(4) does not address the client's problem |
|
|
The nurse cares for clients in the emergency department of an acutecare facility. Four clients have been admitted during the previous 10 minutes.Which admission should the nurse see first? |
1. The client reporting chest pain unrelieved by nitroglycerin.2. A client with full-thickness burns to the face.3. The client with a fractured hip.4. A client reporting epigastric pain.
|
Strategy: Think ABCs. (1) not the highest priority; airway most important (2) correct—face, neck,chest, or abdominal burns result in severe edema, causing airway restriction (3) airway is most important (4) requires further assessment; airway is a priority |
|
|
*The nurse prepares to perform peritoneal dialysis on an older client.The client states that pain occurred the last time the procedure was done.It is most appropriate for the nurseto take which action? |
1. Administer a warm drink to the client. 2. Administer a warm bath to the client. 3. Warm the bag of dialysate solution with a heatingpad. 4. Warm the bag of dialysate solution in a microwave oven. |
Strategy: All answers are implementations. Determine the outcome ofeach answer choice. Is it desired? (1) does not affect pain with fluid infusion (2) does not affect pain with fluid infusion (3) correct—temperaturecan be regulated, warming reduces pain caused by cold solution (4) contraindicated because of unpredictable warming patterns |
|
|
Which symptom are most likelyto be observed by the nurse when a client is withdrawing from heroin? |
1. Severe cravings, depression, fatigue, hypersomnia.2. Depression, disturbed sleep, restlessness, disorientation.3. Nausea and vomiting, tachycardia, coarse tremors, seizures.4. Runny nose, yawning, fever, muscle and jointpain, diarrhea. |
Strategy: Think about the cause of each symptom and how it relates tonarcotic withdrawal. (1) describes cocaine withdrawal (2) describes amphetamine withdrawal (3) describes barbiturate withdrawal (4) correct—narcoticwithdrawal is very much like the symptoms of the flu |
|
|
The nurse cares for a 26-year-old client immediately after deliveryof an 8-lb, 4-oz baby. The client's history indicates a diagnosis of type1 diabetes at age 12. The nurse expects which change to occur in the client? |
1. The blood glucose will fall because of a suddendecrease in insulin requirements. 2. The blood glucose will rise because of a rapid decrease incirculating insulin.3. The blood glucose will gradually rise because of a decreasedlevel of metabolic stress. 4. The blood glucose will gradually fall because of a decreasein food intake. |
Strategy: Think about each answer choice. (1) correct—hormonalinterference in glucose metabolism during pregnancy causes insulin requirementsto increase then decrease after delivery (2) blood glucose will fall after delivery (3) blood glucose level will fall after delivery (4) fall in blood glucose not primarily caused by decrease in food intake |
|
|
When caring for a client with a nursing diagnosis of rape trauma syndrome,acute phase, the nurse should consider which the most important initial goal for the client? |
1. Within 3 to 5 months, the client will state that the memoryof the event is less vivid and distressing.2. The client will indicate a willingness to keep a follow-upappointment with a rape crisis counselor.3. The client will be able to describe the results of the physicalexamination that was completed in the emergency room.4. The client will begin to express reactions andfeelings about the assault before leaving the emergency room. |
Strategy: Think about each answer choice. (1) valid goal that needs to be addressed but after the initial goalhas been met (2) valid goal that needs to be addressed but after the initial goalhas been met (3) valid goal that needs to be addressed but after the initial goalhas been met (4) correct—is nurse'sinitial priority to encourage client to begin dealing with what happened byverbalizing feelings and gaining some acceptance and perspective |
|
|
The nurse leads an in-service education class on legal issues. The nurseidentifies which act constitutes battery? |
1. The nurse restrains an agitated, confused client in the emergencyroom with a health care provider's order.2. The nurse chases a client who tries to run away while outsidefor a walk.3. The nurse holds the arms of a manic client who struck thenurse while the assistant calls for assistance.4. The nurse administers an injection to a schizophrenicclient who refuses to take the medication by mouth because of believing itis poison. |
Strategy: Determine the outcome of each answer choice. (1) restraining a client to prevent injury to self or others is appropriate (2) appropriate behavior (3) restraining a client to prevent injury to self or others is appropriate (4) correct—batteryis harmful or offensive touching of another's person; unless court ordered,clients have the right to refuse medication, even if client is psychotic |
