ATI 1 Flashcards
1
Q
A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? Dyspnea on exertion Tracheal deviation Pericardial rub Weight loss
A
Dyspnea on exertion
Notes: The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.
The nurse should identify that tracheal deviation is an expected manifestation of a tension pneumothorax
The nurse should identify that a pericardial rub is an expected manifestation of pericarditis.
The nurse should identify that weight gain is an expected manifestation of dilated cardiomyopathy. Weight gain is due to ventricular compromise and fluid retention.
2
Q
A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? (Select all that apply.)
Use a wheeled infant walker.
Place soft pillows around the edge of the infant’s crib.
Position the car seat so it is rear-facing.
Secure a safety gate at the top and bottom of the stairs.
Maintain the water heater temperature at 49° C (120° F).
A
Position the car seat so it is rear-facing.
Secure a safety gate at the top and bottom of the stairs.
Maintain the water heater temperature at 49° C (120° F).
3
Q
A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? Terbutaline Nifedipine Magnesium sulfate Methylergonovine
A
Methylergonovine
Notes: administer magnesium sulfate to a client who has preeclampsia to lower blood pressure and minimize the risk of seizures.
administer nifedipine, a smooth muscle relaxant, to a client who is experiencing preterm labor.
administer terbutaline, a smooth muscle relaxant, to a client who is experiencing preterm labor.
4
Q
A nurse is testing the reflexes of a newborn to assess neurologic maturity. Which of the following reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? Rooting Moro Tonic neck Babinski
A
Tonic neck
Notes: rooting reflex, the nurse should touch the newborn’s lip, cheek, or corner of the mouth
Moro reflex, the nurse should hold the newborn in a semi-sitting position and allow the trunk and head to fall backward about 2.5 cm (1 in). The newborn should abduct and extend his arms symmetrically, and the fingers should fan out and form a “C” with the thumb and forefinger
Babinski reflex, the nurse should stroke the bottom of the newborn’s foot upward along the lateral edge, then along the ball of the foot with a finger
5
Q
A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk for uterine atony? (Select all that apply.) Magnesium sulfate infusion Distended bladder Oxytocin infusion Prolonged labor Small for gestational age newbornA nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk for uterine atony? (Select all that apply.) Magnesium sulfate infusion Distended bladder Oxytocin infusion Prolonged labor Small for gestational age newborn
A
Magnesium sulfate infusion
Distended bladder
Prolonged labor
6
Q
A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?
Collect the specimen upon arising in the morning.
Force fluids during the day and collect the specimen in the evening.
Collect the specimen after antibiotics have been started.
Collect 2 mL of sputum before sending the specimen to the laboratory.
A
Collect the specimen upon arising in the morning.
Notes: encourage the client to force fluids, especially clear liquids, to help to thin respiratory secretions. However, evening hours are not the preferred time for obtaining a deep sputum specimen, collect the sputum specimen ordered for culture and sensitivity before the client receives antibiotic therapy, collect 4 to 10 mL of sputum before sending the specimen to the laboratory
7
Q
A nurse is caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client? Establishing a sense of achievement Contributing to society Creating meaningful social relationships Enhancing self-confidence
A
Creating meaningful social relationships
8
Q
A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions? To the left To the right Away from the body Toward the body
A
Away from the body
9
Q
A nurse is assisting with the preparation of an education program regarding advance directives for newly hired staff. Which of the following information should be included about living wills?
Living wills require a written prescription from the provider to be legal.
Living wills allow the client to designate a health care proxy.
Living wills ensure hospitals provide emergency care regardless of health coverage.
Living wills detail treatment wishes of the client in the event of terminal illnes
A
Living wills detail treatment wishes of the client in the event of terminal illness.
Notes: A written prescription from the provider is required for a do-not-resuscitate (DNR) order
The durable power of attorney for health care allows the client to designate a health care proxy, not the living will.
The Emergency Medical Treatment and Active Labor Act ensures that hospitals provide emergency care regardless of health coverage, not the living will.
The living will detail treatment wishes of the client in the event of terminal illness or persistent vegetative state.
10
Q
A nurse is providing education about a new prescription for nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which of the following statements by the client indicates a need for further teaching?
“I’ll make sure that the medication container is kept tightly sealed.”
“I’m lucky I have a prescription plan that allows me to buy pills in bulk quantities.”
“I’ll keep my pills in the medicine cabinet when I’m home.”
“I’ll go to the emergency room if my chest pain doesn’t go away.”
A
“I’m lucky I have a prescription plan that allows me to buy pills in bulk quantities.”
Notes: The client should keep the nitroglycerin tablets in a dark, dry place, and in a dark-colored glass bottle with a tight lid. Tablets lose potency in containers made of plastic or cardboard or when mixed with other capsules or tablets. NitroQuick retains its effectiveness for only 8 to 10 months. Because of the shortened shelf life, the client should not buy the medication in bulk quantities, and the client should be instructed to date the bottle when it is first opened.
Keep the medication in a dark, dry place because exposure to air, heat, and moisture cause loss of potency.
The client should call 911 or go to the nearest emergency department if anginal pain is not relieved within 5 min. Typically, the client can take up to 2 additional nitroglycerin tablets at 5-min intervals while awaiting emergency care.
11
Q
A nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newly licensed nurse indicates a breach of confidentiality and requires intervention by the nurse preceptor?
Faxing laboratory results to a client’s provider
Discussing changes in a client’s plan of care with his friend who is a nurse on another unit
Describing a client’s level of independence to the case manager arranging home health services
Remaining in the room with the client while he reviews his own medical records
A
Discussing changes in a client’s plan of care with his friend who is a nurse on another unit
12
Q
A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indicates the client is experiencing an adverse effect of the medication? Urinary retention Rapid respirations Dilated pupils Diarrhea
A
Urinary retention
Notes: morphine can cause urinary hesitancy, urinary retention, and urinary urgency. Respiratory depression is an adverse effect of morphine.
Morphine can cause pupils to constrict, known as miosis
Constipation is an adverse effect of morphine.
13
Q
A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In which of the following positions should the client be placed for insertion of the catheter? Dorsal recumbent Orthopneic Side-lying Supine
A
Supine
14
Q
A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion?
Determining the client’s respiratory rate
Measuring the client’s chest diameter
Obtaining the client’s level of oxygen saturation
Checking the client’s depth of respirations
A
Obtaining the client’s level of oxygen saturation
15
Q
A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider?
Silver-colored striae
Unilateral nipple inversion present since menarche
Dimpling of the tissue in the upper outer quadrant
Visible symmetrical venous patterns
A
Dimpling of the tissue in the upper outer quadrant
Notes: silver-colored striae of the breast tissue is the result of stretch marks caused by rapid growth of the breast tissue
New onset nipple inversion should be reported as it can indicate underlying disease
Dimpling makes the tissue appear retracted in a particular area and can result from underlying scar tissue or an invasive tumor causing ligaments to pull the skin inward toward the tumor
Visible symmetrical venous patterns is often noted in thin, pregnant, or light-skinned women. However, venous patterns that are unilateral, or hypervascular areas caused by an increased blood flow, should be reported to the provider.
16
Q
A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, “I don’t think I’m going to have the surgery. Everybody has to die sometime.” Which of the following responses by the nurse is appropriate?
“Clients having this surgery are always scared.”
“Why have you changed your mind about the surgery?”
“You shouldn’t worry, everything will be fine.”
“Tell me more about your concerns.”
A
“Tell me more about your concerns.”
17
Q
While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take?
Reposition the client every 4 hr.
Cover the area with a transparent wound barrier.
Massage areas surrounding the redness.
Wash the area with hot water every 8 hr.
A
Cover the area with a transparent wound barrier.
Notes: repositioned every 2 hr instead of every 4 hr to prevent further damage to the tissues
A transparent wound barrier applied to reddened skin or a stage 1 pressure ulcer to prevent contamination and reduce friction
Massaging area surrounding the reddened area can result in trauma to the deep tissues
Washing the area with hot water should be avoided because it can cause further irritation and increase skin dryness
18
Q
A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? Spongy gums that are receding Fissures at eyelid corners Easily plucked hair Deep reddish-colored tongue
A
Deep reddish-colored tongue
Notes: Gums should be pink to red in color, without swelling, bleeding, or receding from the gum line
The eyes should be clear and shiny, without sores or fissures at the corner of membranes or eyelids
Hair should be shiny and firm, unable to be easily plucked.
The tongue should be a healthy pink to a deep, reddish color with surface papillae present, without swelling or lesions.
19
Q
A nurse is precepting a newly licensed nurse while he is charting. Use of which of the following abbreviations indicates a need for further teaching? mcg q.d. mL PO
A
q.d.
20
Q
A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed dexamethasone (Prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication? Hypomagnesemia Hyperglycemia Hyponatremia Hyperkalemia
A
Hyperglycemia
Notes: Adverse effects of dexamethasone include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, peptic ulcer disease, and iatrogenic Cushing’s syndrome
21
Q
A nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin? Cyanosis Jaundice Erythema Pallor
A
pallor
22
Q
A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the floor. Which of the following solutions should the nurse use to clean the spill? Isopropyl alcohol Chlorhexidine gluconate (Hibiclens) Chlorine (bleach) Iodophor
A
Chlorine (bleach)
23
Q
A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. Which of the following actions by the new nurse indicates a need for further teaching to prevent lift injuries? Twisting at the waist and shoulders Standing with feet in a wide stance Positioning self-close to the client Using arms and legs to lift
A
Twisting at the waist and shoulders
24
Q
A nurse is caring for a client who is receiving intermittent enteral tube feedings and having diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings? Chill formula prior to administration. Verify feeding tube placement. Reduce the rate of the feedings. Place the client supine during feedings.
A
Reduce the rate of the feedings.
Note: Chilled formula can cause abdominal cramping, nausea, and vomiting; therefore, formula should be administered at room temperature.
displaced tube will not cause diarrhea. Findings associated with tube displacement include coughing, vomiting, and pulmonary aspiration.
The head of the bed should be elevated to at least 30° during the administration of enteral tube feedings to prevent aspiration.
25
A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. Which of the following activities should be included as a learning strategy in the program?
Watch a video discussing healthy meal preparation.
Prepare a healthy meal to serve at the end of class.
Read pamphlets about preparing a healthy meal.
Discuss healthy meal preparation as a class.
Prepare a healthy meal to serve at the end of class.
Notes: Visual learners learn best from strategies that involve sight
Tactile learners learn best by touching and doing
Auditory learners learn best from strategies that involve hearing
26
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A nurse is caring for a client who had a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professionals should attend the client's next interdisciplinary team meeting to address this complication?
Speech pathologist
Occupational therapist
Social worker
Respiratory therapist
```
Speech pathologist
Notes: A speech pathologist identifies clients at risk for aspiration and develops recommendations for therapy.
An occupational therapist works with clients who have limited functional abilities to develop skills that are necessary to complete activities of daily living.
A social worker offers education and counseling to clients and families to provide links to community resources, plan for discharge, or resolve conflict.
A respiratory therapist provides specialized therapy to clients who have respiratory difficulties, such as oxygen therapy, inhalation therapy, administering pulmonary function tests, collection of sputum specimens, and collection of arterial and venous blood specimens.
27
A nurse is caring for an older adult client who has an allergy to sulfa, is taking valproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states, "I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following?
Celecoxib is contraindicated in clients taking valproic acid.
Celecoxib is contraindicated in older adults.
Celecoxib is contraindicated in clients with a seizure disorder.
Celecoxib is contraindicated in clients with an allergy to sulfonamide.
Celecoxib is contraindicated in clients with an allergy to sulfonamide.
Notes: Celecoxib (Celebrex) is a nonsteroidal anti-inflammatory, cyclooxygenase-2 (COX-2) inhibitor, which is indicated to relieve some manifestations caused by rheumatoid arthritis and osteoarthritis in adults
28
A nurse is caring for a client who has nausea and a prescription for promethazine (Phenergan) 25 mg IM. Which of the following is appropriate when preparing a medication for administration from an ampule?
Use a filter needle to administer the promethazine.
Expel air bubbles back into the ampule.
Set the ampule on a flat surface to withdraw the promethazine.
Break the ampule toward the body.
Set the ampule on a flat surface to withdraw the promethazine.
Notes: A filter needle should be used to withdraw the medication from the ampule
Expelling air bubbles back into the ampule creates pressure in the ampule, which forces the medication out, wasting it. Air bubbles should be expelled by removing the needle from the ampule and tapping the side of the syringe, then pulling back on the plunger, and finally pushing the plunger up gently to remove the air.
To withdraw the medication, the ampule can be set on a flat surface or held upside down, tilted at a slight angle. After the ampule is broken, the rim is considered contaminated and should not be touched with the needle
The ampule should be broken away from the body to prevent injury from the shattering glass.
29
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A nurse is caring for a client who has cancer. The client has decided to stop treatment and requests a referral to hospice. By making the referral as requested, the nurse is illustrating which of the following ethical principles?
Justice
Autonomy
Veracity
Fidelity
```
```
Autonomy
Notes: Justice is the use of fairness
Autonomy is respecting the client's right to make personal health care decisions
Veracity is the act of truth-telling.
Fidelity is the act of keeping promises.
```
30
A nurse in a local clinic is caring for a female client who is 35 years old. Which of the following screenings should the nurse recommend to the client?
Mammogram every year to detect breast cancer
Colonoscopy every 10 years to detect colon cancer
Dermatologist evaluation every 3 years to detect skin cancer
Complete eye examination every year to detect eye disorders
Dermatologist evaluation every 3 years to detect skin cancer
Notes: Women ages 40 or older should have annual mammograms.
Men and women ages 50 and older should have a colonoscopy every 10 years.
Men and women between the ages of 20 and 40 should have a skin cancer screening by a dermatologist every 3 years. Clients above the age of 40 should have annual evaluations.
Clients between the ages of 40 and 64 should have a complete eye examination every 2 years, and clients older than 65 should have a complete eye examination annually.
31
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A nurse in a provider's office is orienting a newly licensed nurse on how to position a client for a vaginal examination. The nurse should include in the teaching to place the client in which of the following positions?
Lithotomy
Dorsal recumbent
Prone
Lateral recumbent
```
Lithotomy
Notes: lithotomy position allows for insertion of the vaginal speculum and facilitates exposure of the female genitalia
dorsal recumbent position can be used as an alternative to the supine position when assessing the head and neck, lungs, breasts, axillae, heart, and abdomen
prone position is used to assess hip joint extension, skin, and buttocks.
lateral recumbent position is used to detect heart murmurs when assessing the heart.
32
A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in discussion with the client?
Acupuncture is loosely regulated by the federal government.
Acupuncture has been discredited by scientific research.
Acupuncture is thought to be effective only as a placebo.
Acupuncture has been proven to reduce pain and increase function.
Acupuncture has been proven to reduce pain and increase function.
33
A nurse is working with the information technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. Which of the following could result in a violation of client confidentiality?
Placement of computer systems in restricted areas
Installation of firewall software on each computer
Ability of staff to access electronic health records of clients throughout the facility
Occurrence of an automatic log-off after a period of inactivity
Ability of staff to access electronic health records of clients throughout the facility
34
A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should be the nurse's priority goal?
Support the client's relationship with his caregivers.
Encourage the client to express his feelings.
Determine who is responsible for the abuse.
Protect the client from further abuse.
Protect the client from further abuse.
35
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A nurse is caring for a client following a bronchoscopy. Which of the following findings requires immediate intervention?
Painful swallowing
Hoarse voice
Difficulty breathing
Blood-tinged sputum
```
Difficulty breathing
Notes: Painful swallowing is an expected finding following a bronchoscopy. The swallowing reflex is usually blocked for about 6 hr after the procedure
A hoarse voice is an expected finding following a bronchoscopy. The client may complain of hoarseness after the bronchoscopy because of the trauma to tissue of the larynx and the trachea
The difficulty in breathing can be caused by edema in the larynx or trachea and is a serious complication.
Blood-tinged mucous and sputum is an expected finding following the procedure because of trauma of the tissue of the larynx, trachea, or bronchi when the bronchoscope is inserted
36
A nurse on the coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client is stabilized, she asks the nurse why she had to be transferred to a unit where her family will be unable to stay with her all the time. Which of the following responses is appropriate?
"I know this must be frightening, but you are going to be fine."
"Let's talk for a minute about your concerns."
"You were transferred because it is in your best interest."
"Why do you feel a family member should be with you?"
"Let's talk for a minute about your concerns."
37
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires the nurse preceptor to intervene?
Including in a client's nurses' note that an incident report was completed after a medication error
Drawing horizontal lines through blank spaces left in the nurses' notes followed by a signature
Refusing to chart the vital signs taken by another nurse on a client's graphic flow sheet
Documenting the provider was contacted to clarify a questionable prescription
Including in a client's nurses' note that an incident report was completed after a medication error
38
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A nurse is caring for a client who is diagnosed with active pulmonary tuberculosis and is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol?
Loss of color discrimination
Nausea and vomiting
Red-orange discoloration to body fluids
Edema of feet and hands
```
Loss of color discrimination
39
A nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheostomy. Which of the following behaviors by the client best indicate to the nurse that teaching has been effective?
Self-reporting the ability to perform the procedure
Answering appropriately when questioned orally
Responding accurately on a written examination
Demonstrating independent performance of the procedure
Demonstrating independent performance of the procedure
40
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A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should be the nurse's first action?
Inform the nurse manager.
Determine the client's condition
Notify the provider.
Complete an incident report.
```
Determine the client's condition.
41
A nurse is reinforcing teaching about transdermal nitroglycerin (Nitro-Dur) to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective?
"I should leave the patch on for 16 to 20 hours each day."
"I will apply a new patch in the same location each day."
"The patch should be effective within an hour of being applied."
"The medication is not absorbed as well when placed on the abdomen."
"The patch should be effective within an hour of being applied."
Notes: The client should only wear the patch for 12 to 14 hr each day for the medication to remain effective and prevent the development of tolerance.
The patch should be applied to a new location each day to prevent development of local irritation.
Upon application of the patch, the medication becomes effective within 20 to 60 min and lasts until the patch is removed.
Adequate results are attained when the patch is applied to the chest, back, abdomen, or anterior thigh.
42
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A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration. Which of the following findings requires immediate intervention?
Blood glucose 150 mg/dL
Potassium 2.5 mEq/L
Total protein 5.2 g/dL
Urine specific gravity 1.040
```
Potassium 2.5 mEq/L
43
A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client?
Raising her voice level when speaking to the client
Asking the client open-ended questions
Clarifying client statements with the family as needed
Having the client use eye blinks to indicate yes or no
Having the client use eye blinks to indicate yes or no
44
A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include?
Medications will eliminate HIV in most clients.
Adolescents are at a lower risk for developing HIV.
Initial HIV symptoms are often similar to the flu.
Using condoms ensures the prevention of HIV during sexual intercourse.
Initial HIV symptoms are often similar to the flu.
45
A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. For which of the following responses by the client should the nurse postpone teaching?
States that pain is an 8 on a scale of 0 to 10
States that her partner should be given the information
Expresses concern about the exercises causing pain when performed after surgery
Expresses uncertainty about the benefits of the exercises
States that pain is an 8 on a scale of 0 to 10
46
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A nurse is collecting data on four clients. Which of following is the highest priority finding by the nurse?
Malaise
Anorexia
Headache
Diarrhea
```
Diarrhea
47
A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first?
A client who has peripheral vascular disease and reports numbness in the toes
A client who has depression and is easily distracted
A client who has Alzheimer's disease and is unable to complete activities of daily living
A client who had abdominal surgery 10 days ago and reports feeling his incision pop
A client who had abdominal surgery 10 days ago and reports feeling his incision pop
48
A nurse is preparing to administer oral medications to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse?
Administer medications with meals when possible.
Ensure client understanding of medication's effects.
Determine the client's ability to self-administer medications.
Have the client position the head with the chin down while swallowing.
Have the client position the head with the chin down while swallowing.
49
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A nurse is conducting therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider?
Lithium carbonate 0.8 mEq/L
Digoxin 3.0 ng/mL
Peak serum gentamicin 6 mcg/mL
Magnesium sulfate 4 mEq/L
```
Digoxin 3.0 ng/mL
50
A nurse is caring for a client who has a urinary tract infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take first?
Ensure all four side rails are up.
Administer a prescribed sedative.
Place the client in soft wrist restraints.
Move the client to a room near the nurses' station.
Move the client to a room near the nurses' station.
51
A nurse is reinforcing discharge teaching to a new mother regarding sudden infant death syndrome (SIDS). Which of the following is the highest priority to include in the instructions?
Place the infant in a supine position when sleeping.
Place the infant on a firm mattress when sleeping.
Avoid covering the infant with loose bedding while sleeping.
Avoid leaving stuffed animals in the crib with the sleeping infant.
Place the infant in a supine position when sleeping.
52
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A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first?
Obtain an ECG.
Administer oral potassium.
Encourage potassium-rich foods.
Monitor I & O.
```
Obtain an ECG.
53
A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first?
Place O2 at 2 L per nasal canula on the client.
Place the client in the orthopneic position.
Perform chest percussion.
Perform nasotracheal suctioning.
Place the client in the orthopneic position.
54
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A nurse is collecting data on four clients. Which of the following findings is the most urgent?
Bladder distension and urgency
Pedal edema
Warmth and pain in the calf
Hypoactive bowel sounds
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Warmth and pain in the calf
55
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A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first?
Initiate oxygen therapy.
Encourage an increase in oral fluids.
Provide room humidification.
Assist client to cough effectively.
```
Assist client to cough effectively.
56
A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first?
Provide assistance with ambulation when indicated.
Determine the mobility status of each client.
Maintain the side rails of each bed in the raised position.
Plan a fall prevention program for clients at risk.
Determine the mobility status of each client.
57
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A nurse is reviewing the lab results for four clients. The client with which of the following values requires immediate intervention?
Cholesterol 220 mg/dL
Platelets 95,000 mm3
BUN 20 mg/dL
Potassium 3.5 mEq/L
```
Platelets 95,000 mm3
58
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A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's station is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse take first?
Check on the client.
Unlock the crash cart.
Begin cardiopulmonary resuscitation.
Announce a code.
```
Check on the client.
59
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A nurse is caring for a client who is in the immediate postoperative period following a tracheotomy. Which of the following is the nurse's priority action?
Providing pain control
Preventing hemorrhage
Maintaining a patent airway
Ensuring adequate fluid intake
```
Maintaining a patent airway
60
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A newly hired nurse is reviewing the facility's emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide priority care to clients who are in which of the following categories during a disaster?
Immediate
Delayed
Minimal
Expectant
```
Immediate
61
A nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern?
A client who has a history of heart failure
A client who has type 1 diabetes mellitus
A client who is reporting pain associated with osteoarthritis of the knees
A client who is having a nosebleed associated with hypertension
A client who is having a nosebleed associated with hypertension
62
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A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for a fluid volume deficit?
Obtain an arterial pH level.
Check the heart rate and blood pressure.
Insert an indwelling catheter.
Collect a serum BUN and creatinine
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Check the heart rate and blood pressure.
63
A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take?
Administer an anticoagulant.
Check the leg for warmth and edema.
Apply elastic stockings.
Promote bed rest and extremity elevation.
Check the leg for warmth and edema.
64
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A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first?
Homelessness
Lack of family support
Hypoxic
Under nourished
```
Hypoxic
65
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A nurse is caring for a client who is immobile and has developed a pressure ulcer. Which of the following characteristics is associated with a stage II pressure ulcer?
Partial thickness skin loss
Visible subcutaneous fat
Non-blanchable redness
Exposed muscle
```
Partial thickness skin loss
Notes: A stage I pressure ulcer involves intact skin with a localized area of non- blanching redness.
A stage II pressure ulcer involves partial thickness skin loss and typically presents as an abrasion or blister.
A stage III pressure ulcer involves full-thickness skin loss and can have visible subcutaneous fat.
A stage IV pressure ulcer involves full-thickness tissue loss and exposed bone, tendon, or muscle. Slough or eschar can also be present.
66
A nurse is preparing to measure the blood pressure of a client who has hypertension. Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading?
Wrapping the cuff loosely around the arm
Using a cuff that is too wide
Leaving client's arm unsupported
Taking client's blood pressure immediately after client sits down
Using a cuff that is too wide
67
```
A nurse is caring for a client who is receiving vancomycin (Vancocin) for a beta-hemolytic streptococci infection. For which of the following adverse effects should the nurse monitor?
Respiratory depression
Hearing loss
Hypertension
Bradycardia
```
Hearing loss (Ototoxicity)
Notes:
nephrotoxicity
68
```
A nurse is preparing to administer a tap water enema to a client. In which of the following positions should the nurse place the client?
Lithotomy
Dorsal recumbent
Prone
Sims'
```
Sims'
69
```
A nurse is caring for a client who has been prescribed a full liquid diet. Which of the following is appropriate to include in the client's diet? (Select all that apply)
Cooked oatmeal
Grape juice
Applesauce
Ice cream
Smooth peanut butter
```
Grape juice
| Ice cream
70
```
A nurse in a provider's office is caring for a client who has depression and is taking St. John's Wort. The herbal supplement is thought to improve which of the following?
Mood
Immunity
Memory
Vitality
```
Mood
Note: Immunity, Echinacea
Memory, Ginkgo biloba
Vitality, Ginseng
71
```
A nurse is performing a respiratory examination on a client who has pneumonia. Which of the following sounds should be elicited over areas of consolidation during percussion?
Dullness
Hyper-resonance
Resonance
Tympany
```
Dullness
Notes: Percussion over dense tissue or a fluid-filled body cavity produces a thud-like sound, which is described as dullness
Percussion over emphysematous lungs produces a booming sound, which is described as hyper-resonance.
Percussion over healthy lung tissue produces a hollow sound, which is described as resonance.
Percussion over an air-filled stomach produces a drum-like sound, which is described as tympany.
72
```
A nurse is assisting with the admission of a client who is scheduled for a surgical procedure. The nurse administers a prescribed dose of lorazepam (Ativan) preoperatively. Which of the following statements by the client indicates the medication has been effective?
"I am wide awake now."
"My mouth is very dry."
"I feel very relaxed."
"My heart is racing."
```
"I feel very relaxed."
73
```
A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle?
1/2 inch
5/8 inch
1 inch
1 1/2 inch
```
1 1/2 inch
Notes: A 1/2 inch needle is used for subcutaneous injections in adults
A 5/8 inch needle is used for subcutaneous injections in adults
A 1 inch needle is used for IM injections in adults who have a low BMI
74
```
A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Which of the following nutritional selections by the client indicates a need for further teaching?
1/2 cup of white rice
1 slice of wheat bread
1 cup of 2% milk
3/4 cup of canned tomato juice
```
3/4 cup of canned tomato juice
75
```
A nurse is caring for a client who is scheduled for a biopsy of a tumor located in the left lower lobe of the lung. The client states, "I will quit smoking if the results don't come back positive for cancer." This statement indicates the client is in which of the following stages of grief?
Anger
Acceptance
Bargaining
Denial
```
Bargaining
76
A nurse is reinforcing teaching to a client who has a fractured ankle and is learning to walk up stairs. Identify the sequence of actions the client should be taught when using a modified 3-point crutch gait.
The first action the client should be taught when using a 3-point crutch gait to go up stairs is to stand and bear weight on the unaffected leg.
The second action the client should be taught when using a 3-point crutch gait to go up stairs is to transfer body weight to the crutches.
The third action the client should be taught when using a 3-point crutch gait to go up stairs is to advance the unaffected leg between the crutches.
The fourth action the client should be taught when using a 3-point crutch gait to go up stairs is to shift weight from the crutches to the unaffected leg.
The fifth action the client should be taught when using a 3-point crutch gait to go up stairs is to align crutches on the stair.
77
```
A nurse is collecting data on a newly admitted client who is reporting abdominal discomfort. When examining the abdomen, which of the following techniques should the nurse perform first?
Percussion
Palpation
Auscultation
Inspection
```
Inspection
78
```
A nurse is preparing to transfer a client from the bed to a chair. The nurse should take which of the following actions to prevent a lift injury?
Lock knees.
Stand close to the client.
Keep feet close together.
Move client by twisting at the waist.
```
Stand close to the client.
79
```
A nurse is reinforcing teaching to a client who is newly diagnosed with Lyme disease. The nurse should include that the disease is transmitted in which of the following ways?
Vector
Airborne
Vehicle
Bloodborne
```
Vector
80
A nurse is preparing to auscultate a client's heart. Which of the following positions is best for detecting a low-pitched diastolic murmur?
lateral recumbent position
81
A charge nurse is assembling a list of clients who can be safely discharged home to accommodate incoming casualties following an earthquake. The nurse should recognize that it is unsafe to discharge which of the following clients?
A client who has osteomyelitis and will require 6 weeks of IV antibiotic therapy
A client who has Crohn's disease and is 1 day preoperative for an ileostomy
A client who has Alzheimer's disease and is awaiting placement in a long-term care facility
A client who has an ileus following spinal surgery 5 days ago and is ambulatory in a brace
A client who has an ileus following spinal surgery 5 days ago and is ambulatory in a brace
82
A home health nurse is performing an assessment of an older adult client's home. Which of the following findings should the nurse recognize as a potential hazard?
Hot water temperature set at 46° C (115° F)
A night light in each room of the house
A secured, large area rug in the living room
Wires to the television tunneled under the carpet
Wires to the television tunneled under the carpet
83
```
A nurse is responding to a community-wide request for health care providers to come to the scene of an explosion. When using the North Atlantic Treaty Organization triage system, the nurse should put which of the following tags on a client who is unresponsive and has third-degree burns over 75% of her body?
Red
Yellow
Green
Black
```
Black
84
```
A nurse manager at a clinic for clients who are homeless notes that many of the clients have a history of mental illness and substance use disorder. While compiling figures for a regulatory agency about the clients who visit the clinic, the nurse should classify these clients as having which of the following conditions?
Codependency
Bipolar disorder
Comorbidity
Somatization disorder
```
Comorbidity
Notes:
Codependency is a set of maladaptive, compulsive behaviors learned by family members to survive in an emotionally painful and stressful environment.
bipolar disorder is a mood disorder characterized by the occurrence of mania alternating with episodes of depression.
Comorbidity is the presence of more than one disease or health condition in an individual at a given time.
Somatization disorder is a psychiatric condition manifesting as a physical complaint. Internal psychological conflicts are unconsciously expressed as physical manifestations.
85
A public health nurse is caring for an older adult client who has chronic airflow limitation disease and is a former cigarette smoker. The client's medications include ipratropium bromide and albuterol inhalers, and she has a new prescription for home oxygen to use as needed. The nurse should recognize that this client's primary prevention needs include which of the following?
Periodic pulmonary function tests
Review of appropriate use of oxygen in the home
Yearly mammography examinations
Annual influenza immunizations
Annual influenza immunizations
86
A home health nurse is caring for a client who is living in a mental health group home. During a visit, the nurse discovers that the client has been hoarding psychotropic medications. Which of the following actions should the nurse take first?
Have the client transported to an acute care facility.
Determine the reason for the client's hoarding behavior.
Alert the staff that has been administering the client's medications.
Require the client to return any hoarded medications.
Determine the reason for the client's hoarding behavior.
87
A nurse is providing teaching to a client who has a prescription for ciprofloxacin following exposure to anthrax. Which of the following statements by the client indicates that further teaching is required?
"I will limit my intake of coffee, tea, or cola beverages."
"I will wear a large-brim hat and long sleeves if I am out in the sun."
"I will take the ciprofloxacin with an antacid if I get an upset stomach."
"I will avoid taking ciprofloxacin along with dairy products."
"I will take the ciprofloxacin with an antacid if I get an upset stomach."
Notes: avoid caffeine while taking ciprofloxacin because it can trigger adverse effects of the nervous system, including irritability, anxiety, and restlessness.
A common adverse effect of ciprofloxacin is extreme photosensitivity, so clients taking ciprofloxacin must avoid sun exposure to prevent sunburns and blistering.
Taking ciprofloxacin with antacids can impair the absorption of the medication, reducing its effectiveness.
Taking ciprofloxacin with dairy products can impair the absorption of the medication, reducing its effectiveness,
88
```
A community health nurse is preparing a disaster preparedness plan about smallpox. Which of the following groups of people should the nurse include in the plan to inoculate?
Newborns
Mortuary workers
Immunosuppressed clients
Clients who have eczema
```
Mortuary workers
89
A charge nurse in an emergency department is notified by the county's emergency medical services that there has been a multiple-casualty crash involving a truck carrying radioactive waste. Which of the following actions should the nurse take first?
Designate a decontamination area to accommodate clients who are irradiated.
Notify the admissions office to clear as many critical care beds as possible.
Clear the department of all nonurgent clients and move those awaiting admission to a holding area.
Determine the number of casualties the emergency department can accommodate.
Clear the department of all nonurgent clients and move those awaiting admission to a holding area.
90
A nurse is teaching a community group about smallpox. When discussing the possible means of transmission, which of the following statements by a member of the group indicates that further teaching is required?
"Smallpox can be transmitted through bodily fluids, such as blood or vomit."
"Smallpox can be transmitted through contaminated objects, such as bedding and clothing."
"Smallpox can be transmitted through bites from insects, such as mosquitoes."
"Smallpox can be transmitted through inhalation of droplets, such as from coughing."
"Smallpox can be transmitted through bites from insects, such as mosquitoes."
91
A nurse is working in the triage area of an emergency department. Which of the following activities is unlikely to be the nurse's responsibility in this setting?
Fostering positive public relations for the facility
Performing a comprehensive client assessment
Preventing cross contamination of infectious clients
Educating a client and his family
Educating a client and his family
92
```
A nurse is caring for several clients who have become ill after a company picnic. After extensive interviews and a review of the food handling practices, the nurse determines that the most likely cause of the illnesses was a poultry dish that had been allowed to cool for several hours before being served. The nurse is performing which of the following steps in the epidemiological process?
Planning
Assessing
Implementing
Evaluating
```
Assessing
93
An industrial health nurse is caring for a client who states, "I have been under a lot of stress lately." When the nurse suggests stress management techniques, the client calmly states that he has a pistol in his car and intends to take his life in the parking lot after work that day. Which of the following actions should the nurse take?
Have the industrial facility's security officers search the client's car and remove the pistol.
Call emergency medical services to transport the client to a proper treatment facility.
Contact the client's family member to pick him up from work and take him for treatment.
Explore with the client the reasons he feels that he has no options except suicide.
Call emergency medical services to transport the client to a proper treatment facility.
94
A nurse is providing psychological counseling at a community center for families whose loved ones died in a fire. After learning that both of their children died in the fire, two parents express disbelief at the loss of their children. One parent states, "How will I make it through this?" Which of the following is an appropriate response by the nurse?
"Are you feeling overwhelmed right now?"
"Don't worry. You will have plenty of help."
"Can I call someone to be here with you?"
"Anyone who has experienced a loss like this would feel that way."
"Are you feeling overwhelmed right now?"
95
A triage nurse is in an emergency department when several hundred clients who were injured in a train collision arrive at the facility for treatment. The nurse should determine that which of the following clients requires immediate treatment?
A client who has neck pain and was transported to the facility on a backboard
A client who has epigastric and left-arm pain and is diaphoretic
A client who has nasal and orbital ecchymosis and a respiratory rate of 16/min
A client who has abdominal pain and is 2 months pregnant
A client who has epigastric and left-arm pain and is diaphoretic
96
```
A nurse is performing a community assessment in a rural setting. Which of the following types of health care should the nurse recognize is most likely to be absent in this setting?
Tertiary care
Primary prevention
Chronic care
Secondary prevention
```
Tertiary care
97
A charge nurse in an emergency department is informed that a tornado touched down in a nearby town and mass casualties are en route. Which of the following actions should the nurse take first?
Follow facility policy to activate the disaster plan.
Prepare the triage rooms.
Obtain additional supplies.
Call in off-duty staff.
Follow facility policy to activate the disaster plan.
98
A nurse is planning to participate in a public education program about prevention of West Nile virus. Which of the following instructions should the nurse include in her presentation?
"Eliminate sources of standing water."
"Make sure your immunizations are up to date."
"Keep all of your pets indoors."
"Spray insect nests with a repellant that contains DEET."
"Eliminate sources of standing water."
99
```
A nurse is providing teaching to a community group who lives near a nuclear power plant about safety related to radiation exposure. A client asks, "Isn't there something we should have on hand in case of a nuclear disaster?" The nurse should recognize that the client is referring to which of the following substances?
Potassium iodide
Potassium cyanide
Ciprofloxacin
Atropine
```
Potassium iodide
Notes:Potassium iodide, if taken in time and at the appropriate dosage, blocks the thyroid gland's uptake of radioactive iodine
Potassium cyanide is one of the most lethal poisons known and can cause death within minutes
Ciprofloxacin is an antibiotic used to treat certain infections caused by bacteria, such as pneumonia, gonorrhea, infectious diarrhea, typhoid fever, and inhalation anthrax (after exposure), as well as bone, joint, skin, and urinary tract infections.
Atropine is an anticholinergic agent used to reverse the effects of nerve gas exposure caused by gases such as sarin, tabun, and soman.
100
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?
"I should expect my heart rate to take longer to return to normal after exercise as I get older."
"Urinary incontinence is something I will have to live with as I grow older."
"I can expect to have less ear wax as I get older."
"My stomach will empty more quickly after meals as I grow older."
"I should expect my heart rate to take longer to return to normal after exercise as I get older."
101
A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect?
Frequent bowel sounds with flatus
Absent bowel sounds with distention
Hyperactive bowel sounds with diarrhea
Normal bowel sounds with increased peristalsis
Absent bowel sounds with distention
| Note: Paralytic Ileus is an immobile bowel
102
```
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2° C (102.6° F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?
Heart rate 105/min
Soft, nontender abdomen
Temperature
Overdue menses
```
Temperature
103
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
Encourage the child to cough frequently to clear congestion from anesthesia.
Place a heating pad at the child's neck for comfort.
Administer analgesics to the child on a routine schedule throughout the day and night.
Provide the child with ice cream when oral intake is initiated.
Administer analgesics to the child on a routine schedule throughout the day and night.
Notes: discouraged from coughing or clearing the throat following a tonsillectomy because these actions can contribute to bleeding.
offer an ice collar
Milk products, such as ice cream and pudding, are avoided because they coat the mouth and throat, causing the child to clear the throat. Ice chips and ice pops are usually the first items offered following a tonsillectomy.
104
```
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?
Audible click
Murmur
Third heart sound
Pericardial friction rub
```
Pericardial friction rub
Notes:
audible clicking sound occurs in clients who have prosthetic valve replacement surgery.
heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts
third heart sound is a low-pitched sound after the second heart sound. An S3 is caused by rapid ventricular filling during diastole.
105
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands."
"I will use cold water when I wash my hands to protect my skin from becoming too dry."
"I will apply friction for at least 10 seconds while washing my hands."
"After washing my hands I will dry them from the elbows down."
"There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands."
Notes: washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.
Hand hygiene should be performed with warm water
friction should be applied for at least 15 to 20 seconds.
Drying should be performed from the cleanest area (fingertips) to the least clean area (forearms)
106
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
Turn on the machine every 15 min to measure the client's blood pressure.
Record only blood pressure readings needed for the 15-min intervals.
Obtain manual and automatic readings and compare them.
Disconnect the machine, and measure the blood pressure manually every 15 min.
Disconnect the machine, and measure the blood pressure manually every 15 min.
107
A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?
The involvement of the client in planning the change
The emphasis the provider places on the dietary changes
The learning theory the nurse uses to teach the dietary changes
The extent of the dietary changes planned for the client
The involvement of the client in planning the change
108
```
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?
Rectal
Tympanic
Oral
Temporal
```
Temporal
Notes:
The oral route is not appropriate for use with children under the age of 3.
109
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?
The client fully understands the provider's explanation of the procedure.
The client has been informed about the risks and benefits of the procedure.
The nurse witnessed the provider's explanation of the procedure.
The signature on the preoperative consent form is the client's.
The signature on the preoperative consent form is the client's.
110
```
A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?
Assessment
Plan of care
Nursing interventions performed
Evaluation of progress
```
Assessment
111
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
The nurse washes each part of her hands with 5 strokes.
The nurse washes from the elbows down to the hands.
The nurse washes with her hands held higher than her elbows.
The nurse uses minimal friction when washing her hands.
The nurse washes with her hands held higher than her elbows.
Notes: Surgical scrubbing requires the nails be scrubbed with 15 strokes and each other part of the hand with 10 strokes.
scrub the hands first, then work toward the elbows.
hands held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.
The use of mechanical friction is necessary to decontaminate the skin effectively.
112
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take?
Measure the pulse using a Doppler ultrasound stethoscope.
Check the client's pedal pulses.
Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
Take the pulse at each peripheral site and count the rate for 30 seconds.
Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
113
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?
Fifth intercostal space just medial to the midclavicular line
Second intercostal space to the left of the sternum
Fifth intercostal space to the left of the sternum
Second intercostal space to the right of the sternum
Second intercostal space to the right of the sternum
114
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?
"It's for your safety. Dentures can slip and block your airway during surgery."
"You wouldn't want your teeth to be lost or broken during surgery, would you?"
"The anesthesiologist requires everyone to remove their dentures."
"What worries you about being without your teeth?"
"What worries you about being without your teeth?"
115
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?
Change the topic because the client is trying to divert attention from the illness to the nurse.
Encourage the client to express his thoughts about death and dying.
Tell the client that religious beliefs are a personal matter.
Offer to contact the client's minister or the facility's chaplain.
Encourage the client to express his thoughts about death and dying.
116
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
"Tell me what I can do to help you overcome your fear of giving yourself injections."
"I am sure your provider will not be pleased that you refuse to give yourself insulin injections."
"It's okay. I'm sure your partner will be able to learn how to give you the insulin injections."
"You won't be able to go home unless you learn to give yourself insulin injections."
"Tell me what I can do to help you overcome your fear of giving yourself injections."
117
```
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?
Call for assistance.
Begin chest compressions.
Confirm unresponsiveness.
Give rescue breaths
```
Confirm unresponsiveness.
118
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?
Holding a community clinic to administer influenza immunizations.
Screening groups of older adults in nursing care facilities for early influenza manifestations.
Educating parents of young children about dangers of influenza.
Finding rehabilitation programs for older adults who have complications from influenza.
Screening groups of older adults in nursing care facilities for early influenza manifestations.
119
```
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?
Open all sterile supplies and solutions.
Stabilize the tracheostomy tube.
Don sterile gloves.
Perform hand hygiene.
```
Perform hand hygiene.
120
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?
Auscultate for the blood pressure at the dorsalis pedis artery.
Measure the blood pressure with the client sitting on the side of the bed.
Place the cuff 7.6 cm (3 in) above the popliteal artery.
Place the bladder of the cuff over the posterior aspect of the thigh.
Place the bladder of the cuff over the posterior aspect of the thigh.
Notes: auscultate for the blood pressure at the popliteal artery.
measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed.
position the cuff 2.5 cm (1 in) above the popliteal artery.
121
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?
Explain the x-ray procedure to the client.
Help the client into a wheelchair before the transporter arrives.
Ask if the client has any questions.
Identify the client using two identifiers.
Identify the client using two identifiers.
122
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?
Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink.
Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back.
Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression.
Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers.
Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back.
123
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
"Drink a minimum of 1,000 milliliters of fluid daily."
"Increase your intake of refined-fiber foods."
"Sit on the toilet 30 minutes after eating a meal."
"Take a laxative every day to maintain regularity."
"Sit on the toilet 30 minutes after eating a meal."
Notes: consume a minimum of 1,500 mL of fluid
increase consumption of coarse-fiber and whole grain
"Take a laxative every day to maintain regularity."
124
```
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?
Identify goals for client care.
Obtain client information.
Document nursing care needs.
Evaluate the effectiveness of care.
```
Obtain client information.
125
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?
Stand toward the client's stronger side.
Instruct the client to lean backward from the hips.
Place the wheelchair at a 45° angle to the bed.
Assume a narrow stance with feet 15 cm (6 in) apart.
Place the wheelchair at a 45° angle to the bed.
126
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss?
Attempt to increase the clients' self-motivation.
Keep detailed records of each client's progress.
Test client learning after each teaching session.
Avoid discussing areas that might cause client anxiety.
Attempt to increase the clients' self-motivation.
127
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
Tie the restraints to the side rails.
Perform range-of-motion exercises to the wrists every 3 hr.
Remove the restraints one at a time.
Obtain a PRN prescription for the restaints.
Remove the restraints one at a time.
Notes: range-of-motion exercises are performed every 2 hr.
Restraint prescriptions can only be written for a 24-hr period and cannot be a PRN prescription.
should not tie the restraints to the side rails because this can injure the client if the rails are lowered.
128
A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?
Contact the family and ask them to stay with the client.
Offer to call the client's minister.
Sit and hold the client's hand.
Leave the room and allow the client to cry privately.
Sit and hold the client's hand.
129
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
"My parents are retired, and they have come to help out with our children."
"I am going to ask my husband to go to counseling with me."
"I keep having nightmares about my upcoming surgery."
"My girlfriends bought me a nice wig."
"I keep having nightmares about my upcoming surgery."
130
perform the abdominal assessment
inspect, auscultate, percuss, and then palpate
131
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
Obtaining hydrogen peroxide for the tracheostomy care
Obtaining cotton balls for the tracheostomy care
Obtaining sterile gloves for the tracheostomy care
Obtaining a sterile brush for the tracheostomy care
Obtaining cotton balls for the tracheostomy care
132
```
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?
Evaluate pedal pulses.
Obtain a medical history.
Measure vital signs.
Assess for leg pain.
```
Evaluate pedal pulses.
133
A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take?
Tell the client it is too late for her to change her mind because the surgery is already scheduled.
Telephone the operating room and cancel the surgery.
Inform the client's family about the situation.
Notify the provider about the client's decision.
Notify the provider about the client's decision.
134
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client?
"Ask your provider to prescribe epoetin before the surgery."
"You should ask your provider about taking iron supplements prior to the surgery."
"Request a family member to donate blood for you."
"Donate autologous blood before the surgery."
"Donate autologous blood before the surgery."
Note: Epoetin is a hematopoietic growth factor used for the treatment of anemia. While taking epoetin prior to surgery can boost the client's hematocrit levels
While taking an iron supplement prior to surgery can boost the client's hemoglobin levels
A blood donation from a family member does not eliminate the risk of acquiring an infection.
Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection.
135
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
The client asks the nurse to repeat the instructions before attempting the exercises.
The client reports severe pain.
The client asks the nurse how often deep breathing should be done after surgery.
The client tells the nurse that this exercise will probably be painful after surgery.
The client reports severe pain.
136
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
Wash the gloved hands and then throw the gloves away.
Prepare an incident report to document the event.
Carefully remove the gloves and follow with hand hygiene.
Ask the provider to order a blood culture to determine the risk of infection.
Carefully remove the gloves and follow with hand hygiene.
137
A nurse observes assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
"The reading will be inaudible if the cuff is too small for the client."
"The width of the cuff bladder should be 75% of the circumference of the client's arm."
"As long as the cuff will circle the arm the reading will be accurate."
"Using a cuff that is too small will result in an inaccurately high reading."
"Using a cuff that is too small will result in an inaccurately high reading."
Notes:
blood pressure reading for a client who is obese may be difficult to hear with any cuff, a cuff that is too small for the client will not yield an inaudible reading.
width of the cuff bladder should be 40% of the circumference of the client's arm.
cuff that is an incorrect size for the client will not yield an accurate reading.
Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement.
138
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed?
Lock the wheels on the bed and stretcher.
Instruct the client to raise his arms above his head.
Elevate the stretcher 2.5 cm (1 in) above the height of the bed.
Log roll the client.
Lock the wheels on the bed and stretcher.
Notes: cross his arms across his chest to prevent injuring the arms during the transfer.
should be no more than 1.3 cm (0.5 in) above the height of the bed.
Logrolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine
139
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?
Place the client supine.
Keep both side rails up.
Raise the level of the bed.
Inspect the client's mouth using a finger sweep.
Raise the level of the bed.
140
A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?
Irrigate the tubing with sterile normal water once each shift.
Cleanse the opening with soap and water after emptying.
Maintain the tubing above the level of the surgical incision.
Collapse the device of air after emptying.
Collapse the device of air after emptying.
Notes: collapse the device of air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device, maintain the drainage tubing below the level of the incision to enhance drainage, cleanse the drain opening with an alcohol wipe after opening it to decrease entry of microorganisms, keep the diaphragm of the device compressed to maintain suction and prevent clotting of sanguineous drainage.
141
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A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?
Calibrate the scales weekly.
Use a different scale each time.
Weigh the client on arising.
Weigh the client without clothing.
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Weigh the client on arising. (After voiding and before breakfast), weigh the client using the same scale each time, calibrate the scales to 0 each day or before each use to provide accurate information, have the client's weight taken wearing the same type of clothing
142
A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?
A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask
A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula
A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar
A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula.
A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask
143
A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?
Place an oxygen mask on the client.
Check the client's pulse.
Determine whether the client is able to breathe.
Wrap arms around the client from behind.
Determine whether the client is able to breathe.
144
A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take?
Don clean gloves to remove the old dressing.
Loosen the dressing by pulling the tape away from the wound.
Remove the entire old dressing at once.
Open sterile supplies after applying sterile gloves.
Don clean gloves to remove the old dressing.
Notes: remove the tape by loosening and pulling toward the wound or dressing to decrease tension or stress on the healing wound edges, remove the old dressing one layer at a time to prevent the removal of drains, open the sterile supplies after the removal of the old dressings, after washing her hands, and before applying sterile gloves
145
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?
Hold the irrigator 1.25 cm (0.5 in) above the eye.
Direct the irrigation solution upward toward the upper eyelid.
Exert pressure on the bony prominences when holding the eyelids open.
Direct the irrigation from the outer canthus to the inner canthus of the eye.
Exert pressure on the bony prominences when holding the eyelids open.
Notes: hold the irrigator 2.5 cm (1 in) above the eye, direct the irrigation solution onto the lower conjunctiva sac, should hold the upper lid against the eyebrow and the lower lid against the cheekbone, direct the irrigation solution from the inner canthus to the outer canthus of the eye
146
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take?
Maintain suction while removing the NG tube.
Instill 100 mL of air into the NG tube before removal.
Pinch the NG tube while removing the tube.
Instruct the client to breathe in and out during the removal of the NG tube.
Pinch the NG tube while removing the tube.
Notes: disconnect the NG tube from the suction apparatus before removal,
instill 50 mL of air into the tube to clear the contents of gastric drainage,
pinch the NG tube while removing the tube, instruct the client to take a deep breath and to hold it during the removal of the NG tube to close off the glottis
147
A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?
Applies sterile gloves to open catheter package
Wipes the labia minora in an anteroposterior direction
Spreads the labia with the dominant hand
Uses one cotton ball to wipe the right and left labia majora
Wipes the labia minora in an anteroposterior direction
Notes: apply sterile gloves after opening the catheter package, wipe anteroposterior both the right and left labia minora, use the nondominant hand to spread the labia, use a separate cotton ball to wipe the right and left labia majora
148
A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?
Speak directly into the client's impaired ear.
Exaggerate lip movements.
Speak loudly.
Face the client when speaking.
Face the client when speaking.
149
A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?
Exhale slowly to reach goal volume.
Hold breath for 5 seconds after goal volume is reached.
Continue to deep breathe between each cycle.
Limit repeat pattern of breathing to 5 breaths.
Hold breath for 5 seconds after goal volume is reached.
Notes: instruct the client to inhale slowly to reach goal volume, instruct the client to hold her breath for 3 to 5 seconds after reaching maximal inspiratory volume, instruct the client to breathe normally for short periods of time between each cycle of breaths,
instruct the client to repeat the patterns for 10 to 20 breaths every hour while awake
150
A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings?
Roll the stocking partially down if too long.
Remove the stocking once per day.
Bunch and pull the stocking halfway up the calf.
Turn the stocking inside out up to the heel before applying.
Turn the stocking inside out up to the heel before applying.
Notes: remove the stockings once every shift to inspect the skin and check circulation, apply another size stocking if the stocking is too long, slide the top of the stocking up over the client's calf
151
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A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?
Apply a fecal collection system.
Apply a barrier cream.
Cleanse and dry the area.
Check the client's perineum.
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Check the client's perineum.
152
A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?
Remove the sleeve of the gown from the arm without the IV line.
Slow the infusion using the roller clamp.
Disconnect the IV line from the pump.
Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown.
Remove the sleeve of the gown from the arm without the IV line.
153
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nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?
Flushing of the skin
Inability of the toddler to cry or speak
Presence of nausea and mild emesis
Capillary refill time 1.5 sec
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Inability of the toddler to cry or speak
| Notes: cyanosis
154
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A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?
Vitamin C and zinc
Vitamin D
Vitamin K and iron
Calcium
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Vitamin C and zinc
Notes: Vitamin D is important when used with calcium to prevent osteoporosis, Vitamin K is important for normal clotting of blood and for impaired intestinal synthesis caused from antibiotics, Calcium is administered to prevent osteoporosis when used with vitamin D
155
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?
Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube.
Position the client on his right side.
Insert the tip of the tubing 8 cm (3.1 in).
Hold the enema container 61 cm (24 in) above the rectum.
Insert the tip of the tubing 8 cm (3.1 in).
Notes: lubricate 5 to 8 cm (2 to 3 in) of the tip of the rectal tube, position the client on the left side in the Sims' position, insert the tip of the tubing 7 to 10 cm (3 to 4 in), hold the enema container a maximum of 45 cm (18 in) above the rectum
156
A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?
Check to determine if the catheter tubing is kinked.
Palpate the bladder.
Obtain a prescription to irrigate the catheter with 0.9% sodium chloride.
Encourage the client to drink more fluids.
Check to determine if the catheter tubing is kinked.
157
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?
Instruct the client to defecate into the toilet bowl.
Transfer the specimen to a sterile container.
Refrigerate the collected specimen.
Place the stool specimen collection container in a biohazard bag.
Place the stool specimen collection container in a biohazard bag.
Notes: client defecate into a bedpan or a container for stool collection, place the stool specimen a clean container using a tongue depressor, send the collected stool specimen immediately to the laboratory after labeling the specimen properly, place the specimen collection container in a biohazard bag with the client label placed on the container and the bag for easy identification
158
A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?
"Does the medication you're taking relieve the pain?"
"Can you point to where the pain is the worst?"
"What do you think caused the onset of your pain?"
"Changing positions makes your pain worse, right?"
"What do you think caused the onset of your pain?"
159
A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?
Drop the eye medication into the lower conjunctival sac.
Apply gentle pressure in the outer opening of the eye for 2 min.
Hold the eye dropper 0.5 cm (0.2 in) from the cornea.
Instruct the client to close eyes tightly after administration.
Drop the eye medication into the lower conjunctival sac.
Notes: apply gentle pressure to the nasolacrimal duct after instilling the eye medication for 30 to 60 seconds,
hold the eye dropper 1 to 2 cm (0.4 to 0.8 in) from the lower conjunctival sac,
should instruct the client to close eyes gently when applying ointment or liquid to distribute the medication
160
A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?
Use a gait belt during ambulation.
Ensure the client is wearing socks before ambulating.
Instruct the client to sit on the edge of the bed for 15 seconds before ambulating.
Walk 2 feet behind the client during ambulation.
Use a gait belt during ambulation.
Notes: ensure the client is wearing nonskid shoes or slippers, encourage the client to dangle her legs on the edge of the bed for 60 seconds before attempting to ambulate, walk beside the client to provide physical support
161
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?
Provide the client with a glass of water.
Assist the client to a sitting position.
Explain the procedure to the client.
Measure the length of tubing to be inserted.
Explain the procedure to the client.
162
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make?
"Lunch trays should be here within the hour."
"I am going to listen to your abdomen."
"I'll get you some water to drink."
"I would wait a bit, or you could feel sick."
"I am going to listen to your abdomen."
163
A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?
Start chest compressions.
Provide breaths with a manual resuscitation bag.
Administer oxygen.
Establish an airway.
Start chest compressions.
164
A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?
Withdraw the specimen from the drainage bag.
Cleanse the collection port with soap and water.
Place the specimen in a clean specimen cup.
Clamp the tubing below the collection port.
Clamp the tubing below the collection port.
Notes: use a fresh urine specimen obtained near the indwelling urinary catheter, cleanse the collection port with an antimicrobial swab, place the specimen in a sterile specimen cup, clamp the tubing below the collection port to allow fresh uncontaminated urine
165
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A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?
Sanguineous exudate
Serous exudate
Serosanguineous exudate
Purulent exudate
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Purulent exudate
Notes: Purulent exudate drainage on the client's dressings is thick yellow, green and brown drainage; Serosanguineous exudate drainage on the client's dressings indicates plasma mixed with light bloody drainage, Serous exudate drainage on the client's dressings indicates plasma from the blood and appears clear to light yellow, and is watery, Sanguineous exudate drainage on the client's dressings indicates an accumulation of RBCs from the plasma that appears bright red on the dressings.
166
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A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?
Lateral thigh
Lower abdomen
Mid-abdominal region
Medial thigh
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Lower abdomen
167
A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?
Pull suction catheter back 1 cm (0.5 in) if the client starts coughing.
Allow 30 seconds between suctioning passes.
Hyperventilate the client with 50% oxygen for 30 seconds.
Perform a maximum of 4 passes with the suction catheter.
Pull suction catheter back 1 cm (0.5 in) if the client starts coughing.
Notes: allow at least 1 min between suctioning passes to prevent hypoxia, hyperventilate the client with 100 % oxygen for at least 2 min before suctioning, maximum of 3 passes with the suction catheter
168
A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?
Redness at the IV catheter entry site
A palpable cord is felt along the vein used for the infusion
Taut skin around the IV catheter site that is cool to the touch
Bleeding at the IV insertion site
Taut skin around the IV catheter site that is cool to the touch
169
A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?
Renew the prescription for the use of restrains within 24 hr.
Secure the restraint with the buckle side next to the client's skin.
Ensure 4 fingers can be inserted under the secured restraint.
Remove the restraint every 3 hr.
Renew the prescription for the use of restrains within 24 hr.
Notes: secure the client's restraints with the softer side next to the client's skin, with the buckle or velco closure on the outside, ensure 2 fingers can be inserted under the restraints, restraint at least every 2 hr
170
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?
Auscultate for bowel sounds after each feeding.
Ensure the formula is cold before administering.
Elevate the client's head of bed 45° before the feeding.
Flush the tubing with 15 mL of water after the enteral feeding.
Elevate the client's head of bed 45° before the feeding.
Notes: auscultate for bowel sounds before each feeding to ensure the client has peristalsis, ensure the formula is at room temperature before administering, client's head of bed between 30° to 45° to prevent aspiration, flush the tubing with at least 30 mL of water after the enteral feeding to maintain patency of the feeding tube
171
A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching?
The wound edges are well-approximated.
The wound is closed at a later date.
A skin graft is placed over the wound bed.
Granulation tissue fills the wound during healing.
Granulation tissue fills the wound during healing.
Notes: Primary intention occurs when the closing of the wound using sutures or staples, Tertiary intention includes using sutures to close an open wound, Tertiary intention can include the provider placing grafted skin over the client's wound bed after a wound is left open to drain and start healing
172
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A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?
Abdominal binder
Montgomery straps
Hypoallergenic tape
Plastic tape
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Montgomery straps
173
A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take?
Place the soiled linens on the chair while making the bed.
Hold the linens away from the body and clothing.
Place the linens on the floor until able to place it in a linen bag.
Shake the clean linens to unfold.
Hold the linens away from the body and clothing.
174
A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?
Encourage the client to drink fluids before swallowing food.
Offer the client tart or sour foods first.
Tilt the client's head backward when swallowing.
Turn on the television.
Offer the client tart or sour foods first.
Notes: consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing
175
A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection?
The lower, medial quadrant of the buttock near the coccyx
The side hip between the iliac crest and anterior iliac spine
The tissue of the posterior upper arm
The lower, inner thigh 4 finger widths above the patella
The side hip between the iliac crest and anterior iliac spine
176
A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching?
Change the colostomy bag following breakfast.
Cleanse the skin around the stoma with warm water.
Change the pouch every day.
Place an aspirin in the ostomy pouch to decrease odor.
Cleanse the skin around the stoma with warm water.
Notes: instruct the client to change the colostomy bag before a meal because drainage from the ostomy is least likely to occur, change the pouch every 3 to 7 days to avoid skin breakdown around the stoma, not to place an aspirin in the ostomy pouch to decrease odor, because it can cause stoma bleeding.
177
A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first?
Use the pain scale to determine the client's pain level.
Discuss the adverse effects of pain medication with the client.
Obtain the client's vital signs.
Check the client's allergies.
Use the pain scale to determine the client's pain level.
178
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
Tenderness when touched
Pink, shiny tissue with a granular appearance
Serosanguineous drainage
A halo of erythema on the surrounding skin
A halo of erythema on the surrounding skin
179
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A nurse is admitting an older adult client who fell at home 3 days ago. The client has a fractured hip, malnutrition, and dehydration. Which of the following laboratory values, noted on admission, should indicate to the nurse prolonged malnutrition?
Increased sodium
Decreased albumin
Increased BUN
Decreased blood glucose
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Decreased albumin
Notes: Increased sodium is indicative of dehydration, Increased BUN is indicative of renal failure, or dehydration, Decreased blood glucose is indicative of inadequate intake of glucose
180
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A nurse is teaching a group of healthy older adult clients about health screenings after age 50 years. Which of the following health screenings should the nurse recommend that the clients complete annually?
Cholesterol
Colonoscopy
Diabetes mellitus
Visual acuity
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Visual acuity
Notes: diabetes mellitus screening performed every 3 years, colonoscopy is every 5 to 10 years beginning at the age of 50 years, cholesterol screening every 3 to 5 years until age 75 years.
181
A nurse is teaching a group of older adult female clients who are postmenopausal about dietary requirements. Which of the following statements about the role of folic acid should the nurse make?
"Clients who are postmenopausal need to limit their intake of folic acid to reduce their risk of stroke."
"Dietary folic acid is not of significant importance after the childbearing years."
"Healthy clients who are postmenopausal require a daily folic acid supplement."
"Adequate folic acid intake is associated with a reduced risk for heart disease."
Adequate folic acid intake is associated with a reduced risk for heart disease."
Notes: increasing daily intake of foods such as orange juice, beans, legumes, and green leafy vegetables, as well as foods enriched with folic acid, such as breads and pastas.
182
A nurse is planning care for a client who had a stroke. Which of the following goals should the nurse identify as the priority for this client?
The client's skin will remain intact during hospitalization.
The client will verbalize one new word each week.
The client will begin to help turn himself in bed, indicating improved mobility.
The client's airway will remain clear, as evidenced by clear breath sounds.
The client's airway will remain clear, as evidenced by clear breath sounds.
183
A nurse in a long-term care facility is promoting reminiscence among older adult clients. Which of the following actions should the nurse take?
Establish a weekly pet therapy visitation program.
Place a calendar and clock in each resident's room.
Institute a daily storytelling hour.
Encourage all clients to eat their meals in the dining room.
Institute a daily storytelling hour.
Notes: Pet therapy visitation programs can be beneficial in promoting socialization and social skills, Placing a calendar and clock in each client's room will promote the client's level of orientation to date and time, Having clients eat their meals in a group dining room is beneficial to promoting socialization
184
A nurse is caring for an older adult client who has dementia. The client becomes agitated and confused at night and wanders into the hallway. Which of the following actions should the nurse take?
Place the client's mattress on the floor.
Restrain the client during the nighttime hours.
Provide continuous orientation to the client.
Turn out the lights in the client's room at night.
Place the client's mattress on the floor.
185
A nurse is planning to administer diphenhydramine hydrochloride to an older adult client. Which of the following actions should the nurse plan to take prior to administration?
Review the medical record for a client history of glaucoma.
Plan to administer the medication 30 min prior to a meal.
Explain to the client he will need to restrict his fluid intake once he takes the medication.
Remind the client that his appetite might increase when starting the medication.
Review the medical record for a client history of glaucoma.
Notes: should administer diphenhydramine with food or milk to decrease gastrointestinal adverse effects, inform the client to increase fluid intake, remind the client that anorexia, nausea, and vomiting are gastrointestinal adverse effects of the medication
186
A nurse is providing teaching to an older adult client who has osteoarthritis of the right hip and lower lumbar vertebrae. Which of the following statements by the client indicates an understanding of the teaching?
"I should avoid the use of a heating pad on my back."
"To relieve the pressure on my hip, I can use a cane while ambulating."
"I will have steroid injections to my joints as the first medication of choice to treat my pain."
"I will exercise even when it causes pain."
"To relieve the pressure on my hip, I can use a cane while ambulating."
187
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A nurse is participating on a committee that is developing age-appropriate care standards for older adult clients. Which of the following of Erikson's developmental tasks should the nurse recommend as the focus?
Intimacy
Identity
Integrity
Initiative
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Integrity
Notes: Intimacy vs. isolation is the conflict that clients must resolve during young adulthood
Identity vs. role confusion is the conflict that clients must resolve during adolescence
Integrity vs. despair is the conflict that older adult client must resolve when they reflect on their lives and their roles.
Initiative vs. guilt is the conflict that clients must resolve during early childhood
188
A nurse is caring for a client who has Alzheimer's disease and refuses to take her morning antihypertensive medication. The client is oriented to name and place and is able to perform ADLs with minimal supervision. Which of the following actions should the nurse take?
Crush the pills and feed them to the client in applesauce.
Insist the client comply by informing her of the possible implications of missing a dose.
Notify the provider of the need for further evaluation of the client's level of competence.
Ask the client to express her reasons for refusing the medication and document the event.
Ask the client to express her reasons for refusing the medication and document the event.
189
A nurse at an assisted living center is conducting an orientation session for a group of newly hired assistive personnel (AP). Which of the following instructions should the nurse include regarding clients who are hearing impaired?
Maintain eye contact with the clients.
Stand to one side of the clients and speak into their good ears.
Speak loudly with exaggerated enunciation.
Ask only questions with yes or no answers.
Maintain eye contact with the clients.
190
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A nurse is developing a plan of care for a client who had a recent stroke and has a history of gastroesophageal reflux disease (GERD). For which of the following disorders should the nurse plan to monitor this client?
Duodenal ulcer disease
Aspiration pneumonia
Viral pneumonia
Esophageal varices
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Aspiration pneumonia
191
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A nurse is assessing an older adult client for signs of dehydration. Which of the following findings should the nurse consider an expected part of the aging process?
Elevation of urine specific gravity
Decreased creatinine clearance
Dry oral mucous membranes
Poor skin turgor over the sternum
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Decreased creatinine clearance
192
A nurse is planning care for an older adult client following abdominal surgery for a bowel obstruction. Which of the following information about pain management should the nurse consider when planning care?
Older adult clients have a diminished capacity to perceive pain.
Older adult clients should not take narcotics for pain control.
Older adult clients have increased pain as a normal part of aging.
Older adult clients are sensitive to the analgesic effect of opiates.
Older adult clients are sensitive to the analgesic effect of opiates.
193
```
nurse is caring for an older adult client who has pneumonia. Which of the following physiologic changes associated with aging places the client at risk for pneumonia?
Decreased anterior-posterior diameter
Increased diameter of the small airways
Decreased number of cilia
Increased alveolar surface area
```
Decreased number of cilia
Notes: calcification of the bronchial and costal (rib) cartilage and diminished chest wall compliance, decreased diameter of the small airways, decrease in the alveolar surface area
194
```
A nurse is reviewing the medical record of a client who is postmenopausal and has osteoporosis. The client has a new prescription for alendronate sodium. Which of the following findings in the client's history should the nurse recognize is a contraindication to this medication?
Glaucoma
Paget's disease
Esophageal achalasia
Long-term corticosteroid use
```
Esophageal achalasia
195
```
A nurse is teaching a newly hired assistive personnel about her role in helping older adult clients with activities of daily living (ADLs). The nurse should explain that which of the following is the most common factor that affects a client's performance of ADLS?
Social withdrawal
Chronic physical disability
Emotional impairment
Cognitive dysfunction
```
Chronic physical disability
196
```
A nurse is caring for an older adult client. Which of the following physiologic changes associated with aging can affect medication dosage in this client?
Increased glomerular filtration rate
Decreased body fat
Decreased gastric motility
Decreased gastric pH
```
Decreased gastric motility
197
```
A home health nurse is visiting an older adult client who has anemia. Which of the following foods should the nurse recommend increasing the client's iron intake?
Greek yogurt
Bran muffin
Peanut butter sandwich
Dried fruit
```
Dried fruit
198
```
A nurse is teaching an older adult client who is on bedrest following development of deep vein thrombosis (DVT) about methods to increase peristalsis. Which of the following high-fiber food choices should the nurse recommend?
Navy bean soup
Canned fruit juice
White rice pudding
Soy milk
```
Navy bean soup
199
An older adult client tells a nurse at a health fair "I am always forgetting things. I cannot even remember where I parked my car! Do you think I have Alzheimer's disease?" Which of the following is a therapeutic response by the nurse?
"Perhaps you should discuss your concerns with your doctor."
"I am forgetful too. I can't remember where I parked my car either!"
"You're probably just having 'senior moments.' Everyone has memory lapses."
"That must be very upsetting. Can you tell me about your forgetfulness?"
"That must be very upsetting. Can you tell me about your forgetfulness?"
200
```
A nurse at an ophthalmology clinic is assessing a client referred by the provider for a potential cataract. Which of the following client reports should the nurse recognize is consistent with cataracts?
Halos when looking at lights
Loss of peripheral vision
Bright flashes of light and floaters
Eyestrain and headache with close work
```
Halos when looking at lights
Notes: Loss of peripheral vision is an initial report by a client who has open-angle glaucoma, Bright flashes of light, especially in the peripheral visual field, and floaters are associated with retinal detachment, Eyestrain and headache with close work is associated with decreased visual acuity
201
A nurse is providing discharge instructions about calcium supplements to an older adult female client who has osteoporosis and a recent repair of a fracture in her right hip. Which of the following instructions should the nurse include?
"You should take your calcium supplement with a large glass of water."
"You should increase your intake of grain cereals while taking calcium supplements."
"You should take at least 2600 milligrams of calcium supplements daily."
"You will not need to take vitamin D with your calcium supplement after menopause.
"You should take your calcium supplement with a large glass of water."
Notes: promote absorption of the supplement., Foods such as oatmeal and other grain cereals contain phytic acid, which can decrease the absorption of calcium supplements, calcium for the older adult female client is 1200 mg, calcium supplement should also take vitamin D to increase absorption even after menopause.
202
A nurse is assessing an older adult client who states he is homeless. Which of the following findings should the nurse document as comorbidities for this client?
Inadequate shelter and clothing for the weather
Malnutrition and poverty
Dementia and tuberculosis
Lack of preventive health care and immunizations
Dementia and tuberculosis
203
```
A nurse at a long-term care facility is providing teaching to a group of adolescents who are new volunteers. The nurse should explain that older adult clients are most likely to exhibit a decrease in which of the following?
Short-term memory
Creative ability
Decision-making skills
Cognitive capacity
```
Short-term memory
204
A nurse is assessing an older adult client during an annual physical. Which of the following client findings should the nurse report to the provider?
BP 118/76 mm Hg
Fasting blood glucose level 160 mg/dL
Report of waking to void two to three times per night
Report of bowel movement every other day
Fasting blood glucose level 160 mg/dL
205
```
A nurse in the clinic is assessing an older adult client for the second time in a week. The client reports a decreased energy level, insomnia, and anorexia. The client's diagnostic tests are within the expected reference ranges. For which of the following conditions should the nurse screen the client?
Sarcopenia
Dementia
Depression
Diabetes
```
Depression
| Notes: Sarcopenia change central and peripheral nervous systems and reduced skeletal protein synthesis
206
A nurse is caring for an older adult client who has a new onset of type 2 diabetes mellitus. Which of the following physiologic changes can contribute to the development of type 2 diabetes?
Increased production of insulin by the pancreas
Decreased sensitivity to the circulating insulin
Increased rate of glucose metabolism
Decreased release of glycogen by the liver
Decreased sensitivity to the circulating insulin
207
```
A nurse is caring for an older adult client who has gout and refuses to eat. The client's provider has approved the family to bring food from home. Which of the following foods should the nurse recommend that the client not eat?
Lentil soup
Cheese sandwich
Yogurt
Raisins
```
Lentil soup
Notes: nurse should encourage the client to eat a purine-restricted diet to decrease elevated uric acid levels. Whole grain breads and cereals, oatmeal, wheat germ, wheat bran, meat gravies, fresh and saltwater fish, beans, organ meats, mushrooms, green peas, spinach, asparagus, cauliflower, and baker's and brewer's yeast are all high in purine. Lentils, which are legumes, are a rich source of purines.
208
A nurse is conducting an admission assessment for an older adult client. Which of the following actions should the nurse take to collect subjective data?
Leave the client a written questionnaire to fill out in private.
Allow sufficient time for the client to respond to the questions.
Talk to family members to obtain the client's health history.
Obtain the health history from the client's medical record.
Allow sufficient time for the client to respond to the questions.
209
```
A nurse is assessing a client who is at 34 weeks of gestation and has a mild placental abruption. Which of the following findings should the nurse expect?
Increased platelet count
Fetal distress
Decreased urinary output
Dark red vaginal bleeding
```
Dark red vaginal bleeding
210
```
A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer?
Betamethasone
Misoprostol
Methylergonovine
Poractant alfa
```
Betamethasone
Notes: betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and thereby prevent respiratory depression
misoprostol to stimulate uterine contractions for a client who is undergoing labor induction
administer methylergonovine to stimulate uterine contractions for a client who is experiencing postpartum hemorrhage.
poractant alfa, a synthetic lung surfactant, to a preterm newborn who is experiencing respiratory distress.
211
```
A nurse is teaching a client who is at 30 weeks of gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching?
Mild constipation
Nasal congestion
Vaginal bleeding
10 fetal movements per hour
```
Vaginal bleeding
Notes: Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor.
212
A nurse is reviewing the medical record of a client who is at 39 weeks of gestation and has polyhydramnios. Which of the following findings should the nurse expect?
Fundal height of 34 cm (13.4 in)
Total pregnancy weight gain of 3.6 kg (8 lb)
Gestational hypertension
Fetal gastrointestinal anomaly
Fetal gastrointestinal anomaly
Notes: Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus; Gastrointestinal malformations and neurologic disorders are expected findings for a fetus
213
```
A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching?
Elevated blood pressure
Feeling of warmth
Hyperactivity
Generalized pruritus
```
Feeling of warmth
| Notes: decreased BP, feel sedated, Generalized pruritus can be a manifestation of an allergic reaction
214
```
A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority?
480 mL urine output in 24 hr
Blood pressure 144/92 mm Hg
+2 edema of the feet
1+ protein in the urine
```
480 mL urine output in 24 hr
215
```
A nurse is teaching a client who is at 12 weeks of gestation about manifestations of potential complications that she should report to her provider. Which of the following information should the nurse include in the teaching?
Swelling of the face
Urinary frequency
White vaginal discharge
Intermittent nausea
```
Swelling of the face
| Notes: indicate a hypertensive disorder or preeclampsia.
216
A nurse is reviewing laboratory results for a client who is at 37 weeks of gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic streptococci, and has a blood type of O negative. Which of the following actions should the nurse take?
Administer a dose of Rho(D) immune globulin.
Request a prescription for an antibiotic until delivery.
Instruct the client to obtain a rubella immunization after delivery.
Inform the client that she will need to deliver via cesarean birth.
Instruct the client to obtain a rubella immunization after delivery.
217
```
A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect?
Atrial septal defect
Renal agenesis
Spina bifida
Hydrocephalus
```
Renal agenesis
Notes: Oligohydramnios is a volume of amniotic fluid less than 300 mL during the third trimester of pregnancy and occurs when there is a renal system dysfunction or obstructive uropathy. Absence of fetal kidneys will cause oligohydramnios
218
```
A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy?
Palpable fetal movement
Chadwick's sign
Positive pregnancy test
Amenorrhea
```
Palpable fetal movement
| Notes: Chadwick's sign is a bluish discoloration in the cervix, vagina, and vulva that occurs at 6 to 8 weeks.
219
```
A nurse is assessing a client who is at 37 weeks of gestation and has a suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect?
Bradycardia
Uterine contractions
Seizures
Bradypnea
```
Uterine contractions
Notes: increase in the client's heart rate,
increased respiratory rate
220
A nurse is caring for a client who is at 26 weeks of gestation and reports constipation. Which of the following responses by the nurse is appropriate?
"You should drink 1 ounce of mineral oil every morning."
"You should walk for at least 30 minutes every day."
"You should eat at least 3 ounces of red meat per day."
"You should stop taking your prenatal vitamin."
"You should walk for at least 30 minutes every day."
221
A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take?
Instruct the client to pant during contractions.
Position the client supine with legs elevated.
Encourage the client to soak in a warm bath.
Apply pressure to the client's sacral area during contractions.
Apply pressure to the client's sacral area during contractions.
222
```
A nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the following findings should the nurse report to the provider?
Deep tendon reflexes 2+
Blood pressure 150/96 mm Hg
Urinary output 20 mL/hr
Respiratory rate 16/min
```
Urinary output 20 mL/hr
223
A nurse is teaching a client who is at 10 weeks of gestation about an abdominal ultrasound in the first trimester. Which of the following information should the nurse include in the teaching?
"You will have a nonstress test prior to the ultrasound."
"You will need to have a full bladder during the ultrasound."
"The ultrasound will determine the length of your cervix."
"You will experience uterine cramping during the ultrasound."
"You will need to have a full bladder during the ultrasound."
224
```
A nurse is caring for a client who is at 35 weeks of gestation and has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status?
Blood pressure
Intake and output
Daily weight
Severity of edema
```
Daily weight
225
A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that which of the following laboratory tests will be used to confirm her pregnancy?
A blood test for the presence of estrogen
A blood test for the amount of circulating progesterone
A urine test for the presence of human chorionic somatomammotropin
A urine test for the presence of human chorionic gonadotropin
A urine test for the presence of human chorionic gonadotropin
226
```
A nurse is caring for a client whose last menstrual period (LMP) began July 8. Using Nagele's rule, the nurse should identify the client's estimated date of birth (EDB) as which of the following?
October 1
April 1
October 15
April 15
```
April 15
Notes: Using Nagele's rule, the nurse determines the EDB by counting back 3 months from the first day of the LMP and adding 7 days.
227
A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal movement for 24 hr. Which of the following actions should the nurse take?
Auscultate for a fetal heart rate.
Have the client drink orange juice.
Reassure the client that a term fetus is less active.
Palpate the uterus for fetal movement.
Auscultate for a fetal heart rate.
228
```
A nurse is assessing a client who is at 12 weeks of gestation and has a hydatidiform mole. Which of the following findings should the nurse expect?
Hypothermia
Dark brown vaginal discharge
Decreased urinary output
Fetal heart tones
```
Dark brown vaginal discharge
| Notes: increased urinary output
229
A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous. The nurse notes that the client is having contractions every 2 min which last 100 to 110 seconds and that the fetal heart rate (FHR) is reassuring. Which of the following actions should the nurse take?
Decrease the infusion rate of the maintenance IV fluid.
Administer oxygen via nonrebreather mask.
Decrease the dose of oxytocin by half.
Administer terbutaline 0.25 mg subcutaneously.
Decrease the dose of oxytocin by half.
230
A nurse is teaching a client who is at 8 weeks of gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following information should the nurse include in the teaching?
"The fibroid will shrink during the pregnancy."
"The fibroid can increase the risk for postpartum hemorrhage."
"You will receive an injection of medroxyprogesterone acetate to shrink the fibroid."
"You will have to undergo a cesarean birth because of the fibroid."
"The fibroid can increase the risk for postpartum hemorrhage."
231
```
A nurse is providing teaching to a client who is at 8 weeks of gestation about manifestations to report to the provider during pregnancy. Which of the following information should the nurse include in the teaching?
Nausea upon awakening
Leg cramps when sleeping
Increase in white vaginal discharge
Blurred or double vision
```
Blurred or double vision
232
A nurse is teaching a client who is at 12 weeks of gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching?
"Breastfeed your newborn to provide passive immunity."
"Abstain from sexual intercourse throughout the pregnancy."
"You will be in isolation after delivery."
"You should continue to take zidovudine throughout the pregnancy."
"You should continue to take zidovudine throughout the pregnancy."
233
A nurse is teaching a client who is at 13 weeks of gestation about the treatment of incompetent cervix with cervical cerclage. Which of the following statements by the client indicates an understanding of the teaching?
"I am sad that I won't be able to get pregnant again."
"I can resume having sex as soon as I feel up to it."
"I should go to the hospital if I think I may be in labor."
"I should expect bright red bleeding while the cerclage is in place."
"I should go to the hospital if I think I may be in labor."
Notes: Cervical cerclage prevents premature opening of the cervix during pregnancy.
The client can expect spotting for 1 to 2 days after cerclage placement.
234
A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse take?
Prepare the client for an ultrasound examination.
Prepare the client for an emergency cesarean birth.
Prepare equipment needed for newborn resuscitation.
Perform endotracheal suctioning as soon as the fetal head is delivered.
Prepare equipment needed for newborn resuscitation.
Notes: The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.
235
```
A nurse is caring for a client who is at 39 weeks of gestation and is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations?
Uteroplacental insufficiency
Fetal head compression
Fetal ventricular septal defect
Umbilical cord compression
```
Uteroplacental insufficiency
Notes: Fetal head compression causes early decelerations in the FHR.
Compression of the umbilical cord causes variable decelerations in the FHR.
236
A nurse is reviewing the medical record of a client who is at 33 weeks of gestation and has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider?
Perform a vaginal examination.
Perform continuous external fetal monitoring.
Insert a large-bore IV catheter.
Obtain a blood sample for laboratory testing.
Perform a vaginal examination.
237
A nurse is caring for a client who is at 37 weeks of gestation and is undergoing a nonstress test. The fetal heart rate (FHR) is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take?
Use vibroacoustic stimulation on the client's abdomen for 3 seconds.
Report the nonreactive test result to the provider immediately.
Request a prescription for an internal fetal scalp electrode.
Auscultate the FHR with a Doppler transducer.
Use vibroacoustic stimulation on the client's abdomen for 3 seconds.
238
A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take?
Offer the newborn glucose water between feedings.
Keep the newborn's eye patches on during feedings.
Apply barrier ointment to the newborn's perianal region.
Use a photometer to monitor the lamp's energy.
Use a photometer to monitor the lamp's energy.
239
A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching?
Apply the diaper tightly over the circumcision area.
Remove the yellow exudate with each diaper change.
Use prepackaged commercial wipes to clean the circumcision site.
Encourage nonnutritive sucking for pain relief.
Encourage nonnutritive sucking for pain relief.
240
A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching?
"I must drink milk every day in order to assure good quality breast milk."
"Drinking lots of fluids will increase my breast milk production."
"After the first few weeks, my nipples will toughen up and breastfeeding won't hurt anymore."
"It is normal for my baby to sometimes feed every hour for several hours in a row."
"It is normal for my baby to sometimes feed every hour for several hours in a row."
241
A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina. Which of the following statements should the nurse make?
"You might have retained placental fragments in your uterus."
"Blood pools in the vagina when you are lying in bed."
"You might have a damaged blood vessel."
"The amount of blood flow will increase during the first few days after giving birth."
"Blood pools in the vagina when you are lying in bed."
242
```
A nurse is assessing a newborn who was born at 39 weeks of gestation. Which of the following findings should the nurse expect?
Symmetric rib cage
Dry, wrinkled skin
Vernix over the entire body
Lanugo abundant on the back
```
A newborn who is born at 39 weeks of gestation is full-term and should have a symmetric rib cage.
243
A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take?
Perform chest percussion.
Place the newborn in a prone position.
Continue routine monitoring.
Request a prescription for supplemental oxygen.
Continue routine monitoring.
244
A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following statements indicates to the nurse the client needs further instruction?
"I can continue to breastfeed."
"I will still need to have my provider perform a rubella titer check with my next pregnancy."
"I cannot receive the rubella immunization during my pregnancy."
"I can conceive any time I want after 10 days."
can conceive any time I want after 10 days."
245
A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development?
Rapidly advance oral feedings.
Position the naked newborn on the parent's bare chest.
Provide frequent periods of visual and auditory stimulation.
Discourage the use of pacifiers.
Position the naked newborn on the parent's bare chest.
246
A nurse is caring for a client who reports intestinal gas pain following a cesarean section. Which of the following actions should the nurse take?
Assist the client to ambulate in the hallway.
Instruct the client to splint the incision with a pillow.
Have the client drink fluids through a straw.
Encourage the client to drink carbonated beverages.
Assist the client to ambulate in the hallway.
247
```
A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min, respiratory rate of 36/min, well flexed extremities, responding to stimuli with a cry, and blue hands and feet. Which of the following is the Apgar score the nurse should assign to the newborn?
7
8
9
10
```
9
Notes: The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 min and 5 min after birth. The nurse should assign a score of 0, 1, or 2 to each of five categories. The nurse should assign a score of 2 for a heart rate greater than 100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows expected normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, known as acrocyanosis.
248
A nurse is providing teaching to the parents of a newborn about bottle feeding. Which of the following instructions should the nurse include in the teaching?
Dilute ready-to-feed formula if the newborn is gaining weight too quickly.
Prop the bottle with a blanket for the last feeding of the day.
Discard unused refrigerated formula after 72 hr.
Boil water for powdered formula for 1 to 2 min.
Boil water for powdered formula for 1 to 2 min.
Notes: should not dilute ready-to-feed formula because the newborn will get full before consuming
hold the bottle when feeding the newborn to prevent aspiration and the development of caries
keep unused prepared formula for 48 hr.
run tap water for 2 min and then boil it for 1 to 2 min before mixing it with the formula
249
```
A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1 to 2 hr of delivery?
Naloxone
Erythromycin ophthalmic ointment
Poractant alpha
Rotavirus immunization
```
Erythromycin ophthalmic ointment
250
A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration?
Continuous lochia flow and a flaccid uterus
Report of increasing pain and pressure in the perineal area
A slow trickle of bright vaginal bleeding and a firm fundus
A gush of rubra lochia when the nurse massages the uterus
A slow trickle of bright vaginal bleeding and a firm fundus
Notes: monitor for excessive vaginal bleeding in the presence of a flaccid uterus to identify that the blood is coming from the uterus. The most common cause of this occurrence is a full bladder or retained placental fragments
monitor for a report of increasing pain and pressure in the perineal area to identify a vulvar hematoma.
massages the uterus, it will contract and help move pooled blood in the uterus to the vaginal opening.
251
A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification?
Monitor the client's intake and output.
Initiate a high-fiber diet for the client.
Monitor the client's weight weekly.
Initiate bedrest with the head of the bed elevated.
Monitor the client's weight weekly.
252
```
A nurse is assessing a newborn 1 hr after birth. Which of the following assessment findings should the nurse report to the provider?
Jaundice of the sclera
Respiratory rate 50/min
Acrocyanosis
Blood glucose 60 mg/dL
```
Jaundice of the sclera
Notes: If the newborn has jaundice within the first 24 hr of life, this can indicate a potential pathological process such as hemolytic disease. Pathologic jaundice can result in high levels of bilirubin that can cause damage to the neonatal brain.
253
```
A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the client's bedside?
Naloxone
Calcium gluconate
Protamine sulfate
Atropine
```
Calcium gluconate
Notes: should monitor the client for a respiratory rate less than or equal to 12/min, muscle weakness, and depressed deep-tendon reflexes.
naloxone available to give to a client who is receiving opioid medication in case of respiratory depression.
protamine sulfate available to give to a client who is receiving heparin in case of hemorrhage.
atropine available to give to a client who is receiving medications that can lead to asystole or sinus bradycardia, such as beta-adrenergic blockers.
254
A nurse is assessing a 4-hour-old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take?
Apply an oxygen hood over the newborn's head and neck.
Check the newborn's temperature using a temporal thermometer.
Place the naked newborn on the mother's bare chest and cover both with a blanket.
Give the newborn glucose water between feedings.
Place the naked newborn on the mother's bare chest and cover both with a blanket.
255
A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching?
"I will place my baby on his back when it is time for him to sleep."
"I will keep my baby's crib close to the heat vents to keep him warm."
"I will use an infant carrier when I drive to places close to my house."
"I will tie my baby's pacifier around his neck with a piece of yarn."
"I will place my baby on his back when it is time for him to sleep."
256
A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse take first?
Perform a detailed physical assessment.
Place the newborn directly on the client's chest.
Give the newborn vitamin K IM.
Administer erythromycin ophthalmic ointment.
Place the newborn directly on the client's chest.
257
A nurse is assessing a client who is 14 hr postpartum and has a third-degree perineal laceration. The client's temperature is 37.8° C (100° F), and her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movement since delivery. Which of the following actions should the nurse take?
Notify the provider about the elevated temperature.
Assist the client to empty her bladder.
Administer a bisacodyl suppository.
Massage the client's fundus.
Assist the client to empty her bladder.
258
A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she inquires about the finding?
"This will resolve within 3 to 6 weeks without treatment."
"This will resolve on its own within 3 to 4 days."
"The provider might drain this area with a syringe."
"This is expected at birth so you don't need to worry about it."
"This will resolve within 3 to 6 weeks without treatment."
Notes: This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum, that will resolve within 2 to 6 weeks.
A caput succedaneum is present at birth and extends across suture lines. It is edema of the scalp and will resolve in 3 to 4 days.
259
```
A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. Which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication?
Urinary output
Blood pressure
Fundal consistency
Pulse rate
```
Fundal consistency
260
A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching?
Stand under a hot shower with your breasts exposed.
Place ice packs on your breasts.
Wear a loose-fitting, comfortable bra.
Limit fluid intake to 1 L per day.
Place ice packs on your breasts.
Notes: Warm water running over the breasts can stimulate the breasts to produce more milk, not less.
wear a well-fitting, supportive bra to provide comfort as the breasts fill with milk.
should drink 2 to 3 L of fluid per day to promote normal bowel function.
261
```
A nurse is caring for a newborn who is premature at 30 weeks of gestation. Which of the following findings should the nurse expect?
Abundant lanugo
Good flexion
Heel creases covering the bottom of feet
Dry, parchment-like skin
```
Abundant lanugo
Notes: Newborns who are premature have abundant lanugo, fine hair, especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinnas, and forehead.
Newborns who are premature demonstrate hypotonia and a relaxed posture. Full-term newborns demonstrate moderate flexion of the arms and legs.
Newborns who are premature have few heel creases. Full-term newborns have heel creases that cover most of the bottom of the feet.
Newborns who are premature have abundant vernix caseosa, a thick whitish substance, covering and protecting their skin in utero. Post-mature newborns are likely to have dry, parchment-like skin.
262
A nurse is assessing a newborn for congenital hip dysplasia. Which of the following findings should the nurse expect?
Legs that are shorter than the arms
Temperature of one leg differing from that of the other
Symmetrical gluteal folds
Limited abduction of one hip
Limited abduction of one hip
263
A nurse in a mental health clinic is caring for a client who has bipolar disorder and states, "I no longer take my medication because I like the feeling of being manic." Which of the following responses by the nurse is an example of therapeutic communication?
"You might feel good now, but what about when you get depressed?"
"Why do you think you like feeling manic?"
"You feel better when you don't take your medication?"
"What do you think your provider will say about you going off your medication?"
You feel better when you don't take your medication?"
264
A nurse is planning reminiscence therapy for an older adult client. The nurse should identify which of the following goals for the client's therapy?
The client will gain increased self-esteem.
The client will maintain orientation to place and time.
The client will independently perform ADLs.
The client will achieve optimal sensory stimulation.
The client will gain increased self-esteem.
265
A nurse in an emergency department is caring for an 18-month-old toddler who has a fractured left femur. Which of the following statements by the toddler's parent should cause the nurse to suspect child abuse?
"My child fell down the stairs."
"My child was riding a bicycle and fell off."
"My child slipped out of the high chair."
"My child climbed up on a chair and it tipped over."
"My child was riding a bicycle and fell off."
266
A nurse in a pediatric emergency department is caring for four clients. The nurse should suspect possible abuse with which of the following clients?
A 14-month-old toddler who has recently learned to walk and has many bruises on bony prominences in various stages of healing
A 9-month-old infant who reportedly nearly drowned after climbing into the tub and turning on the water
A 6-year-old toddler who has a fracture of the tibia and fibula, which reportedly occurred while riding a bicycle
A 3-year-old toddler who has burns in a splash pattern over the face and chest, reportedly sustained when a tablecloth was pulled, spilling a teapot
A 9-month-old infant who reportedly nearly drowned after climbing into the tub and turning on the water
267
```
A nurse is caring for a client who has a new diagnosis of colon cancer. Shortly after the client receives the diagnosis, the nurse enters the client's room and the client begins yelling, "I have received terrible care here and no one cares about me." The nurse should recognize that the client is demonstrating which of the following defense mechanisms?
Denial
Displacement
Reaction formation
Projection
```
Displacement
Notes: denial as the refusal to accept reality and to act as if a painful event, thought, or feeling does not exist
displacement as the redirection of thoughts, feelings, and impulses from an object that causes to anxiety to a safer, more acceptable one.
reaction formation when the client exhibits a behavior or emotion that is the opposite of what the client actually feels.
projection when the client attributes undesired impulses to another.
268
A nurse receives a call on a crisis intervention hotline from a client. Which of the following statements should the nurse identify as an overt statement indicating the client's risk for suicide?
"Everything will be better soon."
"Soon no one will have to worry about me."
"There's no point in living any longer."
"I want to donate my organs to help others."
"There's no point in living any longer."
269
A nurse is caring for a client who has depression and started taking paroxetine one week ago. The client states to the nurse, "My family would be better off without me." Which of the following responses should the nurse make?
"Why do you feel your family would be better off without you?"
"Many people feel this way when they are depressed."
"You sound upset. Are you thinking of hurting yourself?"
"Your medication hasn't started working yet. Then you'll be feeling differently. "
"You sound upset. Are you thinking of hurting yourself?"
270
A nurse is admitting a client following care in the emergency department for an intentional overdose of opioids. The client states, "I feel so alone. No one can help me." Which of the following responses by the nurse is therapeutic?
"Let's finish your admission and then talk about your feelings."
"How come you feel that no one can help you when you are receiving help now?"
"Why do you feel that no one can help you?"
"I would like to sit and talk with you."
"I would like to sit and talk with you."
271
```
A nurse is caring for a client who has schizophrenia. The client states, "My internal organs have turned to stone." The nurse should document this finding as which of the following types of delusions?
Somatic
Reference
Persecutory
Grandiose
```
Somatic
Notes: Clients experiencing a somatic delusion believe that a body part is no longer functioning in a realistic or expected manner.
delusion of reference believes that occurrences in the environment are about or because of him.
persecutory delusion believes that someone or something wants to intentionally harm him.
grandiose delusion believes that he is superior or more important than others.
272
A nurse is conducting a counseling session with a client who has a substance use disorder. The client repeatedly asks personal questions about the nurse. Which of the following actions should the nurse take?
Explain that this time is designated to focus on the client.
Answer the personal inquiry questions matter-of-factly.
Tell the client that interest in someone besides himself is an indication of improvement.
Request that personal questions be asked after the counseling session is over.
Explain that this time is designated to focus on the client.
273
A nurse is preparing to apply wrist restraints on a client who is threatening to harm others and has not responded to less invasive interventions. Which of the following actions should the nurse plan to take?
Obtain a PRN prescription for restraints from the client's provider.
Visually observe the client every 10 min until restraints are removed.
Ensure that three fingers can fit between the restraint and the client's wrist.
Document the client's behavior every 15 min while restraints are in place.
Document the client's behavior every 15 min while restraints are in place.
274
A nurse in a mental health clinic is caring for a client who states, "I think I might have a problem with alcohol." Which of the following actions should the nurse take first?
Provide the client with information about a 12-step recovery program.
Encourage the client to accept responsibility for his alcohol use.
Teach the client alternate coping mechanisms to use in place of alcohol.
Ask the client to complete a CAGE Questionnaire.
Ask the client to complete a CAGE Questionnaire.
275
A nurse is assessing a client who has anorexia nervosa. The nurse should expect the client to display which of the following characteristics?
Refuses to participate in physical exercise activities
Possesses feelings of decreased self-worth
Preoccupied with concerns about personal health
Avoids discussion of food
Possesses feelings of decreased self-worth
276
```
A nurse is caring for a client at a college mental health counseling center. The client received a failing grade in a course and spends the entire counseling session blaming the teacher. The nurse should recognize this behavior as an example of which of the following defense mechanisms?
Projection
Dissociation
Undoing
Compensation
```
Projection
Notes: dissociation, which results in the client's compartmentalization of undesirable personal attributes.
undoing, which results in the client's attempt to make up for an unacceptable action.
compensation, which results in the client's attempt to focus on a strength to compensate for a perceived weakness.
277
A nurse is establishing a therapeutic relationship with a client who has hallucinations. Which of the following actions should the nurse take during the orientation phase?
Identify the client's perception of the reason for therapy.
Ask the client to provide a detailed description of the hallucinations.
Assist the client with the development of problem-solving skills.
Explore the client's relationship with family members.
Identify the client's perception of the reason for therapy.
Notes: orientation phase of the nurse-client relationship, the nurse should establish rapport and confidentiality with the client.
detailed assessment of the client's hallucinations, during the working phase of the therapeutic nurse-client relationship.
development of problem-solving skills during the working phase of the therapeutic nurse-client relationship.
assessment of the client's family relationships, during the working phase of the therapeutic nurse-client relationship.
278
A nurse is planning care for a client who has thoughts of suicide. Which of the following goals should the nurse include in the client's plan of care?
The client will identify positive aspects of others.
The client agrees to notify a staff member of thoughts of self-harm.
The client will engage in an independent diversional activity.
The client will not verbalize thoughts or feelings related to suicide.
The client agrees to notify a staff member of thoughts of self-harm.
279
```
A nurse is caring for a school-age client who begins wetting the bed after finding out that her parents are getting a divorce. The nurse should identify that the client is exhibiting which of the following defense mechanisms?
Regression
Projection
Repression
Splitting
```
Regression
Notes: Projection is the unconscious rejection of unacceptable features in oneself by attributing them to others.
Repression is the unconscious removal of thoughts or memories from one's awareness.
Splitting is the inability to integrate the positive and negative qualities of oneself or others into a combined idea.
280
A nurse is caring for a client who has borderline personality disorder. The client has previously identified another nurse as his favorite stating, "He's the best nurse ever." When that nurse calls in sick, which of the following statements indicates that the client is using splitting as a method of coping?
"He's the worst nurse that's ever taken care of me."
"You're just lying to me. He's not really sick."
"He's my favorite nurse and I'm really worried about him."
"If anyone else tries to take care of me, I'm going to get really upset."
"He's the worst nurse that's ever taken care of me."
281
A nurse is completing an admission assessment for an adolescent client who has depression. The nurse should identify which of the following findings as the priority?
The client is confrontational with his parents.
The client is getting Ds in his classes because he frequently skips school.
The client states he smokes half a pack of cigarettes per day.
The client gave his favorite possessions to friends.
The client gave his favorite possessions to friends.
282
A nurse at a college campus health clinic is caring for a client who reports manifestations of bulimia nervosa. The client tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot control it." Which of the following responses should the nurse make?
"Why do you think you are experiencing these behaviors of binges and vomiting?"
"Are other students in your dorm also experiencing this behavior?"
"You are feeling helpless about changing this behavior?"
"You know you must stop because you are endangering your health."
"You are feeling helpless about changing this behavior?"
283
A community mental health nurse is planning strategies to address substance use by adolescents. Which of the following interventions should the nurse plan as a method of primary prevention?
Offer substance use treatment options for adolescents from low-income households.
Encourage the use of random testing for substance use for adolescents participating in extracurricular activities.
Educate high school teachers about how to detect the manifestations of substance use.
Provide a presentation at area high schools on resisting peer pressure for substance use.
Provide a presentation at area high schools on resisting peer pressure for substance use.
284
A nurse is caring for a client who has borderline personality disorder. The nurse enters the client's room and finds the client cutting into his flesh with a paper clip. After providing first aid, which of the following actions should the nurse take first?
Encourage the client to discuss feelings about his self-injurious behavior during group therapy.
Fill out an incident report for risk management about the client's self-injurious behavior.
Document the client's self-injurious behavior in his medical record.
Identify the client's feelings that led to the self-injurious behavior.
Identify the client's feelings that led to the self-injurious behavior.
285
A nurse is caring for a client who has alcohol use disorder and is receiving treatment for alcohol withdrawal. The client reports hand tremors 12 hr after admission. Which of the following statements should the nurse make?
"The tremors are permanent due to nerve damage caused by chronic alcohol use."
"The tremors will persist for a few days as you are withdrawing from alcohol."
"Try not to worry about the tremors. Everyone has these during alcohol withdrawal."
"These tremors are an indication of seizures that are associated with alcohol withdrawal."
"The tremors will persist for a few days as you are withdrawing from alcohol."
286
A nurse in an emergency department is caring for a female client who has ecchymosis of the trunk and face. The client reports that her partner hit her, causing the injuries. When offered information about shelters for intimate partner violence, the client declines, stating, "I could never leave my husband because of my kids." Which of the following responses should the nurse make?
"Aren't you worried about the safety of your children?"
"Can you identify your behaviors that provoke your partner?"
"The next time this occurs, what might you do to ensure your safety?"
"You need to remove yourself and your children from the abusive situation."
"The next time this occurs, what might you do to ensure your safety?"
287
A nurse is assessing a client who is experiencing moderate-level anxiety. Which of the following findings should the nurse expect?
The client has a heightened perceptual field.
The client has difficulty concentrating.
The client reports shortness of breath.
The client reports a sense of impending doom.
The client has difficulty concentrating.
Notes: mild anxiety to have a heightened perceptual field
moderate-level anxiety to have difficulty concentrating and focusing
shortness of breath, for a client who is experiencing a panic level of anxiety.
impending doom for a client experiencing a severe level of anxiety.
288
```
A nurse is providing support for the parents of a child who has a new diagnosis of a terminal brain tumor. The nurse should expect the parents to experience which of the following stages of grief first?
Denial
Bargaining
Anger
Depression
```
Denial
289
A nurse at an acute mental health facility is caring for a client who has acute mania due to bipolar disorder. At 0300, the client runs to the nurse's station and demands to see the provider immediately. Which of the following responses should the nurse make?
"Your request is unreasonable. We cannot call your provider at 3:00 in the morning."
"If you can calm down for 5 minutes then I will call your provider for you."
"Calm down, go back to your room, and come back in 15 minutes and we'll talk about how you're feeling."
"You must be very upset about something to want to see your provider in the middle of the night."
"You must be very upset about something to want to see your provider in the middle of the night."
290
A nurse is caring for a client whose adolescent child died in a motor-vehicle crash. The client is crying inconsolably. Which of the following actions should the nurse take?
Suggest that the client call the facility's chaplain.
Provide a quiet place for the client to be alone.
Stay with the client and allow the client to cry.
Express sympathy for the client's loss.
Stay with the client and allow the client to cry.
291
```
A nurse is caring for a client who is brought to the clinic by her adult son who states that his father recently died. The client repeatedly yells at her son stating, "Quit lying about your father!" The nurse should recognize that the client is demonstrating which of the following defense mechanisms?
Denial
Identification
Introjection
Sublimation
```
Denial
Notes: Identification is taking on the characteristics of another person.
Introjection is adopting the values and beliefs of another person.
Sublimation is the conversion of unacceptable drives into socially sanctioned activities.
292
A nurse is caring for a client who has major depressive disorder and recently started taking an antidepressant. The nurse should identify which of the following client statements as the priority?
"I hate being so helpless. I can't even manage my own finances anymore."
"At group therapy today I wanted to leave. I didn't feeling like being with other people."
"I have it all figured out. Everything is going to be okay now."
"I don't feel like showering. I'd rather just stay in bed today."
"I have it all figured out. Everything is going to be okay now."
293
A nurse enters a client's room and observes that the client is agitated and pacing rapidly. The client looks at the nurse and says, "Back off. Leave me alone." Which of the following statements should the nurse make?
"I demand that you calm down now. Your behavior is unacceptable."
"I will close the door to provide privacy, and you can tell me what is bothering you."
"I will give you space if you calm down. Tell me what is causing you to feel so tense."
"I will leave you alone for a few minutes while you try to control yourself."
"I will give you space if you calm down. Tell me what is causing you to feel so tense."
294
A nurse is caring for a client who attempted suicide and refuses to sign a no-suicide contract. Which of the following actions should the nurse take when implementing suicide precautions?
Assign the client to a private room.
Request that the dietary department provide the client with finger foods.
Place the client on one-to-one observation.
Keep the door to the client's room closed.
Place the client on one-to-one observation.
295
A nurse is caring for a client who has dementia. The client states to the nurse, "Everyone wants to kill me." Which of the following responses should the nurse make?
"Tell me how everyone wants to hurt you."
"You must feel very frightened to think someone wants to hurt you."
"No one here wants to kill you."
"Who in particular do you think wants to kill you?"
"You must feel very frightened to think someone wants to hurt you."
296
A nurse in a mental health facility is reviewing confidentiality requirements with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the information?
"I am legally required to notify a client's employer about a substance use disorder."
"If a client is involuntarily committed, I can discuss information with the client's next of kin."
"I can discuss a client's treatment with others as long as they are employees of the facility."
"I should keep information private even after a client dies."
"I should keep information private even after a client dies."
297
```
A nurse is caring for a client who reminds her of a negative person in her past. These memories cause the nurse to unconsciously displace negative feelings towards the client. The nurse should recognize that she is demonstrating which of the following behaviors?
Suppression
Countertransference
Transference
Assertiveness
```
Countertransference
Notes: The nurse demonstrates suppression through the conscious denial of a disturbing feeling.
countertransference by unconsciously attributing feelings, positive or negative, about another towards the client.
transference through the unconscious displacement of feelings towards the nurse.
assertiveness through communication and the expression of feelings without denying those of others.
298
A nurse is caring for a client who has depression. The nurse observes that the client has not come to breakfast and is still in bed. The client states, "I'm not worth your time. Leave me alone and go help someone else." Which of the following responses should the nurse make?
"Many people feel this way when they first start treatment."
"In other words, you seem to be saying that you feel unworthy of help."
"You'll feel better once you get up and have some breakfast."
"I disagree with your feeling that you are not worth my time."
"In other words, you seem to be saying that you feel unworthy of help."
299
A nurse is counseling a client who seems relaxed initially, but then becomes restless and begins wringing his hands. The nurse states that the client seems tense, and the client agrees. Which of the following statements should the nurse make?
"Did I say something wrong that made you feel tense?"
"Do you often feel tense when you are talking to a health care provider?"
"What were we discussing when you began to feel uncomfortable?"
"It is ok to feel nervous during our counseling sessions."
"What were we discussing when you began to feel uncomfortable?"
300
A nurse is performing a mental status assessment on an older adult client who has dementia. Which of the following questions should the nurse ask to assess the client's remote memory?
"What year did you graduate from high school?"
"What is your favorite childhood memory?"
"What did you have for supper yesterday?"
"What is today's date?"
"What year did you graduate from high school?"
Notes: assessing a client's remote memory, the nurse should ask questions that determine the client's ability to remember things from the distant past.
301
A nurse is administering an oral sedative to a client who is receiving care following an involuntary admission. The client states, "I'm not taking any more medication." Which of the following actions should the nurse take?
Administer the medication by another route.
Refer the client's refusal to the facility's ethics committee.
Inform the client that, due to her involuntary admission, she cannot refuse a sedative.
Document the client's refusal of the medication in the medical record.
Document the client's refusal of the medication in the medical record.
302
A nurse is caring for a client who has been taking isoniazid and rifampin for 3 weeks for the treatment of active pulmonary tuberculosis (TB). The client reports his urine is an orange color. Which of the following statements should the nurse make?
"Stop taking the isoniazid for 3 days and the discoloration should go away."
"Rifampin can turn body fluids orange."
"I'll make an appointment for you to see the provider this afternoon."
"Isoniazid can cause bladder irritation."
A nurse is caring for a client who has been taking isoniazid and rifampin for 3 weeks for the treatment of active pulmonary tuberculosis (TB). The client reports his urine is an orange color. Which of the following statements should the nurse make?
"Stop taking the isoniazid for 3 days and the discoloration should go away."
"Rifampin can turn body fluids orange."
"I'll make an appointment for you to see the provider this afternoon."
"Isoniazid can cause bladder irritation."
303
```
A nurse is providing teaching to a newly licensed nurse about caring for a client who has a prescription for gemfibrozil. The nurse should instruct the newly licensed nurse to monitor which of the following laboratory tests?
Platelet count
Electrolyte levels
Thyroid function
Liver function
```
```
Liver function
Notes: Gemfibrozil can decrease WBCs
Gemfibrozil can cause hyperglycemia
Gemfibrozil can cause myopathy
Gemfibrozil reduces triglycerides by decreasing the liver's uptake of fatty acids. It can cause liver toxicity
```
304
A nurse is administering subcutaneous heparin to a client who is at risk for deep vein thrombosis. Which of the following actions should the nurse take?
Administer the medication into the client's abdomen.
Inject the medication into a muscle.
Massage the site after administering the medication.
Use a 22-gauge needle to administer the medication.
Administer the medication into the client's abdomen.
Notes: nurse should apply firm pressure to the injection site after administration.
administer heparin using a 25-gauge or smaller needle to decrease the risk of hemorrhage.
305
```
A nurse is caring for a client who has a new prescription for ergotamine. The nurse should recognize that ergotamine is administered to treat which of the following conditions?
Raynaud's phenomenon
Migraine headaches
Ulcerative colitis
Anemia
```
Migraine headaches
Notes: can cause peripheral vasoconstriction and cyanosis to digits.
Ergotamine prevents or stops a migraine headache
Ergotamine is contraindicated for clients who have anemia or malnutrition.
306
```
A nurse is providing teaching to a client who has gout and a new prescription for allopurinol. The nurse should instruct the client to discontinue taking the medication for which of the following adverse effects?
Nausea
Metallic taste
Fever
Drowsiness
```
Fever
Notes: Mild gastrointestinal adverse effects, such as nausea, vomiting, abdominal pain, and diarrhea
Metallic taste is a mild adverse effect of allopurinol
Fever can indicate a potentially fatal hypersensitivity reaction
Drowsiness is a mild adverse effect of allopurinol
307
```
A nurse is caring for a client who is at 28 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer?
Oxytocin
Nifedipine
Dinoprostone
Misoprostol
```
Nifedipine
Notes: Oxytocin is an oxytocic medication used to stimulate uterine contractions for clients who are at term and to control postpartum hemorrhage. It is contraindicated for clients who are experiencing preterm labor.
Dinoprostone is an oxytocic medication used to stimulate uterine contractions for clients who are at term and to control postpartum hemorrhage. It is contraindicated for clients who are experiencing preterm labor.
Misoprostol is a prostaglandin used to promote ripening of the cervix and induce labor. It is contraindicated for clients who are experiencing preterm labor.
308
```
A nurse is teaching a newly licensed nurse about contraindications to ceftriaxone. The nurse should include a severe allergy to which of the following medications as a contraindication to ceftriaxone?
Gentamicin
Clindamycin
Piperacillin
Sulfamethoxazole-trimethoprim
```
Piperacillin
309
```
A nurse is caring for a client who has a new prescription for enalapril. The nurse should monitor the client for which of the following adverse effects of this medication?
Ecchymosis
Jaundice
Hypotension
Hypokalemia
```
Hypotension
Notes: Enalapril can cause a decrease in Hgb and Hct
Enalapril can cause kidney failure
Enalapril, an angiotensin-converting enzyme (ACE) inhibitor, can cause hypotension and postural hypotension
Enalapril increases potassium levels
310
```
A nurse is providing teaching to a client who has cirrhosis and a new prescription for lactulose. The nurse should instruct the client that lactulose has which of the following therapeutic effects?
Increases blood pressure
Prevents esophageal bleeding
Decreases heart rate
Reduces ammonia levels
```
Reduces ammonia levels
| Notes: Lactulose is a laxative that promotes the excretion of ammonia
311
```
A nurse is providing teaching to a client who has rhematoid arthritis and a prescription for long-term prednisone therapy. The nurse should instruct the client to monitor for which of the following adverse effects?
Stress fractures
Orthostatic hypotension
Gingival ulcerations
Weight loss
```
Stress fractures
Notes: Prednisone can cause demineralization of the bones and can lead to osteoporosis and stress fractures.
Clients who take prednisone are at risk for hypertension due to sodium and fluid retention.
Clients who take prednisone are at risk for weight gain due to water retention.
312
```
A nurse is caring for a client who has peptic ulcer disease and reports a headache. Which of the following medications should the nurse plan to administer?
Ibuprofen
Naproxen
Aspirin
Acetaminophen
```
Acetaminophen
313
```
A nurse is providing teaching to a client who has ulcerative colitis and a new prescription for sulfasalazine. The nurse should instruct the client to monitor for which of the following adverse effects of this medication?
Jaundice
Constipation
Oral candidiasis
Sedation
```
Jaundice
Notes: bloody diarrhea.
stomatitis
headache and peripheral neuropathy
314
```
A nurse is caring for a client who has a new prescription for amphotericin B. The nurse should plan to monitor the client for which of the following adverse effects?
Hyperkalemia
Hypertension
Constipation
Nephrotoxicity
```
Nephrotoxicity
Notes: antifungal medication that can cause hypokalemia, hypotension, diarrhea
nurse should monitor the client's creatinine every 3 to 4 days and increase fluid intake. The dosage of amphotericin B should be reduced if the client's creatinine is 3.5 mg/dL or greater.
315
```
A nurse is reviewing the laboratory values for a client who is receiving a continuous IV heparin infusion and has an aPTT of 90 seconds. Which of the following actions should the nurse prepare to take?
Administer vitamin K
Reduce the infusion rate
Give the client a low-dose aspirin
Request an INR
```
Reduce the infusion rate
Notes: aPTT of 90 seconds is outside the expected reference range of 60 to 80 seconds, which can cause anticoagulation. The nurse should contact the provider, reduce the infusion rate, and assess the client for bleeding.
Vitamin K is used to reverse the effects of warfarin
Aspirin can inhibit platelet aggregation and is contraindicated for a client who is receiving heparin.
An INR is indicated for a client who is receiving warfarin
316
```
A nurse is reviewing laboratory values for a client who reports fatigue and cold intolerance. The client has an increased thyroid stimulating hormone (TSH) level and a decreased total T3 and T4 level. The nurse should anticipate a prescription for which of the following medications?
Methimazole
Somatropin
Levothyroxine
Propylthiouracil
```
Levothyroxine
Notes: Methimazole inhibits thyroid production for a client who has hyperthyroidism
Somatropin is a growth hormone prescribed for a client who has a growth hormone deficiency of the anterior pituitary gland.
propylthiouracil blocks thyroid production and is a second-line medication used to treat hyperthyroidism.
317
A nurse is providing teaching to a parent of a child who has asthma and a new prescription for a cromolyn sodium metered dose inhaler. Which of the following statements by the parent indicates the need for further teaching?
"I will give my child a dose as soon as wheezing starts."
"My child should rinse out his mouth after using the inhaler."
"My child should exhale completely before placing the inhaler in his mouth."
"If my child has difficulty breathing in the dose, a spacer can be used."
"I will give my child a dose as soon as wheezing starts."
Notes: Cromolyn administered by inhaler can cause mouth and throat irritation. The client should rinse or gargle with water after each use.
The client should exhale completely, and then breathe in evenly while depressing the canister.
A spacer provides a chamber to hold the medication exhaled in suspension. It allows clients who have difficulty breathing in the entire dose in one inhalation to continue to receive medication in subsequent breaths.
318
```
A nurse is caring for a client who has a prescription for chlorothiazide to treat hypertension. The nurse should plan to monitor the client for which of the following adverse effects?
Thrombophlebitis
Hyperactive reflexes
Muscle weakness
Hypoglycemia
```
Muscle weakness
Notes: Chlorothiazide can cause hypercalcemia
Chlorothiazide can cause hypoactive reflexes.
Chlorothiazide is a thiazide diuretic used to treat hypertension and congestive heart failure
Chlorothiazide can cause hyperglycemia
319
```
A nurse is reviewing the laboratory results for a client who has a prescription for filgrastim. The nurse should recognize that an increase in which of the following values indicates a therapeutic effect of this medication?
Erythrocyte count
Neutrophil count
Lymphocyte count
Thrombocyte count
```
Neutrophil count
320
```
A nurse is administering subcutaneous epinephrine for a client who is experiencing anaphylaxis. The nurse should monitor the client for which of the following adverse effects?
Hypotension
Hyperthermia
Hypoglycemia
Tachycardia
```
Tachycardia
| Notes: Hyperglycemia, Hypertension, dysrhythmias is an adverse effect of epinephrine.
321
Tachycardia
| Notes: Hyperglycemia, Hypertension, dysrhythmias is an adverse effect of epinephrine.
Proteinuria
| Notes: Gentamicin can cause hypokalemia, apnea, impaired hearing
322
A nurse is providing teaching to a client who has a new prescription for hydrochlorothiazide 50 mg PO daily to treat hypertension. Which of the following instructions should the nurse include in the teaching?
"Take hydrochlorothiazide as needed for edema."
"Check your weight once each week."
"Take the hydrochlorothiazide on an empty stomach."
"Take the hydrochlorothiazide in the morning."
"Take the hydrochlorothiazide in the morning."
Notes: take hydrochlorothiazide on a regular basis, check his weight daily to monitor for edema, take hydrochlorothiazide with food to reduce gastric distress, take hydrochlorothiazide in the morning to allow for diuresis during the day and prevent nocturia.
323
```
A nurse is providing teaching to a newly licensed nurse about metoclopramide. The nurse should include in the teaching that which of the following conditions is a contraindication to this medication?
Hyperthyroidism
Intestinal obstruction
Glaucoma
Low blood pressure
```
Intestinal obstruction
Notes: Metoclopramide reduces nausea and vomiting by increasing gastric motility and promoting gastric emptying
Metoclopramide can be administered to a client who has hyperthyroidism
Metoclopramide can be administered to a client who has glaucoma.
Metoclopramide can be administered to a client who has hypotension
324
```
A nurse is providing teaching to a group of new parents about medications. The nurse should include that aspirin is contraindicated for children who have a viral infection due to the risk of developing which of the following adverse effects?
Reye's syndrome
Visual disturbances
Diabetes mellitus
Wilms' tumor
```
Reye's syndrome
325
```
A nurse is assessing a client who has a new prescription for chlorpromazine to treat schizophrenia. The client has a mask-like facial expression and is experiencing involuntary movements and tremors. Which of the following medications should the nurse anticipate administering?
Amantadine
Bupropion
Phenelzine
Hydroxyzine
```
Amantadine
Notes: Bupropion is an atypical antidepressant
Phenelzine is an MAOI antidepressant
Hydroxyzine is an antihistamine used to treat mild to moderate anxiety
326
```
A nurse is caring for a client who has a prescription for clopidogrel. The nurse should monitor the client for which of the following adverse effects?
Insomnia
Hypotension
Bleeding
Constipation
```
Bleeding
Notes: Clopidogrel can cause dizziness and headache
Clopidogrel can cause hypertension
Clopidogrel is an antithrombotic medication that inhibits platelet aggregation. It is used to prevent stenosis of coronary stents, myocardial infarctions, and strokes
Clopidogrel can cause diarrhea
327
```
A nurse is planning care for a client who has a seizure disorder and a new prescription for valproic acid. Which of the following laboratory values should the nurse plan to monitor? (Select all that apply.)
BUN
PTT
Aspartate aminotransferase (AST)
Urinalysis
Alanine aminotransferase (ALT)
```
```
PTT
Aspartate aminotransferase (AST)
Alanine aminotransferase (ALT)
```
328
A nurse is providing teaching to a newly licensed nurse about administering morphine via IV bolus to a client. Which of the following information should the nurse include in the teaching?
Respiratory depression can occur 7 min after the morphine is administered.
The morphine will peak in 10 min.
Withhold the morphine if the client has a respiratory rate less than 16/min.
Administer the morphine over 2 min.
respiratory depression can occur 7 min after the morphine is administered.
Notes: IV morphine peaks in 20 min.
withhold the morphine if the client has a respiratory rate less than 12/min.
administer morphine via IV bolus slowly over 4 to 5 min to prevent hypotension and respiratory depression.
329
```
A nurse is caring for an older adult client who has a prescription for zolpidem at bedtime to promote sleep. The nurse should plan to monitor the client for which of the following adverse effects?
Ecchymosis
Decreased urine output
Increased blood pressure
Dizziness
```
Dizziness
| Notes: Zolpidem can cause dizziness and daytime drowsiness. It can cause confusion in the older adult client.
330
```
A nurse is caring for an older adult client who has a new prescription for amitriptyline to treat depression. Which of the following diagnostic tests should the nurse plan to perform prior to starting the client on this medication?
Hearing examination
Glucose tolerance test
Electrocardiogram
Pulmonary function tests
```
Electrocardiogram
331
```
A nurse is caring for a client who has a new diagnosis of oral candidiasis after taking tetracycline for 7 days. The nurse should recognize that candidiasis is a manifestation of which of the following adverse effects?
Allergic response
Superinfection
Renal toxicity
Hepatotoxicity
```
Superinfection
332
A nurse on a medical unit is preparing to administer alendronate 40 mg PO for an older adult client who has Paget's disease of the bone. Which of the following actions should be the nurse's priority?
Administer the medication to the client before breakfast in the morning.
Ambulate the client to a chair prior to administering the medication.
Give the medication to the client with water rather than milk.
Teach the client how to take the medication at home.
Ambulate the client to a chair prior to administering the medication.
333
A nurse is providing teaching to a client who has a urinary tract infection and new prescriptions for phenazopyridine and ciprofloxacin. Which of the following statements by the client indicates the need for further teaching?
"If the phenazopyridine upsets my stomach, I can take it with meals."
"The phenazopyridine will relieve my discomfort, but the ciprofloxacin will get rid of the infection."
"I need to drink 2 liters of fluid per day while I am taking the ciprofloxacin."
"I should notify my provider immediately if my urine turns an orange color."
"I should notify my provider immediately if my urine turns an orange color."
Notes: Phenazopyridine is a urinary tract analgesic used to relieve pain and burning during urination. Ciprofloxacin is a fluoroquinolone antibiotic that acts by destroying and inhibiting bacteria.
The client should drink 2 to 3 L of fluid while taking ciprofloxacin to dilute the urine and flush the urinary tract.
334
```
A nurse is providing teaching to a client who has chronic kidney failure with an AV fistula for hemodialysis and a new prescription for epoetin alfa. Which of the following therapeutic effects of epoetin alfa should the nurse include in the teaching?
Reduces blood pressure
Inhibits clotting of fistula
Promotes RBC production
Stimulates growth of neutrophils
```
Promotes RBC production
Notes: Epoetin alfa can cause hypertension
Epoetin alfa cause clot formation.
335
```
A nurse is caring for a client who has a new prescription for tamoxifen. The nurse should recognize that tamoxifen has which of the following therapeutic effects?
Antiestrogenic
Antimicrobial
Androgenic
Anti-inflammatory
```
Antiestrogenic
Notes: Tamoxifen is an antiestrogen medication used to treat cancer of the breast in both pre- and postmenopausal women. It is also used to prevent breast cancer in women who are at an increased risk.
336
A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse?
Remove the child's contaminated clothing.
Check the child's respiratory status.
Administer an antidote to the child.
Establish IV access for the child.
Check the child's respiratory status.
337
A nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include?
"Your child should be referring to himself using the appropriate pronoun by 18 months of age."
"A toddler's interest in looking at pictures occurs at 20 months of age."
"A toddler should have daytime control of his bowel and bladder by 24 months of age."
"Your child should be able to scribble spontaneously using a crayon at the age of 15 months."
"Your child should be able to scribble spontaneously using a crayon at the age of 15 months."
Notes: A toddler's use of the appropriate pronoun when referring to self does not occur until 30 months of age.
A toddler develops an intense focus and interest in pictures at 15 months of age.
Most toddlers have bowel and bladder control during the daytime by 30 months of age.
The nurse should teach the parent that at the age of 15 months, the toddler should be able to scribble spontaneously
338
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take?
Perform the assessment in a head to toe sequence.
Minimize physical contact with the child initially.
Explain procedures using medical terminology.
Stop the assessment if the child becomes uncooperative.
Minimize physical contact with the child initially.
339
```
A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory?
Pneumococcal polysaccharide
Meningococcal polysaccharide
Rotavirus
Herpes zoster
```
Meningococcal polysaccharide
Notes: final dose of the rotavirus immunization is administered prior to the age of 8 months
herpes zoster immunization is recommended for adults over the age of 60
pneumococcal polysaccharide immunization is administered to children between the ages of 2 and 18 years
340
```
A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most common food allergy in children?
Cow's milk
Wheat bread
Corn syrup
Eggs
```
Cow's milk
341
A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching?
"I lock my medications in the medicine cabinet."
"I keep my child's crib mattress at the highest level."
"I turn pot handles to the side of my stove while cooking."
"I will give my child syrup of ipecac if she swallows something poisonous."
"I lock my medications in the medicine cabinet."
342
```
A nurse is performing a physical assessment on a 6-month-old infant. Which of the following highlight reflexes should the nurse expect to find?
Stepping
Babinski
Extrusion
Moro
```
Babinski
Notes: stepping reflex, in which the infant takes reflexive steps when placed on his or her feet in an upright position, disappears by the age of 4 weeks.
The Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year
The extrusion reflex, which causes the infant to spit out food placed on the tongue rather than moving it to the back of the mouth, is absent by the age of 4 months.
Moro reflex should disappear at the age of 3 to 4 months. It is an extension of the arms and flexion of the elbows in response to a sudden jarring, followed by flexion and adduction of the extremities.
343
A nurse is preparing to administer recommended highlight immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer?
Human papillomavirus (HPV) and hepatitis A
Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP)
Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV)
Varicella (VAR) and live attenuated influenza vaccine (LAIV)
Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV)
Notes: The HPV immunization series is started at the age of 11 years
MMR immunization is administered at 12 to 15 months of age, and the TDaP immunization is administered at 11 to 12 years of age.
Varicella is not administered to children younger than 12 months, and the LAIV immunization is not administered to children under 2 years of age.
344
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care?
Assign an assistive personnel to feed the child.
Explain sounds the child is hearing.
Have the child use a cane when ambulating.
Rotate nurses caring for the child.
Explain sounds the child is hearing.
345
```
A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain?
Ask the parents.
Use the FACES scale.
Use the numeric rating scale.
Check the child's temperature.
```
Use the FACES scale.
346
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment?
Grabs feet and pulls them to her mouth
Posterior fontanel is closed
Legs remain crossed and extended when supine
Birth weight has doubled
Legs remain crossed and extended when supine
Notes: The posterior fontanel closes at approximately 2 months of age. The anterior fontanel is closed by 18 months of age.
Crossed and extended legs when supine is a finding associated with cerebral palsy.
Infants should double their birth weight by 6 months and triple their birth weight by 12 months.
347
```
A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child?
Hand-eye coordination
Sense of trust
Object permanence
Egocentrism
```
Object permanence
Notes: Egocentrism refers to the fact that infants are self-centered and cannot see things from a point of view other than their own
348
A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following actions should the nurse take?
Have the toddler wear a disposable gown when in the unit's playroom.
Wear sterile gloves when changing the toddler's diapers.
Wear a mask when assisting the toddler with meals.
Ask visitors to wear an N-95 mask when entering the room.
Wear a mask when assisting the toddler with meals
349
A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider?
Head lags when pulled from a lying to a sitting position
Absence of startle and crawl reflexes
Inability to pick up a rattle after dropping it
Rolls from back to side
Head lags when pulled from a lying to a sitting position
Notes: startle reflex disappears by the age of 4 months, and the crawl reflex disappears around the age of 6 weeks.
At the age of 5 months, the infant can visually follow a dropped object, but the infant is unable to pick the object up until around the age of 6 months.
able to roll from her back to her side at the age of 4 months.
350
A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take?
Wash and dry the infant's genitalia and perineum thoroughly.
Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area.
Avoid placing the scrotum inside the collection bag.
Wait several hours after positioning the device before checking it.
Wash and dry the infant's genitalia and perineum thoroughly.
351
A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following information is appropriate for the nurse to include in the teaching?
Decrease the child's vitamin C intake until the blood lead level decreases to zero.
Administer a folic acid supplement to the child each day.
Give pancreatic enzymes to the child with meals and snacks.
Ensure the child's dietary intake of calcium and iron is adequate.
Ensure the child's dietary intake of calcium and iron is adequate.
352
A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)
Observe the parents' actions when feeding the child.
Maintain a detailed record of food and fluid intake.
Follow the child's cues as to when food and fluids are provided.
Sit beside the child's high chair when feeding the child.
Play music videos during scheduled meal times.
MY ANSWER
Observe the parents' actions when feeding the child.
| Maintain a detailed record of food and fluid intake.
353
A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluation?
The child prefers playmates of the same sex.
The child is competitive when playing board games.
The child complains daily about going to school.
The child enjoys spending time alone.
The child complains daily about going to school.
354
A nurse is providing education to the parent of a toddler who is about to receive an MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching?
"My child should not play with other children for 2 days."
"I will need to return in 2 weeks for my child to receive the varicella immunization."
"I will help my child to blow bubbles during the injection."
"My child may have some drainage from the injection site."
"I will help my child to blow bubbles during the injection."
355
```
A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group?
Copies a circle
Cuts foods using a table knife
Begins writing in cursive
Prints first and last name clearly
```
Copies a circle
Notes: cutting food using a table knife is a fine-motor skill expected of 7-year-old children.
cursive writing is an expected skill for an 8- to 9-year-old child.
children will print their first name around the age of 5 years.
356
```
A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play?
Brightly colored mobile
Plastic stethoscope
Small piece jigsaw puzzle
A book of short stories
```
Plastic stethoscope
357
A nurse in an emergency department is caring for an 8-year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering?
Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine
A single injection of tetanus immune globulin (TIG) mixed with the pediatric tetanus booster (DT)
Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine
Adult tetanus booster (Td)
Adult tetanus booster (Td)
358
A nurse providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include?
Follow a nightly routine and established bedtime.
Encourage active play prior to bedtime.
Let the child remain awake until tired enough to go to sleep.
Reward the child with a food treat just prior to sleep if the child goes to bed on time.
Follow a nightly routine and established bedtime.
359
A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take?
Ask the child to hold his breath and then blow it out slowly.
Ask the child to describe a pleasurable event.
Bounce the child gently while holding him upright.
Rock the child in long rhythmic movements.
Rock the child in long rhythmic movements.
360
A nurse is assessing a 6-year-old child at a well-child visit. Which of the following findings requires further assessment by the nurse?
Presence of sparse, fine pubic hair
Decreased head circumference compared to full height
Increased leg length related to height
Presence of a loose, central incisor
Presence of sparse, fine pubic hair
Notes: The development of sexual characteristics prior to the age of 9 years in boys, and 8 years in girls, is an indication of precocious puberty
The head circumference of a school-age child decreases when compared to full height due to skeletal lengthening.
Body proportion varies with a slimmer appearance and longer legs in the school-age child. Leg length increases and waist circumference decreases when related to height in this age group.
The deciduous teeth are being shed at this age, starting with the lower central incisors at approximately the age of 6.
361
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.)
The child views death as similar to sleep.
The child is interested in what happens to his body after death.
The child recognizes that death is permanent.
The child believes his thoughts can cause death.
The child thinks death is a punishment.
The child views death as similar to sleep.
The child believes his thoughts can cause death.
The child thinks death is a punishment.
362
A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take?
Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication.
Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain.
Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10.
Reinforce teaching with the client about how to push the button to deliver the medication.
Reinforce teaching with the client about how to push the button to deliver the medication.
363
```
A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile of height. Which of the following findings should the nurse report to the provider?
Heart rate 175/min
Respiratory rate 26/min
Blood pressure 88/40 mm Hg
Temperature 37.6° C (99.7° F)
```
Heart rate 175/min
364
A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching?
"I can give my baby 4 ounces of juice to drink each day."
"I will offer my baby dry cereal and chilled banana slices as snacks."
"I am introducing my baby to the same foods the family eats."
"My infant drinks at least 2 quarts of skim milk each day."
"My infant drinks at least 2 quarts of skim milk each day."
| Notes: can result iron deficiency anemia
365
```
A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions?
Side-lying
Semi-recumbent
Flexed sitting
Supine
```
Supine
366
```
A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay?
Creeps on hands and knees
Inability to vocalize vowel sounds
Uses crude pincer grasp
Stands by holding onto support
```
Inability to vocalize vowel sounds
367
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take?
Administer the medication while the infant is supine.
Give the medication at the side of the infant's mouth.
Add the medication to a full bottle of the infant's formula.
Administer the medication slowly while holding the nares closed.
Give the medication at the side of the infant's mouth.
368
```
A nurse on a pediatric unit is reviewing the health record of a child who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization?
Age 10
Frequent hospitalizations
Parent bonding with child
Calm, quiet demeanor
```
Frequent hospitalizations
369
A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion?
"The absence of oral burns excludes the possibility of esophageal burns."
"Treatment focuses on neutralization of the chemical."
"Injury by a corrosive liquid is more extensive than by a corrosive solid."
"Immediate administration of activated charcoal is warranted."
"Injury by a corrosive liquid is more extensive than by a corrosive solid."
370
A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent?
"The PICC line will last several weeks with proper care."
"The public health nurse will rotate the insertion site every 3 days."
"You will need to make certain the arm board is in place at all times."
"Your child will go to the operating room to have the line placed."
"The PICC line will last several weeks with proper care."
371
```
A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance?
Give the toddler milk.
Go to an emergency department.
Call the poison control center.
Induce vomiting.
```
Call the poison control center.
372
```
A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child?
Cutting figures from colored paper
Drawing stick figures using crayons
Riding a tricycle
Building towers of blocks
```
Building towers of blocks
Notes: Riding a tricycle is an appropriate activity for a 3-year-old child.
draw stick figures is an appropriate activity for a 4-year-old child.
2-year-old children do not have the coordination abilities to cut with scissors. This activity is appropriate for a 3-year-old child.
373
```
A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse?
Primary dentition is complete
Unable to hop on one foot
Birth weight is tripled
Able to state first and last name
```
Birth weight is tripled
374
```
A school nurse has requested the school board remove a piece of playground equipment due to a documented increase in injuries that can be linked back to it. The nurse's actions are an example of which of the following?
Deontology
Morality
Principlism
Advocacy
```
Advocacy
375
```
A nurse is reinforcing teaching about the diet for dumping syndrome to a client who is postoperative following a gastrectomy. Which of the following food selections by the client indicates the teaching was effective?
Toast with peanut butter
Apple juice
Yogurt with fresh fruit
Beef broth
```
Toast with peanut butter
376
```
A nurse is reviewing the records of a group of older adult clients. Which of the following findings should the nurse identify as an unexpected manifestation of the aging process?
Decreased absorption of nutrients
Impaired excretion of medications
High-pitched frequency hearing loss
Obesity
```
Obesity
Notes: The nurse should identify decreased nutrient absorption as an expected finding in the older adult client. With aging, the villi in the intestine flatten and are less able to absorb nutrients such as vitamins B and D, calcium, iron, and fat.
The nurse should identify impaired medication excretion as an expected finding in the older adult client due to the decreased ability of the kidney to filter metabolites.
The nurse should identify hearing loss of high-pitched sounds as an expected finding in the older adult client. Impaired hearing of high-frequency sounds makes it difficult for older adult clients to discriminate voices from background noise in a room.
The nurse should recognize that, although obesity is found among a large percentage of the older adult population, this is an unexpected finding and can lead to cardiovascular disease, diabetes, and stroke.
377
A nurse is caring for an older adult client who has a hip fracture and is rating his pain at 8 on a scale of 0 to 10. Which of the following medications should the nurse administer?
Capsaicin topical gel
Oxycodone/acetaminophen 7.5/325 tablet PO
Celecoxib 200 mg capsule PO
Aspirin 325 mg tablet PO
Oxycodone/acetaminophen 7.5/325 tablet PO
Notes: The nurse should administer capsaicin topical gel to a client who has minor pain.
A client who rates his pain as 8 on a scale of 0 to 10 is experiencing severe pain, and the nurse should administer an opioid for this type of pain. Oxycodone/acetaminophen is a combination of an opioid and a nonopioid analgesic medication and is an appropriate medication to administer to the client. The nurse should monitor the client for adverse effects, such as respiratory depression, and proactively address constipation that occurs with opioid use.
The nurse should administer celecoxib, an NSAID, to treat mild to moderate pain.
The nurse should administer aspirin, an NSAID, to treat mild to moderate pain.
378
```
A community health nurse is assessing an older adult client who lives alone. The nurse finds that, although the client is able to answer all questions appropriately, the client has a decreased attention span, expresses feelings of overwhelming sadness, and has a low energy level. The nurse should identify that the client is exhibiting manifestations of which of the following disorders?
Delusions
Dementia
Delirium
Depression
```
Depression
Notes: A client who has false personal beliefs despite evidence to the contrary is exhibiting manifestations of delusions.
A client who has severe memory loss and an inability to solve problems is exhibiting manifestations of dementia.
A client who has a sudden onset of confusion, disorientation, altered level of consciousness, and an inability to focus is exhibiting manifestations of delirium.
The client who has an inability to sleep or complete ADLs is exhibiting manifestations of depression. Depression involves a cluster of manifestations that include changes in sleep habits, appetite, and relationships with others. Clients who have depression might have a decreased ability to make decisions or concentrate and, in some cases, complete ADLs. Anhedonia, the inability to feel happy, is another manifestation of depression.
379
A nurse is caring for an older adult client who is unresponsive following a stroke. Which of the following actions should the nurse take while providing oral care?
Turn the client on his side before starting oral care.
Use the thumb and index finger to keep the client's mouth open.
Cleanse the client's oral mucosa with a toothbrush.
Perform oral care using sterile gloves.
Turn the client on his side before starting oral care.
Notes: The nurse should place the client in a lateral position to allow excess fluids to run out of his mouth into a basin, which reduces the risk of aspiration of fluids and secretions
The nurse should use a padded tongue blade or an oral airway, not a thumb and index finger, to keep the client's mouth open. The client might suddenly bite down and injure the nurse's fingers.
The nurse should use a moistened foam swab to clean the oral mucosa. The nurse should cleanse each area of the mouth with a separate swab to avoid transferring microorganisms from one area to another.
The nurse should apply clean gloves prior to performing oral care for a client.
380
```
A nurse is teaching a group of healthy, older adult clients about expected age-related changes and sexual response. Which of the following changes should the nurse include as an age-related change?
Decreased refractory time
Decreased vaginal lubrication
Loss of female clients' orgasm ability
Premature ejaculation
```
Decreased vaginal lubrication
| Notes:
381
A nurse is caring for an older adult client who is expressing feelings of grief and longing for his earlier life. Which of the following actions should the nurse take?
Listen attentively and allow the client to talk about the past.
Change the topic of conversation.
Let the client know that this is a common issue for older adult clients.
Tell the client about some younger clients who are in worse shape than he is.
Listen attentively and allow the client to talk about the past.
382
```
A nurse in an assisted living facility is assessing an older adult client who moved in 3 months ago following the death of his partner. The client reports awakening early in the morning and admits to feeling very sad. The nurse should identify that the client is experiencing which of the following types of grief?
Anticipatory grief
Delayed grief
Acute grief
Disenfranchised grief
```
Acute grief
Notes: The nurse should identify anticipatory grief as an expected response occurring prior to an actual loss. Clients experiencing anticipatory grief might be preoccupied with the impending loss, make extensive funeral arrangements, or exhibit a change in attitude toward the lost thing or individual.
The client experiencing delayed grief is unable to accept the reality of a loss. The client remains in the denial stage of grief and is unable to allow himself to experience feelings of sorrow and loss.
The client experiencing acute grief will have both somatic and psychological manifestations of distress, such as the inability to sleep well or profound sadness. The nurse should identify that this client is experiencing acute grief and further assess his support system, concurrent stressors in his life, and his ability to manage stress.
The client experiencing disenfranchised grief cannot openly acknowledge the loss because of societal or religious norms.
383
A nurse is assessing an older adult client who reports feeling anxious about financial concerns and having difficulty sleeping for several months. Which of the following factors should the nurse identify as a factor in the client's sleep pattern?
Older adults require much less sleep than young adults.
Older adults seldom awake at night once they have fallen asleep.
Older adults have an increase in stages III and IV of sleep.
Anxiety can cause disturbed sleep patterns.
A nurse is assessing an older adult client who reports feeling anxious about financial concerns and having difficulty sleeping for several months. Which of the following factors should the nurse identify as a factor in the client's sleep pattern?
Older adults require much less sleep than young adults.
Older adults seldom awake at night once they have fallen asleep.
Older adults have an increase in stages III and IV of sleep.
Anxiety can cause disturbed sleep patterns.
384
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A community health nurse is visiting the home of an older adult client and her caregiver. The client has excoriations to her wrists and ankles. Which of the following actions should the nurse take first?
Refer the caregiver to a support group.
Interview the client in private.
Document the client's wounds.
Contact adult protective services.
```
Interview the client in private.
385
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A nurse is performing an assessment on an older adult client who has chronic pain. Which of the following effects of unrelieved pain should the nurse identify as a priority finding to report?
Impaired mobility
Decreased independence
Decreased self-esteem
Impaired socialization
```
Impaired mobility
386
A nurse is completing medication reconciliation for an older adult client who is receiving multiple medications. Which of the following actions should the nurse take first?
Clarify the client's list of medications with the pharmacist.
Compare the current list against the new medication prescriptions.
Investigate any discrepancies on the list.
Ask the client about over-the-counter medications she is taking.
Ask the client about over-the-counter medications she is taking.
Notes: Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. When performing medication reconciliation, it is important that the nurse collect a list of all the medications the client takes in order to compare the full list of medications against any new medications the client will take. The list should include prescriptions, over-the-counter medications, and herbal and nutritional supplements.
387
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A nurse is caring for an older adult client who is on bed rest. Which of the following foods should the nurse plan to include on the client's breakfast tray to prevent constipation?
A banana
Hash brown potatoes
An egg and cheese omelet
Stewed prunes
```
Stewed prunes
388
A nurse is teaching an older adult client about methods to improve sleep. Which of the following statements should the nurse include in the teaching?
"Go to bed at the same time every night."
"Watch television in bed until you are sleepy."
"Drink a glass of wine before going to bed."
"Engage in physical activity in the evenings."
"Go to bed at the same time every night."
Notes: The nurse should recommend that the client keep consistent sleep and wake times, even on the weekends. Having a regular sleep schedule will help minimize the alterations to the circadian rhythm that occurs in the older adult client.
The nurse should discourage the client from watching television or performing any work in bed because this disrupts sleep quality. Instead, the nurse should recommend light reading or listening to relaxing music to assist the client in falling asleep.
The nurse should discourage the use of alcohol or caffeine products prior to bedtime because these are stimulants and diuretics and inhibit sleep. Instead, the client can have a light carbohydrate or a glass of milk as a bedtime snack.
The nurse should recommend the client participate in physical activity during the daytime as this can enhance sleep. However, the client should not participate in physical activity within 3 hr prior to bedtime because this can impair sleep.
389
A nurse is teaching an older adult client who had a total hip arthroplasty about ambulating with a standard walker. Which of the following actions by the client indicates an understanding of the teaching?
The client adjusts the height of the walker so the hand grips are at the level of his waist.
The client moves the walker ahead about 15.24 cm (6 in) and then steps into the walker.
The client uses the walker to pull himself up from a sitting to a standing position.
The client uses the walker to climb the stairs.
The client moves the walker ahead about 15.24 cm (6 in) and then steps into the walker.
Notes: The nurse should instruct the client that placing the walker at this height will increase the strain on his upper extremities. The client should have a slight bend in the elbow when his hands are on the walker grips.
The correct technique for using a walker is to balance on both feet; lift the walker and place it in front; walk into the walker, using it for support when standing on the affected limb; and then balance on both feet before repeating the sequence. This provides maximum support for the client.
The nurse should emphasize the safe manner in which to go from a sitting to a standing position is to push up from the chair, gain balance, and then move the hands to the walker one at a time. Pulling oneself up by using the walker causes instability and can result in a client fall.
The nurse should instruct the client that the use of the walker on stairs is unsafe and might result in a fall. When climbing or descending stairs, the client should hold onto the hand rails and use the walker only on flat surfaces.
390
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A nurse is caring for an older adult client who has a terminal illness. The client tells the nurse, "I just want to live one more month so I can see my grandchild get married." Which of the following Kübler-Ross stages of grief should the nurse identify the client is experiencing?
Depression
Acceptance
Denial
Bargaining
```
Bargaining
391
```
A nurse is reviewing the medical record of an older adult client. For which of the following medications should the nurse conduct a hearing assessment of the client?
Omeprazole
Ferrous sulfate
Digoxin
Furosemide
```
Furosemide
Notes: The nurse should monitor the client who is taking omeprazole for bone loss.
The nurse should monitor the client who is taking ferrous sulfate for gastrointestinal effects, such as bloating or changes in elimination.
The nurse should monitor the client who is taking digoxin for manifestations of hypokalemia, such as muscle weakness.
Furosemide can cause ototoxicity, especially in the older adult client, because there is a decrease in medication metabolism in the kidneys
392
A nurse is caring for a client who has aphasia following a stroke. Which of the following actions should the nurse take?
Present one idea in a sentence.
Avoid using nonverbal communication techniques.
Speak loudly.
Use simplified language.
Present one idea in a sentence.
| Notes: Aphasia is an inability to comprehend or formulate language
393
A nurse is teaching a group of older adult clients about dietary needs. Which of the following dietary recommendations should the nurse include in the teaching?
"You should consume 1,200 milligrams of calcium daily."
"Consume 4 percent of your diet as fat."
"You should drink 1,500 milliliters of fluid daily."
"Consume 40 percent of your diet as protein."
You should consume 1,200 milligrams of calcium daily.
Notes: The nurse should encourage the older adult client to limit fat intake to 20% to 30% of his total daily intake. Increased fat consumption leads to cardiovascular disease and inflammation.
For older adult clients, the nurse should recommend a fluid intake of 3.7 L for male clients and 2.7 L for female clients. Insufficient intake of fluids leads to constipation and dehydration.
The nurse should emphasize that protein requirements for the older adult client ranges from 10% to 35% of total daily intake. Less than the recommended amount of protein leads to protein calorie malnutrition and an excess amount causes ketosis and can be harmful to kidney function.
394
```
A nurse managing an adult day care is developing treatment plans for older adult clients. Which of the following therapeutic strategies should the nurse use to help the clients achieve Erikson's developmental task for this age group?
Music therapy
Reminiscence therapy
Meditation therapy
Pet therapy
```
Reminiscence therapy
395
A nurse is transferring an older adult client who has right-sided weakness from the bed to a wheelchair. Which of the following actions should the nurse take to provide a safe transfer?
Keep the client at arm's length while performing the transfer.
Bend at the waist to get down to the client's level.
Maintain a straight back and bend at the knees.
Place the wheelchair at the head of the bed on the client's right side.
Maintain a straight back and bend at the knees.
396
A nurse at a long-term care facility is teaching an older adult client about ambulating with a quad-cane. Which of the following statements should the nurse include in the teaching?
"Adjust the height of the cane so that you can flex your elbow at 45 degrees."
"Hold the cane in the hand on the stronger side of your body."
"Place the flat side of the cane away from your foot."
"Move the cane and your stronger leg at the same time."
"Hold the cane in the hand on the stronger side of your body."
Notes: The nurse should instruct the client that the cane's height should allow the elbow to be slightly flexed. Having a flexion of 45º would make the cane too tall for safe use.
The client should hold the cane with the hand on the stronger side of her body so that she can move the cane to support the weaker leg. This action allows for a more normal gait, with the ipsilateral arm and weaker leg moving at the same time.
The client should place the flat edge of the base of the cane facing toward her foot. This allows the client to ambulate without the risk of getting her foot caught in the base of the cane and falling.
The nurse should instruct the client to move the cane and her weaker leg at the same time. This action allows for a more normal gait with the ipsilateral arm and weaker leg moving at the same time.
397
```
A nurse is performing skin assessments for a group of older adult clients. Which of the following findings should the nurse identify as a benign, age-related skin change commonly seen in older adult clients?
Liver spots
Nevi
Atopic dermatitis
Psoriasis
```
Liver spots
Notes: Liver spots, also known as age spots or lentigines, are flat, brownish-black macules that usually occur in sun-exposed areas of the body. Aging and exposure to sunlight, or other forms of ultraviolet light, can result in increased pigmentation. Liver spots are extremely common after 40 years of age; they occur most often on the forearms, shoulders, face, forehead, and backs of the hands, which are also the areas of highest sun exposure. They are harmless and painless, but they can affect the client's cosmetic appearance.
398
A nurse at a long-term care facility is planning care for a client who has Alzheimer's disease and wanders at night. Which of the following interventions should the nurse include in the plan?
Place the client in wrist restraints at night.
Request a prescription for a psychotropic medication.
Assign the client to a room closer to the nurse's station.
Keep the television on at night.
Assign the client to a room closer to the nurse's station.
399
A nurse at a long-term care facility is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan?
Vary the staff members caring for the client.
Use photographs as memory triggers.
Provide a minimum of three activity choices to the client.
Break client tasks down to three or four steps at a time.
Use photographs as memory triggers.
400
A nurse is caring for an older adult client who reports that he has just retired and expresses feelings of loneliness due to the loss of daily interactions with coworkers. Which of the following responses should the nurse make?
"Do you know about the local senior citizen group?"
"You need to take a vacation."
"But now you can finally relax and enjoy your life."
"Why don't you go into work and visit with your old friends?"
"Do you know about the local senior citizen group?"
401
```
A public health nurse is planning an immunization clinic for older adults. At which of the following times should an older adult client receive the influenza vaccine?
Once during the client's lifetime
Every 10 years
Every 5 years
Annually in the fall
```
Annually in the fall
402
A home-health nurse is caring for a client who has cancer and is using a fentanyl transdermal patch for pain control. Which of the following actions should the nurse take when caring for this client?
Avoid using a heating pad on the area with the patch.
To decrease the dose, cut the patch in half.
Dispose of the used patch by placing it in the trash can.
Assess the client for urinary retention every 8 hr.
Avoid using a heating pad on the area with the patch.
Notes: Applying heat over the site of the transdermal patch will increase the rate of absorption of the opioid medication and might cause respiratory depression.
The nurse should obtain a new patch with the appropriate dosage of medication. Cutting the patch will effect delivery of the medication and will result in inappropriate dosage delivery.
The nurse should dispose of a used patch by folding it with the adhesive edges together and placing it in a tamper-proof receptacle.
The nurse should assess the client using a fentanyl patch for urinary retention every 4 to 6 hr.
403
```
A nurse working in a community health center is completing an assessment of an older adult female client. Which of the following findings should the nurse identify as a priority?
Rales heard in the bases of the lungs
Constipation
Urinary frequency
Painful intercourse
```
Rales heard in the bases of the lungs
| Notes: an abnormal rattling sound heard when examining unhealthy lungs with a stethoscope.
404
A nurse is admitting an older adult client who has urinary incontinence and smells strongly of urine. The client's partner, who has been caring for her at home, states that he is sorry and embarrassed about the unpleasant smell. Which of the following responses should the nurse make?
"A lot of clients who are cared for at home have the same problem."
"Don't worry about it. She will get a bath, and that will take care of the odor."
"It must be difficult to care for someone who has incontinence."
"When was the last
"It must be difficult to care for someone who has incontinence."
405
```
A nurse is conducting an in-service for a group of assistive personnel about the basic needs of older adult clients. Which of the following statements should the nurse include in the teaching?
"Caloric needs are increased."
"Renal function is increased."
"Deep sleep is decreased."
"Exercise needs are decreased."
```
"Deep sleep is decreased."
406
A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) and has been losing weight about ways to improve his nutritional intake. Which of the following statements by the client indicates an understanding of the teaching?
"I will choose hot foods to decrease the sense of fullness when eating."
"I should add grated cheese to sauces and vegetables."
"I will eat my largest meal of the day in the evening."
"I should consume a diet high in carbohydrates."
"I should add grated cheese to sauces and vegetables."
Notes: The nurse should emphasize to the client that consuming cold foods will decrease his sense of satiety, allowing him to consume more calories.
The nurse should reinforce that adding cheese to side dishes will increase the protein and calcium intake as well as increase calories. This will assist the client in regaining weight and stamina.
The nurse should recommend that the client consumes his largest meal early in the day, when energy is highest. This will allow him to consume more calories without causing fatigue.
The nurse should emphasize that the client who has COPD should consume a high-protein diet. The client should limit carbohydrates because these break down into carbon dioxide and increase food-related dyspnea.
407
A nurse is providing teaching to a client who is to start taking alendronate sodium. Which of the following recommendations should the nurse include in the teaching?
"The medication may be crushed if you have difficulty swallowing it."
"Drink a full glass of milk when you take the medication."
"Take the medication at bedtime."
"Discontinue the medication if you develop heartburn."
"Discontinue the medication if you develop heartburn."
Notes: The nurse should instruct the client that this medication must be taken whole. Crushing or chewing alendronate can cause esophagitis or esophageal cancer.
The nurse should instruct the client to take alendronate with a full glass of water. Food or fluids other than water interfere with the medication's absorption.
The nurse should instruct the client to take alendronate in the morning before eating or drinking. It is also important to reinforce that the client must remain upright for 30 to 60 min after taking this medication to avoid esophagitis.
The nurse should instruct the client to stop taking the medication if she develops heartburn or if it worsens and to contact her provider. This is an indication that esophageal irritation has occurred. Ways to avoid this are to take alendronate with 240 mL (8 oz) of water and to avoid lying down for 30 to 60 min after taking the medication.
408
```
A nurse is caring for an older adult client who is having a stroke. After assessing airway, breathing, and circulation, which of the following assessments is the nurse's priority?
Level of consciousness
Muscle tone
Sensory changes
Gag reflex
```
Level of consciousness
Notes: The nurse should assess the client's level of consciousness to evaluate for increases in intracranial pressure that might have occurred. The nurse should use the NIH stroke scale or the Glasgow coma scale to evaluate level of consciousness.
409
A nurse is providing teaching to a client who is to start taking finasteride. Which of the following statements by the client indicates an understanding of the teaching?
"I will see improvement in my symptoms within one week."
"I can expect an increased libido with this medication."
"I should see a decrease in my PSA levels."
"I must take this medication within 60 min of sexual activity."
"I should see a decrease in my PSA levels."
Notes: The nurse should reinforce that this medication might take up to 6 months before the client responds.
The nurse should inform the client that one of the adverse effects of this medication is a decrease in libido. Other side effects include orthostatic hypotension, gynecomastia, and decreased ejaculate volume.
The nurse should emphasize that the decrease in PSA levels with this medication will be measured 6 months after starting treatment. The expected decline is 30% to 50% in the PSA level.
The nurse should emphasize that this medication decreases mechanical obstruction of the prostate, and it has no effect on sexual activity.
410
A nurse is teaching an older adult client who is healthy and has chronic constipation about establishing a bowel retraining program. Which of the following statements should the nurse include in the teaching?
"Limit physical activity during the day."
"Set a time limit of 10 minutes when attempting to defecate."
"Increase the fiber content of your diet."
"Increase your fluid intake to 5,000 milliliters per day."
"Increase the fiber content of your diet."
Notes: The client should increase exercise throughout the day to stimulate and promote bowel function. The client can walk, perform modified sit-ups, and perform pelvic tilt exercises to stimulate peristalsis.
An important factor in bowel training is allowing a reasonable amount of time to defecate. The nurse should encourage the client to attempt defecation for a period of 15 to 20 min.
The purpose of a bowel training program is to manipulate factors within the client's control to produce the elimination of a soft-formed stool at regular intervals. The increase of fiber in the client's diet will help to increase the effectiveness of a bowel training program.
The client should increase his fluid intake to 2,500 to 3,000 mL per day. Increasing fluid intake to 5,000 mL is unreasonable.
411
A nurse is assessing an 85-year-old client. Which of the following findings should the nurse report to the provider?
A widened anterior-posterior chest diameter
Presence of an S4 heart sound
Differences in pulse strength between lower extremities
Post-void residual of 75 mL
Differences in pulse strength between lower extremities
412
```
A nurse is caring for an older adult client who has moderate hearing loss. Which of the following actions should the nurse take to enhance communication?
Speak with exaggerated lip movement.
Speak at a moderate rate.
Speak in a louder voice.
Speak using a higher pitch.
```
Speak at a moderate rate.
413
A nurse is assessing an older adult client who has right-sided heart failure. Which of the following findings is the nurse's priority?
Oxygen saturation is 92% on room air.
The client consumes 20% of meals.
Weight has increased 0.91 kg (2 lb) in 24 hr.
The client has 1+ edema in the lower extremities.
Weight has increased 0.91 kg (2 lb) in 24 hr.
Notes: The nurse should monitor the oxygen saturation of the client because a decrease in oxygen saturation below 90% indicates a worsening of condition and, potentially, pulmonary edema.
The nurse should evaluate the client's food intake and appetite. Anorexia and nausea are common manifestations of right-sided heart failure and place the client at risk for nutritional deficiencies
The nurse should report pitting edema because this is an indication of fluid retention
nurse should evaluate daily weight of client's experiencing heart failure. A weight gain of 0.45 to 0.91 kg (1 to 2 lb) overnight or 1.36 kg (3 lb) within one week is an indication of worsening heart failure.
414
A nurse is teaching an older adult client about osteoporosis. Which of the following statements should the nurse include in the teaching?
"Cottage cheese is a good source of calcium."
"Increase your caffeine intake."
"Brisk walking will help prevent bone loss."
"Hormone replacement therapy with estrogen will increase your risk of osteoporosis."
"Brisk walking will help prevent bone loss."
Notes: The nurse should include dietary sources of calcium and vitamin D in the teaching. Cottage cheese, however, is not a good source of calcium as it loses the calcium during processing.
The nurse should encourage the client to limit caffeine intake because it enhances the excretion of calcium.
The nurse should encourage weight-bearing exercises to help minimize bone loss in the older adult client. A sedentary lifestyle, on the other hand, leads to a loss of minerals in the bones, especially calcium and phosphorus
The nurse should provide information about medications for prevention and treatment of osteoporosis. Estrogen can reduce the fracture rate in women who have osteoporosis, although there are other complications related to its use, such as cancer.
415
A nurse is caring for a client who is using a continuous passive motion (CPM) device following a right total knee replacement. Which of the following actions should the nurse take when applying the CPM device?
Apply the CPM device in the flexed position.
Line up the frame joints of the CPM device with the client's knee.
Check the range-of-motion settings on the CPM device daily.
Place the head of the client's bed at 45º during CPM use.
Line up the frame joints of the CPM device with the client's knee.
Notes: The nurse should apply the CPM device while it is in the extended position for client comfort and to ensure proper placement.
To avoid damage to the operative knee, the nurse should line up the joints of the CPM machine with the client's operative knee.
The nurse should assess the settings on the CPM device every 8 hr to ensure the appropriate flexion and extension cycle is occurring.
The nurse should initially place the client in a supine position when applying the CPM device. Following placement, the nurse should place the head of the bed at 20º if the client is able to tolerate this angle.
416
A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect?
Weight gain 1 kg (2.2 lb) in 1 day
Pitting edema +1
Client report of nocturnal cough
B-Type Natriuretic Peptide (BNP) level of 100 pg/mL
Weight gain 1 kg (2.2 lb) in 1 day
Notes: A weight gain of 1 kg (2.2 lb) in 1 day is an indication that the client's heart failure is worsening.
Pitting edema of +3 is an indication that the client has developed fluid volume overload and the heart failure is worsening.
The client who is in the early stages of heart failure might report a cough that is irritating, occurs at night, and is nonproductive.
BNP levels increase as the result of the ventricular hypertrophy that occurs in heart failure. A BNP level above 100 pg/mL is indicative of heart failure. Levels continue to increase with the severity of the heart failure.
417
```
A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect?
Midsternal chest pain
Thrill
Pitting edema in lower extremities
Lower back discomfort
```
Lower back discomfort
Notes: The nurse should assess for mid or lower abdominal pain to the left of the midline because of the enlarged artery mass.
The nurse should auscultate for a bruit heard over the location of the mass.
Pitting edema is a manifestation of heart failure. This is not an assessment the nurse should find with an abdominal aortic aneurysm.
Abdominal aortic aneurysm involves a widening, stretching, or ballooning of the aorta. Back and abdominal pain indicate that the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain.
418
```
A nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which of the following IV solutions?
0.45% sodium chloride
Dextrose 5% in 0.9% sodium chloride
Dextrose 10% in water
0.9% sodium chloride
```
0.9% sodium chloride
419
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse include in the plan?
Administer ferrous sulfate supplementation.
Increase dietary intake of folic acid.
Initiate weekly injections of vitamin B12.
Initiate a blood transfusion.
Initiate weekly injections of vitamin B12.
Notes: The nurse should administer ferrous sulfate to a client who has iron deficiency anemia, which is a decrease in the red blood cells caused by inadequate intake of dietary iron.
The nurse should increase the intake of food containing folic acid for a client who has megaloblastic anemia, which is a decrease in the red blood cells caused by folate deficiency.
The nurse should initiate a blood transfusion for a client who has aplastic anemia when bleeding is life-threatening from a low platelet count or if a client has blood loss from trauma or surgery.
420
A nurse is administering a unit of packed red blood cells (RBCs) to a client who is postoperative. The client reports itching and has hives 30 min after the infusion begins. Which of the following actions should the nurse take first?
Maintain the IV access with 0.9% sodium chloride.
Stop the infusion of blood.
Send the blood container and tubing to the blood bank.
Obtain a urine sample.
Stop the infusion of blood.
421
```
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document?
Coarse crackles
Wheezes
Rhonchi
Friction rub
```
Coarse crackles
Notes: A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing.
The client who has wheezes will manifest a high-pitched musical squeak on inspiration or expiration through a narrow or obstructed airway.
The client who has rhonchi will manifest coarse, loud, low-pitched sounds during inspiration or expiration. Coughing often clears the airway and stops the sound.
The client who has a friction rub will manifest loud, dry, rubbing or grating sounds over the lower lateral anterior chest surface during inspiration or expiration.
422
Coarse crackles
Notes: A client who had a recent myocardial infarction is at risk for left-sided heart failure. Crackles are breath sounds caused by movement of air through airways partially or intermittently occluded with fluid and are associated with heart failure and frothy sputum. Crackling sounds are heard at the end of inspiration and are not cleared by coughing.
The client who has wheezes will manifest a high-pitched musical squeak on inspiration or expiration through a narrow or obstructed airway.
The client who has rhonchi will manifest coarse, loud, low-pitched sounds during inspiration or expiration. Coughing often clears the airway and stops the sound.
The client who has a friction rub will manifest loud, dry, rubbing or grating sounds over the lower lateral anterior chest surface during inspiration or expiration.
jugular vein distension
Moist crackles
Increased heart rate
423
```
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
Decreased capillary refill
Dyspnea
Orthopnea
Dependent edema
```
Dependent edema
424
A nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching?
Hospitalization is required when administering each treatment.
The maximum effect of the medication will occur in 6 months.
Hypertension is a common adverse effect of this medication.
Blood transfusions are needed with each treatment.
Hypertension is a common adverse effect of this medication.
Notes: The nurse should teach the client that epoetin alfa can be self-administered at home.
The nurse should teach that the maximum effect of epoetin alfa will occur in 2 to 3 months.
The nurse should teach that a common adverse effect of epoetin alfa is hypertension because of the rise in the production of erythrocytes and other blood cell types. Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level.
The nurse should teach that epoetin alfa is administered to decrease the need for periodic blood transfusions.
425
A charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. Which of the following statements by a staff nurse indicates an understanding of the teaching?
"I will use clean technique when suctioning a client's endotracheal tube."
"I will use a rotating motion when removing the suction catheter."
"I will suction the oropharyngeal cavity prior to suctioning the endotracheal tube."
"I will suction a client's endotracheal tube every 2 hours."
"I will use a rotating motion when removing the suction catheter."
Notes: The nurse should use sterile technique when performing endotracheal suctioning to avoid the introduction of pathogens into the sterile respiratory system.
The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.
The nurse should suction the endotracheal tube prior to suctioning the nonsterile oropharyngeal cavity to prevent cross contamination.
The nurse should suction the endotracheal tube only when needed. Routine suctioning can result in hypoxia, tissue damage, bleeding, and bronchospasms.
426
A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider?
Increased anterior-posterior chest diameter
Productive cough with green sputum
Clubbing of the fingers
Pursed-lip breathing with exertion
Productive cough with green sputum
Notes: The nurse should report this finding to the provider because it can indicate infection. The rest are expected findings.
427
A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include?
Schedule respiratory treatments following meals.
Have the client sit up in a chair for 2-hr periods three times per day.
Provide a diet that is high in calories and protein.
Combine activities to allow for longer rest periods between activities.
Provide a diet that is high in calories and protein.
Notes: The nurse should schedule respiratory treatments before meals.
The nurse should provide short periods of activity frequently throughout the day.
The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.
The nurse should schedule activities that are short in duration with adequate rest periods in between to prevent fatigue.
428
A nurse is assessing a client who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
Decreased fremitus (vibration felt with speaking or coughing)
SaO2 95% on room air
Temperature 38.8° C (101.8° F)
Bradypnea
Temperature 38.8° C (101.8° F)
Notes: Increased fremitus is an expected finding
An oxygen saturation level of lower than 95% is an expected finding
Tachypnea is an expected finding
429
```
A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider?
Rhonchi on inspiration
Elevated temperature
Barrel-shaped chest
Diminished breath sounds
```
Elevated temperature
Notes: The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections. Rest is expected findings
430
A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the nurse's priority?
Provide a quiet environment.
Encourage use of incentive spirometry every 1 to 2 hr.
Obtain a blood sample for electrolyte study.
Administer heparin via continuous IV infusion.
Administer heparin via continuous IV infusion.
Notes: the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation.
431
A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription?
A client who has epistaxis
A client who has amyotrophic lateral sclerosis
A client who has pneumonia
A client who has emphysema
A client who has epistaxis
Notes: The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.
432
A charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in place following thoracic surgery with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider?
"I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration."
"I will notify the provider if there is continuous bubbling in the water seal chamber."
"I will notify the provider if there is drainage of 60 milliliters in the first hour after surgery."
"I will notify the provider if there are several small, dark-red blood clots in the tubing."
"I will notify the provider if there is continuous bubbling in the water seal chamber."
Notes: Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.
Small, dark-red blood clots are an expected finding for a client who is postoperative after chest surgery. The nurse should continue to monitor the client, but notification of the provider is not required at this time.
433
```
A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client?
Extra drainage system
Suture removal set
Container of sterile water
Nonadherent pads
```
Container of sterile water
Notes: The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax.
434
A nurse working in an emergency department is caring for a client following an acute chest trauma. Which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax?
Collapsed neck veins on the affected side
Collapsed neck veins on the unaffected side
Tracheal deviation to the affected side
Tracheal deviation to the unaffected side
Tracheal deviation to the unaffected side
Notes: The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.
435
A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism?
A client who is 48 hr postoperative following a total hip arthroplasty
A client who is 8 hr postoperative following an open surgical appendectomy
A client who is 2 hr postoperative following an open reduction external fixation of the right radius
A client who is 4 hr postoperative following a laparoscopic cholecystectomy
A client who is 48 hr postoperative following a total hip arthroplasty
436
A nurse is caring for a newly admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing?
Lateral position with a pillow at the back and over the chest to support the arm
High-Fowler's position with the arms supported on the overbed table
Semi-Fowler's position with pillows supporting both arms
Supine position with the head of the bed elevated to 15°
High-Fowler's position with the arms supported on the overbed table
Notes: A lateral position promotes alignment of the back and can be a good position for sleeping. However, this position does not promote maximum chest expansion to facilitate breathing.
The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table.
The semi-Fowler's position, which has the head and trunk elevated to a 30° to 45° angle, does not promote maximum chest expansion to facilitate breathing.
Supine position allows the diaphragm and abdominal organs to place pressure on the thoracic cavity and compromise chest expansion. This position does not promote maximum chest expansion to facilitate breathing.
437
```
A nurse is developing a plan of care for a client who has active tuberculosis. Which of the following isolation precautions should the nurse include in the plan?
Airborne
Neutropenic
Contact
Droplet
```
Airborne
438
```
A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm?
Excess secretions
Kinks in the tubing
Artificial airway cuff leak
Biting on the endotracheal tube
```
Artificial airway cuff leak
Notes: An excess of secretions in the airway causes the high-pressure alarm to sound.
Kinks in the tubing can cause an obstruction, which causes the high-pressure alarm to sound.
An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound.
Biting on the endotracheal tube causes the high-pressure alarm to sound.
439
A nurse is caring for a client who is postoperative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis?
pH 7.50, PO2 95 mm Hg, PaCO2 25 mm Hg, HCO3- 22 mEq/L
pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/L
pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/L
pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L
pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L
Notes:
These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.
440
A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include?
"Ringing in the ears is an adverse effect of this medication."
"Have your skin test repeated in 4 months to show a positive result."
"Expect your urine and other secretions to be orange while taking this medication."
"Remember to take this medication with a sip of water just before your first bite of each meal."
"Expect your urine and other secretions to be orange while taking this medication."
Notes: Tinnitus is not an adverse effect of rifampin. However, the nurse should inform the client that rifampin can cause gastrointestinal disturbances.
The nurse should inform the client that the purified protein derivative skin test results will continue to show positive, even after the disease is no longer active.
The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise.
The nurse should instruct the client to take rifampin 1 hr before or 2 hr after a meal.
441
A nurse is assisting a provider who is performing a thoracentesis at the bedside of a client. Which of the following actions should the nurse take? (Select all that apply.)
Wear goggles and a mask during the procedure.
Cleanse the procedure area with an antiseptic solution.
Instruct the client to take deep breaths during the procedure.
Position the client laterally on the affected side before the procedure.
Apply pressure to the site after the procedure.
Wear goggles and a mask during the procedure
Cleanse the procedure area with an antiseptic solution
Apply pressure to the site after the procedure
Notes: nurse and provider should both wear goggles and a mask to reduce the risk for exposure to pleural fluid.
The use of an antiseptic solution decreases the risk for infection, which is increased due to the invasive nature of the procedure.
The nurse should instruct the client to remain as still as possible during the procedure to reduce the risk for puncturing the pleura or lung.
The nurse should position the client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid.
The application of pressure decreases the risk for bleeding at the procedure site.
442
Wear goggles and a mask during the procedure
Cleanse the procedure area with an antiseptic solution
Apply pressure to the site after the procedure
Notes: nurse and provider should both wear goggles and a mask to reduce the risk for exposure to pleural fluid.
The use of an antiseptic solution decreases the risk for infection, which is increased due to the invasive nature of the procedure.
The nurse should instruct the client to remain as still as possible during the procedure to reduce the risk for puncturing the pleura or lung.
The nurse should position the client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid.
The application of pressure decreases the risk for bleeding at the procedure site.
Blood-tinged sputum
Notes: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.
The nurse should expect an increase, rather than a decrease, in tactile fremitus because of tumor tissue or fluid replacing airspaces.
The nurse should expect a dullness or flat sound, rather than resonance, upon percussion because of the presence of masses in the lungs.
The nurse should expect cyanosis of the lips and fingertips. However, peripheral edema is not an expected finding for a client who has lung cancer.
443
A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. Which of the following client statements indicates an understanding of the teaching?
"I will monitor my heart rate every day while taking this medication."
"I will make sure I have this medication with me at all times."
"I will need to carefully rinse my mouth after I take this medication."
"I will take this medication every night even if I don't have symptoms."
"I will take this medication every night even if I don't have symptoms."
Notes: Clients who take short-acting beta2 agonists should monitor their heart rate because tachycardia is an adverse effect of these medications. However, tachycardia is not an adverse effect of montelukast.
Clients who take short-acting beta2 agonists should have their medication with them at all times because these medications are used to relieve bronchoconstriction during an asthma attack.
Clients who take inhaled glucocorticoids should rinse their mouths and gargle after use because oral candidiasis is an adverse effect of these medications.
Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.
444
```
A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider?
Decreased bowel sounds
Oxygen saturation 92%
CO2 24 mEq/L
Intercostal retractions
```
Intercostal retractions
Notes: The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.
445
```
A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding?
Pallor
Insertion site pain
Persistent cough
Temperature 37.3° C (99.1° F)
```
Persistent cough
Notes: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency.
446
A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?
"I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma."
"I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage."
"I should remove the old twill ties after the new ties are in place."
"I should apply suction while inserting the catheter into my tracheostomy tube."
"I should remove the old twill ties after the new ties are in place."
Notes: The client should use gauze squares moistened in 0.9% sodium chloride to cleanse around the stoma or, if prescribed, half-strength hydrogen peroxide can be used on the skin to clean crusty areas. Using a cotton-tipped applicator places the client at risk for aspiration of cotton fibers. Also, the client should be careful not to get hydrogen peroxide into the tracheal stoma.
Cutting a 4-inch square gauze dressing places the client at risk for aspiration of gauze fibers. The client should apply a commercially-prepared split gauze tracheostomy dressing under the flange of the tracheostomy tube.
As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.
The client should apply suction only when withdrawing the catheter to prevent tracheal tissue trauma.
447
```
A nurse in an emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect?
Arterial pH 7.50
PaCO2 25 mm Hg
SaO2 92%
PaO2 58 mm Hg
```
PaO2 58 mm Hg
448
```
A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack?
Cromolyn sodium
Prednisone
Fluticasone/salmeterol
Albuterol
```
Albuterol
Notes: The nurse should administer cromolyn sodium, an anti-inflammatory agent, for maintenance therapy of asthma, rather than for treatment during an acute asthma attack.
The nurse should administer prednisone following an acute attack to promote anti-inflammatory effects.
The nurse should administer fluticasone/salmeterol for maintenance therapy of asthma because it combines a glucocorticoid and a long-acting beta2-adrenergic agonist.
The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.
449
```
A nurse is caring for a client who is in acute respiratory failure and is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen?
Blood pressure
Capillary refill
Arterial blood gases
Heart rate
```
Arterial blood gases
450
```
A nurse is assessing a client who is 4 hr postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider?
Bleeding at the surgical site
Decreased oxygen saturation
Urinary retention
Increased pain level
```
Decreased oxygen saturation
451
```
A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen?
Nasal cannula
Nonrebreather mask
Simple face mask
Partial rebreather mask
```
Nonrebreather mask
Notes: The oxygen flow rate via nasal cannula is 1 to 6 L/min and provides oxygen at a concentration of 24% to 44%. It does not provide the highest level of oxygen for a client who is in respiratory distress.
The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2.
A simple face mask delivers oxygen concentrations between 40% and 60% and has open exhalation ports that allow room air in and exhaled air out. It does not provide the highest level of oxygen for a client who is in respiratory distress.
The partial rebreather mask delivers oxygen concentrations of 60% to 75%. The exhalation ports are open, which will allow room air in and exhaled air out. It does not provide the highest level of oxygen for a client who is in respiratory distress.
452
```
A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should identify that which of the following assessments is the priority?
Presence of gag reflex
Pain level rating using a 0 to 10 scale
Hydration status
Appearance of the IV insertion site
```
Presence of gag reflex
453
```
A nurse in an emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first?
Apply supplemental oxygen.
Increase the rate of IV fluids.
Administer pain medication.
Initiate cardiac monitoring.
```
Apply supplemental oxygen.
454
```
A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client?
Hyperkalemia
Dyspnea
Tachycardia
Candidiasis
```
Tachycardia
Notes: The nurse should monitor the client for hypokalemia, which is a potential adverse effect of albuterol.
The nurse should monitor the client for a decrease in dyspnea. A decrease in dyspnea is a therapeutic effect of albuterol, not an adverse effect.
The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.
The nurse should monitor a client who is taking an inhaled glucocorticoid, such as beclomethasone, for candidiasis.
455
A nurse in an emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals they are 1 week postoperative following an open cholecystectomy. The nurse should identify that which of the following interventions is contraindicated?
Administering IV morphine sulfate
Administering oxygen at 2 L/min via nasal cannula
Helping the client to the bedside commode
Assisting with thrombolytic therapy
Assisting with thrombolytic therapy
456
A nurse is reviewing the laboratory results of several male clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which of the following laboratory values?
Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL
Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL
Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL
Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL
Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL
Notes: These laboratory values for HDL and LDL are outside of the expected reference range and indicate that the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males and above 55 mg/dL for females; and for LDL is less than 130 mg/dL.
457
A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse?
"My arthritis is really bothering me because I haven't taken my aspirin in a week."
"My blood pressure shouldn't be high because I took my blood pressure medication this morning."
"I took my warfarin last night according to my usual schedule."
"I will check my blood sugar because I took a reduced dose of insulin this morning."
"I took my warfarin last night according to my usual schedule."
458
A nurse is providing health teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?
A client who has hypothyroidism
A client who has diabetes mellitus
A client whose daily caloric intake consists of 25% fat
A client who consumes two 12-oz (0.35-L) bottles of beer a day
A nurse is providing health teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?
A client who has hypothyroidism
A client who has diabetes mellitus
A client whose daily caloric intake consists of 25% fat
A client who consumes two 12-oz (0.35-L) bottles of beer a day
459
```
A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to supraventricular tachycardia. The nurse should prepare to assist with which of the following interventions?
Initiate chest compressions
Vagal stimulation
Administration of atropine IV
Defibrillation
```
Vagal stimulation
Notes: The nurse should initiate chest compressions for pulseless ventricular tachycardia until a defibrillator is available. Supraventricular tachycardia does not require chest compressions.
The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.
The nurse should identify that atropine is used to treat bradydysrhythmias. Supraventricular tachycardia does not require atropine.
The nurse should identify that cardioversion, rather than defibrillation, is used to treat supraventricular tachycardia. Defibrillation is used to treat ventricular fibrillation or pulseless ventricular tachycardia.
460
```
A nurse in an emergency department is assessing a client who has a bradydysrhythmia. Which of the following findings should the nurse monitor for?
Confusion
Friction rub
Hypertension
Dry skin
```
Confusion
Notes: Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.
The nurse should expect to hear a friction rub during cardiac auscultation for a client who has pericarditis.
The nurse should monitor a client who has a bradydysrhythmia for hypotension.
The nurse should monitor a client who has a bradydysrhythmia for diaphoresis.
461
```
A nurse is caring for a client who is 8 hr postoperative following a coronary artery bypass graft (CABG). Which of the following findings should the nurse report?
Mediastinal drainage 100 mL/hr
Blood pressure 160/80 mm Hg
Temperature 37.1° C (98.8° F)
Potassium 4.0 mEq/L
```
Blood pressure 160/80 mm Hg
Notes: Mediastinal drainage of up to 150 mL/hr is expected during this time.
The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.
A body temperature of 37.1° C is within the expected reference range and is desired following a CABG.
A potassium level of 4.0 mEq/L is the expected level during the postoperative period following a CABG.
462
```
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?
Slurred speech
Irregular pulse
Dependent edema
Persistent fatigue
```
Slurred speech
Notes: The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.
463
```
A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find?
Increased abdominal girth
Weak peripheral pulses
Jugular venous neck distention
Dependent edema
```
Weak peripheral pulses
Notes: Increased abdominal girth, Jugular venous neck distention, Dependent edema is a finding related to systemic congestion resulting from right-sided heart failure.
464
```
A nurse is preparing a client for coronary angiography. Which of the following findings should the nurse report to the provider prior to the procedure?
Hemoglobin 14.4 g/dL
History of peripheral arterial disease
Urine output 200 mL/4 hr
Previous allergic reaction to shellfish
```
Previous allergic reaction to shellfish
Notes: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.
465
A nurse is providing discharge teaching to a client who has a prescription for transdermal nitroglycerin patches. Which of the following instructions should the nurse include in the teaching?
Apply the new patch to the same site as the previous patch.
Place the patch on an area of skin away from skin folds and joints.
Keep the patch on 24 hr per day.
Replace the patch at the onset of angina.
Place the patch on an area of skin away from skin folds and joints
Notes: The nurse should instruct the client to rotate the patch site to help prevent skin irritation.
The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly.
The nurse should instruct the client to have a patch-free interval of 10 to 12 hr each day to prevent tolerance to the medication.
The nurse should emphasize that nitroglycerin patches offer ongoing prevention of angina attacks. The nurse should instruct the client that patches do not treat angina attacks because they do not take effect immediately.
466
A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?
Initiate seizure precautions.
Tell the client to report vision changes.
Elevate the head of the client's bed.
Start a peripheral IV.
Elevate the head of the client's bed.
Notes: The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.
467
```
A nurse is planning a presentation for a group of clients who have hypertension. Which of the following lifestyle modifications should the nurse include? (Select all that apply.)
Limited alcohol intake
Regular exercise program
Decreased magnesium intake
Reduced potassium intake
Tobacco cessation
```
Limited alcohol intake
Regular exercise program
Tobacco cessation
468
A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the client's aPTT is 96 seconds?
Increase the heparin infusion flow rate by 2 mL/hr.
Continue to monitor the heparin infusion as prescribed.
Request a prothrombin time (PT).
Stop the heparin infusion
Stop the heparin infusion.
469
A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling?
"I'm still hungry after the bowl of cereal I ate at 7 a.m."
"I didn't take my heart pills this morning because the doctor told me not to."
"I have had chest pain a couple of times since I saw my doctor in the office last week."
"I smoked a cigarette this morning to calm my nerves about having this procedure."
"I smoked a cigarette this morning to calm my nerves about having this procedure."
470
```
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
Ventricular depolarization
Guillain-Barré syndrome
Myelodysplastic syndrome
Valvular disease
```
Valvular disease
Notes: Ventricular depolarization occurs during a normal cardiac cycle and is not a potential complication of endocarditis.
Guillain-Barré syndrome is associated with certain bacterial and viral infections but is not a potential complication of endocarditis.
Myelodysplastic syndrome is a disorder of the bone marrow and is not a potential complication of endocarditis.
Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.
471
A nurse is providing discharge teaching to a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider?
Weight gain of 0.9 kg (2 lb) in 24 hr
Increase of 10 mm Hg in systolic blood pressure
Dyspnea with exertion
Dizziness when rising quickly
Weight gain of 0.9 kg (2 lb) in 24 hr
Notes: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.
472
A nurse is caring for a client who is 1 hr postoperative following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider?
Serosanguineous drainage on dressing
Severe pain with coughing
Urine output of 20 mL/hr
Increase in temperature from 36.8° C (98.2° F) to 37.5° C (99.5° F)
Urine output of 20 mL/hr
Notes: Serosanguineous drainage 1 hr postoperative is expected and is not a manifestation of shock. Serosanguineous drainage should decrease over the first few days and discontinue after day 5.
Coughing is painful after an aortic aneurysm repair. However, it is not a manifestation of shock.
Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.
This temperature is within the expected reference range and is not a manifestation of shock.
473
A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. Which of the following focused assessments should the nurse use to help differentiate between an arterial ulcer and a venous stasis ulcer?
Explore the client's family history of peripheral vascular disease.
Note the presence or absence of pain at the ulcer site.
Inquire about the presence or absence of claudication.
Ask if the client has had a recent infection.
Inquire about the presence or absence of claudication.
Notes: Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.
474
```
A nurse is teaching a client who has a new prescription for an ACE inhibitor to treat hypertension. The nurse should instruct the client to notify their provider if they experience which of the following adverse effects of this medication?
Tendon pain
Persistent cough
Frequent urination
Constipation
```
Persistent cough
Notes: Tendonitis is an adverse effect of fluoroquinolone antibiotics.
A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication.
Frequent urination is an expected outcome of this medication.
Constipation is an adverse effect of ACE inhibitors. However, the client does not need to discontinue use or report this to the provider.
475
```
A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?
"I can't get rid of these hiccups."
"I feel dizzy when I stand."
"My incision site stings."
"I have a headache."
```
"I can't get rid of these hiccups."
Notes: Hiccups can indicate that the pacemaker is stimulating the chest wall or diaphragm, which can occur as a result of a lead wire perforation.
476
```
A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should identify that an increase in which of the following values is diagnostic of a myocardial infarction (MI)?
Myoglobin
C-reactive protein
Creatine kinase-MB
Homocysteine
```
Creatine kinase-MB
Notes: Myoglobin is elevated following an MI, and with skeletal muscle injury. However, it is not specific to the cardiac muscle.
C-reactive protein increases soon after the beginning of an inflammatory process, such as rheumatoid arthritis, and is not specific to cardiac muscle.
Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.
Homocysteine is always present in the blood. An increased level might indicate a risk factor for the development of cardiovascular diseas
477
```
A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the client's condition?
Absence of adventitious breath sounds
Presence of a nonproductive cough
Decrease in respiratory rate at rest
SaO2 86% on room air
```
Absence of adventitious breath sounds
478
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A nurse is assessing a client who has a history of deep-vein thrombosis and is receiving warfarin. Which of the following findings should indicate to the nurse that the medication is effective?
Hemoglobin 14 g/dL
Minimal bruising of extremities
Decreased blood pressure
INR 2.0
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INR 2.0
Notes: The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke
479
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A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication?
Shortness of breath
Lightheadedness
Dry cough
Metallic taste
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Lightheadedness
480
A nurse is caring for a client who was admitted for treatment of left-sided heart failure and is receiving intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first?
Obtain the client's current weight.
Review serum electrolyte values.
Determine the time of the last digoxin dose.
Check the client's urine output.
Review serum electrolyte values
481
A nurse is providing teaching to a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in the teaching?
"You might no longer be able to feel chest pain."
"Your level of activity intolerance will not change."
"After 6 months, you will no longer need to restrict your sodium intake."
"You will be able to stop taking immunosuppressants after 12 months."
"You might no longer be able to feel chest pain."
Notes: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart.
The client's activity tolerance should gradually improve as the healing process progresses.
The client will need to permanently maintain a diet that is restricted in sodium and fat.
The client will remain on immunosuppressants for the remainder of their life to help prevent rejection of the heart.
