Preparation for NCLEX 2 Flashcards

1
Q

Just prior to administering lorazepam 2 mg I.V. to an agitated client, the client knocks the medication to the floor. After retrieving the medication, what is the best action by the nurse?

a. Ask another nurse to witness the waste of the medication.
b. Attempt to administer the medication to the client.
c. Place the syringe with the medication into the sharps container.
d. Dispose of the medication into the sink.

A

a. Ask another nurse to witness the waste of the medication.

Lorazepam is a Schedule IV controlled substance. Federal law requires two nurses to witness and document the waste of all controlled substances in order to prevent diversion and misuse of the substance. The nurse should ask another nurse to witness the waste of the medication either into the sink or an approved pharmaceutical waste container as per the facility policy. Controlled substances should never be placed into a sharps container as these are not secure and may lead to diversion of the substance. A nurse would not administer a medication that had been knocked to the floor as this would result in contamination of the syringe.

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2
Q

A 36-year-old multigravid client at 12 weeks’ gestation has a history of chronic hypertension and obesity. The client was treated with methyldopa before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when they make which statement?
a. “I need to reduce my caloric intake to 1200 calories a day.”
b. “A regular diet is recommended during pregnancy.”
c. “I should eat more frequent meals if I get heartburn.”
d. “I need to consume more fluids and fiber each day.”

A

a. “I need to reduce my caloric intake to 1200 calories a day.”

Pregnancy is not an appropriate time for clients to begin a diet. Clients with chronic hypertension need to consume adequate calories to support fetal growth and development. They also need an adequate protein intake. Meat and beans are good sources of protein. Most pregnant clients report that eating more frequent, smaller meals decreases heartburn caused by the reflux of acidic secretions into the lower esophagus. Clients who are pregnant need adequate hydration (fluids) and fiber to prevent constipation.

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3
Q

On a crisis shelter hotline, the nurse talks to two 11-year-old children who think a friend has inhalant use disorder. They say their friend’s breath sometimes smells like glue and they act drunk. They say they are afraid to tell their parents about the friend. When the nurse is formulating a reply, what is the most important factor for the nurse to consider?
a. The callers probably fear punishment.
b. Inhalant use is illegal.
c. The callers’ observations could be wrong.
d. Inhalant use is a minor form of substance use disorder.

A

a. The callers probably fear punishment.

Telephoning the crisis shelter indicates that the children are alarmed but are reluctant to talk with their parents. They may fear that their parents will assume that they have been using inhalants and punish them. The nurse should focus on helping the children talk with their parents. The legality of using inhalants varies, but crisis hotlines are geared at providing supportive services. To prove that the observations are incorrect requires an intervention beginning with the children’s parents. Inhalant use disorder is a very dangerous, not minor, form of substance use disorder.

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4
Q

A client has a ureteral catheter in place after renal surgery. What should the nurse do to provide safe care of the ureteral catheter?

a. Irrigate the catheter with 30 mL of normal saline every 8 hours.
b. Ensure that the catheter is draining freely.
c. Clamp the catheter every 2 hours for 30 minutes.
d. Ensure that the catheter drains at least 15 mL per hour.

A

b. ensure that the catheter is draining freely.

The ureteral catheter should drain freely without bleeding at the site. The catheter is rarely irrigated, and any irrigation would be done by the health care provider (HCP). The catheter is never clamped. The client’s total urine output (ureteral catheter plus voiding or indwelling urinary catheter output) should be at least 30 mL per hour.

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5
Q

A client that works as a pilot tells the nurse that they use illegal drugs for recreational purposes every weekend. Using the ethical principle of nonmaleficence to guide the nurse’s interaction with the client, which is the nurse’s best response?
a. “Using drugs jeopardizes your health and you should consider quitting.”
b. “If tested, you will lose your job.”
c. “You could easily have an error in judgement and cause a serious accident.”
d. “There’s a problem with you choosing to use drugs as a way to cope with the stressors you experience.”

A

c. “You could easily have an error in judgement and cause a serious accident.”

Because the nurse’s statement refers to those who could be harmed as a result of the pilot’s drug use, the nurse’s suggestion that the client should consider how an error in judgment could result in a serious accident reflects the principle of nonmaleficence (the obligation to do no harm). Telling the client that recreational drug use jeopardizes the client’s health and decision-making ability addresses the personal danger of drug use, not the principle of nonmaleficence. Commenting that the pilot could test positive in a random drug test does not address any of the four basic ethical principles (autonomy, beneficence, nonmaleficence, and justice). Telling the client that there is a problem with their use of drugs to cope with stress reflects the principle of autonomy by addressing how the client’s actions influence the rights of others.

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6
Q

A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to
a. install safety devices in the home.
b. wear worn, comfortable shoes.
c. get help when lifting objects.
d. wear protective devices when exercising.

A

a. install safety devices in the home.

Most accidents occur in the home, and safety devices such as hand rails are the most important element in minimizing injury. Shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or lifting objects. Protective devices aren’t usually necessary when the client exercises.

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7
Q

The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply.

a. The spouse places soiled dressing supplies in the kitchen garbage can.
b. Disinfectant spray is used on the table where dressing supplies are prepared.
c. Clean gloves are used for wound dressing removal.
d. Sheets with wound drainage are washed in lukewarm water.
e. Dressing supplies are placed in a clean, dry location.
f. Routine hand hygiene is performed before and after care.

A

a. The spouse places soiled dressing supplies in the kitchen garbage can.
d. sheets with wound drainage are washed in lukewarm water.

Methicillin resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body and is resistant to some commonly used antibiotics. Infection control practices prevent the spread of the infection. Further teaching is needed if a nurse notes that soiled dressing supplies are placed in a community garbage can such as one located in the kitchen. Soiled sheets need to be wash in hot water and dried in a clothes dryer. It is correct to clean and disinfect the area where dressing supplies are prepared. Routine hand hygiene followed by wearing clean gloves is appropriate when removing the dressing. Sterile gloves may be needed when completing dressing care.

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8
Q

In discharge planning after scleral buckling for a detached retina, the nurse should teach the client to avoid which activity during the early recovery period?

a. watching television
b. reading
c, talking on the telephone
d. walking in the yard

A

b. reading

Reading involves too much jerky eye movement and should be avoided during recovery.

Watching television, talking on the telephone, and walking outdoors are appropriate activities and can be encouraged.

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9
Q

A primigravid client at 34 weeks’ gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. The client’s cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client’s vital signs, the client says, “I think my bag of water just broke.” Which intervention would the nurse do first?
a. Check the status of the fetal heart rate.
b. Reassess the client’s vital signs.
c. Test the leaking fluid for fetal fibronectin.
d. Perform a sterile vaginal examination.

A

a. check the status of the fetal heart rate.

The priority is to determine whether a prolapsed cord has occurred as a result of the spontaneous rupture of membranes. The nurse’s first action should be to check the status of the fetal heart rate. Complications of premature rupture of the membranes include a prolapsed cord or increased pressure on the fetal umbilical cord that inhibits fetal nutrient supply. Variable decelerations or fetal bradycardia may be seen on the external fetal monitor. The cord also may be visible. Turning the client to their right side is not necessary. If the cord does prolapse, the client should be placed in a knee-to-chest or Trendelenburg position. A vaginal examination may be appropriate once the status of the fetus has been evaluated. The nurse can continue to measure the client’s vital signs at routine intervals.

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10
Q

A client being treated for complications of chronic obstructive pulmonary disease needs to be intubated. The client has previously discussed their wish to not be intubated with the client’s partner of 5 years, whom the client has designated as health care power of attorney. The client’s children want their parent to be intubated. A nurse caring for this client knows that
a. clients commonly confer health care power of attorney on someone who shares their personal values and beliefs.
b, the client’s partner is responsible for national legislation regarding surrogate decision makers.
c, the children’s biological relationship with their parent supersedes the partner’s wishes.
d. health care providers must honor the children’s wishes to avoid a lawsuit.

A

a. clients commonly confer health care power of attorney on someone who shares their personal values and beliefs.

The health care power of attorney is someone who can make decisions when the client can’t. Clients tend to select individuals who share their personal values and beliefs as their health care power of attorney. Family members and designated surrogates don’t always agree; state laws regarding surrogate decision makers may differ. The legal rights of a health care power of attorney in regards to health care decisions supersede those of family members. The law designates the health care power of attorney as the person to make decision; violating this designation could result in a lawsuit.

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11
Q

Which finding in the client’s history would be the least likely to have predisposed the client to renal calculi?
a. having had several urinary tract infections in the past 2 years
b. having taken large doses of vitamin C over the past several years
c. drinking less than the recommended amount of milk
d. having been on prolonged bed rest after an accident the previous year

A

c. drinking less than the recommended amount of milk.

A high, rather than low, milk intake predisposes to renal calculi formation, owing to the calcium in milk.

Recurrent urinary tract infections are implicated in stone formation as certain bacteria promote stone formation.

High daily doses of vitamins C are a risk factor because they can increase the citric acid level.

Prolonged immobility is a risk factor for renal calculi because it causes calcium to be released into the bloodstream.

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12
Q

A nurse and a nursing student drive to the home of a client with postpartum depression and discover the client and the baby completely naked in the backyard. The client is unable to communicate in an effective manner. What is the nurse’s most appropriate response to resolve this situation?
a. Contact the client’s partner to come home from work and immediately take the client to the emergency department.
b. Contact the client’s health care provider and the baby’s pediatrician.
c. Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation.
d. Ask the nursing student to stay with the client while the nurse performs the last home visit in the community.

A

c. Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation.

The nurse should contact the immediate nursing supervisor to clarify or guide the correct nursing actions in this acute mental health situation. Community mental health services may be available that could visit the home and assess and intervene in this situation. The nurse should help the birth parent and baby inside and stay with them until the supervisor advises how best to manage the situation. It is inappropriate to call the client’s partner and have them come home because the nurse first needs to assess and address any immediate safety concerns for the birth parent and baby. Asking the nursing student to remain with this client while the nurse leaves is inappropriate because this may jeopardize the safety of the nursing student. In addition, given the context, the care required may be beyond the nursing student’s scope of practice.

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13
Q

The parent of a newborn is voicing concerns about their baby’s ability to hear. What should the nurse tell the parent?
a. Newborns cannot hear well until they are at least 6 weeks old.
b. Their concern is unfounded because hearing problems are rare in newborns.
c. Most American states and Canadian jurisdictions mandate hearing tests for infants.
d. They can test the baby’s hearing by clapping their hands 24 inches (60 cm) from the infant’s head.

A

c. Most American states and Canadian jurisdictions mandate hearing tests for infants.

The American Academy of Pediatrics and the American College of Obstetrics and Gynecology recommend hearing screening for all newborns. Currently more than 30 states mandate screening, which is done by otoacoustic emissions or auditory brainstem response. Newborns can hear as soon as the amniotic fluid drains from the ear canal. Even though hearing problems are not common in newborns, the parent’s concerns should be addressed. Clapping to elicit a response is crude and unreliable. If done for minimal screening, the distance should be no more than 12 inches.

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14
Q

After the nurse teaches the parent of an 18-month-old child being discharged with a prescription for co-trimoxazole about the medication, which statement by the parent would indicate the need for additional teaching?

a, “I’ll watch to see that they’re wetting their diapers as usual.”
b. “This medicine must be given on an empty stomach.”
c, “If they develop a sunburn-type rash, I’ll stop the medication and call my health care provider.”
d. “I’ll make sure they drink plenty of extra fluids.”

A

b. “This medicine must be given on an empty stomach.”

When co-trimoxazole is prescribed, it can be given on an empty stomach, but it can also be given with food or milk if it causes an upset stomach. Monitoring the child’s urinary output by observing the child’s diapers is important because diminished renal function is a possible adverse effect. The child needs to be monitored for Stevens-Johnson syndrome, a possible and serious adverse effect that causes a sunburn-type rash. If it develops, the medication should be withheld, and the health care provider should be notified. Drinking extra fluids is essential to promote adequate renal function for the child receiving a sulfa-type antibiotic.

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15
Q

A nurse is providing preoperative teaching to a client undergoing a cholecystectomy. Which topic should be the priority for the nurse to include in the teaching plan?
a. postoperative respiratory care exercises
b. nasogastric intubation and care
c. nutritional care during recovery
d. postoperative analgesia and pain control methods

A

a. postoperative respiratory care exercises.

The nurse must teach the client about respiratory care such as using an incentive spirometer to promote lung expansion. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. The client will need to use incentive spirometry to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Most clients do not have a nasogastric tube in place after a cholecystectomy. Teaching about nutritional care and pain control after surgery should be included, but would not be the priority.

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16
Q

A 4-year-old has just returned from surgery. The child has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, “I’m going to throw up.” What should the nurse do first?
a. Notify the health care provider because the child has an NG tube.
b. Immediately give the child an antiemetic IV
c. Irrigate the NG tube to ensure patency.
d. Encourage the parent to calm the child down.

A

c. Irrigate the NG tube to ensure patency

The nurse should first irrigate the NG tube because if the tube isn’t draining properly or is kinked, the child will experience nausea. There’s no reason to notify the health care provider immediately because a nurse should be able to handle the situation. Giving the child an antiemetic doesn’t really address the problem. Encouraging the parent to calm the child is always a good intervention but isn’t the first thing to do in this case.

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17
Q

An 8-year-old child is admitted with a T3 spinal cord compression following a motor vehicle accident. The child has an abrupt onset of elevated blood pressure, headache, profuse sweating, and flushing of the skin. What is the priority action for the nurse to take?

a. Place the child in a supine position.
b. Administer a fluid bolus.
c. Empty the child’s bladder.
d. Obtain a blood glucose level.

A

c. Empty the child’s bladder.

Autonomic dysreflexia is an emergency condition that can occur in children with spinal cord injuries above T6. The response is often triggered by a full bladder. Treatment includes placing the child in an upright position and emptying the bladder. Supine positioning, fluids, and blood glucose will not relieve the autonomic dysreflexia.

18
Q

A client was admitted to the behavioral health unit with a diagnosis of severe depression. The client was started on bupropion. Forty-eight hours after initiating the drug therapy, the client has recovered from depression, is laughing, singing, and dancing in the hallway and in the sitting room. How should the nurse interpret this behavior?
a. The medication is therapeutic.
b. The client is acting this way so that they can be discharged.
c. The client is most likely bipolar rather than depressed, and the health care provider should be notified of the behavior.
d. These are unusual side effects of the medication.

A

c. The client is most likely bipolar rather than depressed, and the health care provider should be notified of the behavior.

This behavior is often seen in clients who are bipolar when placed on an antidepressant. A mood stabilizer, such as lithium or lamotrigine, is needed to balance emotional states. The medication has affected the depression, but the client is bipolar and needs a mood stabilizer instead. These side effects occur in a person who is bipolar rather than someone suffering from depression.

19
Q

The nurse is preparing to administer vitamin K intramuscularly to a term neonate of a primipara who has just given birth. After explaining the purpose of the drug to the birth parent, which statement by the client indicates effective teaching?
a. “Vitamin K will help my baby breathe easier.”
b. “Vitamin K will prevent my baby from becoming jaundiced.”
c. “Vitamin K will help my baby’s blood to clot properly.”
d. “Vitamin K will prevent my baby from developing an infection.”

A

c. “Vitamin K will help my baby’s blood to clot properly.”

At birth, vitamin K-dependent blood clotting factors are significantly decreased, and there is a transitory deficiency in blood coagulation during the second and fifth days of life. As a preventive measure, 0.5 to 1 mg of vitamin K is administered to the newborn during the first day of life to aid in blood clotting.
Vitamin K does not help improve respirations or make the baby breathe more easily; suctioning and oxygen are used as needed. Vitamin K does not prevent jaundice. If jaundice does appear, phototherapy is used.
Vitamin K does not prevent infections; antibiotics are used if needed.

20
Q

On the first postpartum day after a cesarean birth, the client is prescribed a full liquid diet as tolerated. Before providing a full liquid breakfast, the nurse should assess which factor?
a. breath sounds
b. desire to eat
c. bowel sounds
d. degree of pain

A

c. bowel sounds

Before providing the client with a full liquid meal, the nurse should first assess for the presence of bowel sounds to evaluate the functioning of the client’s gastrointestinal tract. After cesarean birth, the client is at risk for paralytic ileus or intestinal obstruction due to the effects of the surgery or anesthesia used.
Assessing breath sounds, although an important assessment, would be indicated if the client was experiencing a respiratory problem. It has no relevance related to the client’s eating.
The client’s desire to eat may or may not be present. The client’s gastrointestinal function manifested by active bowel sounds indicates that the client can be allowed to eat.
The degree of pain is an important assessment but not in relation to the client’s diet.

21
Q

A 5-year-old child diagnosed with cerebral palsy has just been prescribed oral baclofen. Which assessment finding by the nurse would indicate effective drug therapy?

a. The child is exhibiting less spasticity.
b. The child has less frequent seizures.
c. The child no longer sleeps during the daytime.
d. The child is better able to concentrate on mental activities.

A

a. the child is exhibiting less spasticity.

Baclofen is a skeletal muscle relaxant that is effective in reducing overall spasticity. It is not an anti-seizure drug. Significant side effects of this drug are drowsiness and confusion, so this child would not be sleeping less, nor demonstrating a better ability to concentrate on mental activities.

22
Q

A client, who is taking lithium, asks the nurse why they have to have their blood drawn for a lithium level. What is the nurse’s most appropriate response?

a. Lithium levels are obtained to determine if you have any liver and renal damage.
” Lithium levels demonstrate whether you are taking a therapeutic dose range of the drug.”
c. Lithium levels indicate whether the drug has passed through your blood-brain barrier.”
d. Lithium levels are unnecessary if you commit to taking the drug as ordered.”

A

b. “Lithium levels demonstrate whether you are taking a therapeutic dose range of the drug.”

Lithium levels determine if lithium dosage is adequate to maintain a therapeutic level of the drug. The drug is contraindicated for clients with renal, cardiac, or liver disease. Lithium levels aren’t drawn for the purpose of determining whether the drug passes through the blood-brain barrier. Taking the drug as ordered doesn’t eliminate the need for blood work.

23
Q

A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as
a. the relationship between law and culture
b. moral values are considered to be universal
c. the principles that determine whether an act is right or wrong
d. the laws that govern acceptable and unacceptable behavior

A

c. the principles that determine whether an act is right or wrong.

Ethics involves moral or philosophical principles that direct actions as being either right or wrong. Laws are often rooted in ethics but the two terms are not synonymous. Similarly, morals and values are closely associated with ethics but these do not constitute the definition of ethics. Ethics are not universally agreed upon, as many different applications exist.

24
Q

The community health nurse is providing education to a client who gave birth 74 hours earlier. What would the nurse teach the client is a sign or symptom of hemorrhage?
a. backache
b. passing a quarter-sized clot
c. foul smelling lochia
d. peripad soaked over the course of 1 hour

A

d. peripad soaked over the course of 1 hour.

With a late postpartum hemorrhage (greater than 72 hours), clients report heavy bleeding and soaking a peripad in less than 1 hour. The clot could indicate placental fragments but not necessarily a postpartum hemorrhage. Clots larger than a golf ball should be reported. Leukorrhea, backache, and foul lochia may occur if a puerperal infection is the cause.

25
Q

The client becomes upset when the nurse asks if the client has an advance directive and states, “Why do I need an advance directive?” What is the most appropriate explanation for the nurse to give this client about an advance directive?

a. “The advance directive allows your health care team to provide optimal health care under any circumstances that happen to you.”
b. “An advance directive is all about living well and having your specified treatment plans followed by your health care provider.”
c. “In all situations the advance directive allows you to appoint other people to decide what the best end-of-life care is for you.”
d. “Let’s talk about how an advance directive enables you to have your health care preferences known to your health care providers.”

A

d. “Let’s talk about how an advance directive enables you to have your health care preferences known to your health care providers.”

The client’s statement indicates a need to learn the purpose of an advance directive (which is to have the client’s health care preferences made known to the health care providers). Inviting clients to talk about making decisions and stating their wishes about end-of-life care and health care treatment enables the clients to discuss what is important and culturally appropriate to them. An advance directive does not ensure the arrangement of ideal or optimal care in all medical circumstances, but assists the client to select desired care and a health care proxy. It gives the clients a voice in decision making and establishes that their wishes will be followed.

26
Q

Eight hours ago, an infant with Hirschsprung’s disease had surgery to create a colostomy. Which finding should alert the nurse to notify the health care provider (HCP) immediately?

a. a 3-cm increase in abdominal circumference
b. periods of occasional fussiness
c. absence of bowel sounds since surgery
d. bright red stoma

A

a 3-cm increase in abdominal circumference

Abdominal circumference is measured to monitor for abdominal distention. An increase of 3 cm in 8 hours would require notification of the HCP; it would indicate a substantial degree of abdominal distention, possibly from fluid or gas accumulation. Normally, after surgery, an infant experiences occasional periods of fussiness. However, as long as the infant is able to be quiet by themself or with the aid of a pacifier, the HCP does not need to be contacted. Absence of bowel sounds would be expected after surgery because of the effects of anesthesia. It takes approximately 48 hours for gastric motility to resume. New stomas are typically bright red or pink.

27
Q

The nurse is teaching a client about managing a hiatal hernia. Which lifestyle modification should the nurse encourage the client with a hiatal hernia to include in activities of daily living?

a. engaging in daily aerobic exercise
b. eliminating smoking and alcohol use
c. balancing activity and rest
d. avoiding high-stress situations

A

b. eliminating smoking and alcohol use.

Smoking and alcohol use both reduce esophageal sphincter tone and can result in reflux. They therefore should be avoided by clients with hiatal hernia. Daily aerobic exercise, balancing activity and rest, and avoiding high-stress situations may increase the client’s general health and well-being, but they are not directly associated with hiatal hernia.

28
Q

Which nursing intervention is most appropriate for a client with multiple myeloma?
a. monitoring respiratory status
b. balancing rest and activity
c. restricting fluid intake
d. preventing bone injury

A

d. preventing bone injury

When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict their fluid intake.

29
Q

Nurses should be aware of their own feelings about clients and the difficulty of maintaining effective relationships with depressed clients experiencing suicidal ideation because of which behaviors?
a. pessimism, which arouses frustration and anger in others
b. poor personal grooming, which invites disgust and ridicule from others
c. independence, which prevents them from asking for assistance
d. laziness, which keeps them from putting forth the necessary effort to get well

A

a. pessimism, which arouses frustrations and anger in others.

Depressed clients are difficult to relate to because of their hopelessness, negativity, helplessness, and general apathy. The concomitant feelings of hopelessness and lack of success experienced by the nurse may lead the nurse to withdraw or to feel angry with the client. It is important for nurses to be aware of their feelings and how their feelings might affect nursing care.
Poor personal grooming is typical of clients with depression and suicidal ideation. The nurse can intervene and help the client with grooming.
Depressed clients are typically dependent on others.
Depressed clients are not lazy but are fatigued and apathetic.

30
Q

A child is receiving amoxicillin for otitis media. Which action should the nurse recommend the parent do when the child develops diarrhea?
a. Begin clear fluids.
b. Withhold food and fluids for 2 hours.
c. Offer yogurt several times a day.
d. Restrict the intake of pizza.

A

c. offer yogurt several times a day

Diarrhea is a common adverse effect of amoxicillin because the drug kills normal intestinal bacteria. Yogurt with live cultures helps restore the normal intestinal flora. Restricting the child to clear fluids will not help stop the diarrhea or recolonize the intestine.

Withholding food and fluids for 2 hours is suggested when a child vomits.

Pizza tends to be spicy and aggravates the diarrhea.

31
Q

A 14-month-old child has a severe diaper rash. Which recommendation should the nurse provide to the parents?
a. Continue to use baby wipes.
b. Change the diaper every 4 to 6 hours.
c. Wash the buttocks using mild soap.
d. Apply powder to the diaper area.

A

c. Wash the buttocks using mild soap.

Because the toddler has a severe diaper rash, it may be best to change all that the parents are doing. The buttocks need to be washed thoroughly with mild soap and dried well. In fact, it is helpful to leave the diaper off and expose the buttocks to the air. Baby wipes commonly contain additives and perfumes that may be irritating to the baby’s sensitive skin. The diaper needs to be changed more often than every 4 to 6 hours. Otherwise, the moist diaper environment will continue to irritate the skin, causing the rash to worsen. Powder has limited absorbing ability and will most likely irritate the area more. In addition, some powders contain perfumes or are scented and can irritate the skin.

32
Q

Two days after a myocardial infarction (MI), a client’s temperature is elevated. The nurse understands which response to be most likely related to the infarction?
a. possible infection
b. tissue necrosis
c. pulmonary infarction
d. pneumonia

A

b. tissue necrosis

The body’s general inflammatory response to myocardial necrosis causes an elevation of temperature as well as leukocytosis within 24 to 48 hours. Possible infection is not correct because an MI won’t cause infection. Pneumonia is not related to an MI. Pneumonia could be related to less movement, a potential later cause not associated with MI.

33
Q

A school-age child is admitted to the hospital with acute rheumatic fever. What intervention should the nurse teach the parents is necessary in the child’s long-term care plan?
a. physical therapy
b. antibiotic therapy
c. psychological therapy
d. anti-inflammatory therapy

A

b. antibiotic therapy.

A child who has had rheumatic fever is likely to develop the illness again after a future streptococcal infection. Therefore, it is advised that the child receive antibiotic prophylaxis for at least 5 years and sometimes even longer after the acute attack to prevent recurrence.

34
Q

A client with a diagnosis of metastatic breast cancer asks the nurse, “Why has God done this to me? I need to see a minister and go back to church.” What interventions would be most helpful to the client at this point in time? (Select all that apply.)

a. Discuss feelings related to the illness.
b. Address the use of spiritual resources.
c. Teach the client about the dying process.
d. Encourage communication about religious beliefs.
e. Determine expectations for life-sustaining treatments.

A

a. discuss feelings related to the illness
b. address the use of spiritual resources.
d. encourage communication about religious beliefs.

The nursing care interventions that would be most helpful to this client at the time are interventions that offer support related to the diagnosis of metastatic breast cancer. Therefore, the nurse will focus on discussing the client’s feelings, communicating with the client about religious beliefs, and addressing available and useful spiritual resources. Later on in the treatment process, education on the dying process and expectations of treatment would be appropriate.

35
Q

A client is started on sulfamethoxazole-trimethoprim for reports of severe burning on urination and frequent, urgent voiding of small amounts of urine. As the nurse explains the medication, the client requests something to relieve the painful urination. Which treatment order would the nurse anticipate for the client’s discomfort?

a. nitrofurantoin
b. ibuprofen
c. hydration with water and cranberry juice
d. phenazopyridine

A

d. phenazopyridine

Phenazopyridine may be ordered in conjunction with an antibiotic for painful bladder infections to promote comfort. Because of its local anesthetic action on the urinary mucosa, phenazopyridine specifically relieves bladder pain. Nitrofurantoin is another choice for antibiotic treatment and would not be recommended in conjunction with trimethoprim-sulfamethoxazole. Although ibuprofen is an analgesic, phenazopyridine has more direct effect on urinary tract infections.

36
Q

Which option is an example of a primary preventive measure?
a. participating in a cardiac rehabilitation program
b. having an annual physical examination
c. practicing monthly breast self-examination
d. avoiding overexposure to the sun

A

d. avoiding overexposure to the sun.

Primary prevention involves promoting health and helping clients achieve maximum wellness. Primary preventive measures are designed to prevent or delay the onset of specific illnesses; these measures typically include lifestyle changes such as avoiding overexposure to the sun to prevent skin cancer. Participating in a cardiac rehabilitation program is an example of a tertiary preventive measure, which attempts to prevent complications of an existing disease. Annual physical examinations and monthly breast self-examinations are examples of secondary preventive measures, which promote early detection and treatment of disease.

37
Q

A client is admitted to the psychiatric unit accompanied by their spouse. The client brings six suitcases and three shopping bags and orders the nurse to carry the bags. The client’s spouse states they have been purchasing items that they cannot afford and has not slept for 4 nights. Which additional information would be a priority for the nurse to seek from the client’s spouse?
a. the client’s fluid and food intake
b. their current financial status
c. the client’s usual sleeping pattern
d. whether or not the client becomes agitated easily

A

a. the client’s fluid and food intake.

Assessing nutritional status is a priority in this situation. Clients with bipolar disorder, manic phase, commonly do not have time to eat or drink because of their state of constant activity and easy distractibility. Altered nutritional status and constant physical activity can lead to malnutrition, weight loss, and physical exhaustion. These states can lead to death if appropriate intervention is not instituted.
Financial status is neither important nor something that the nurse can modify.
Clients with bipolar disorder, manic phase, have disturbed sleep patterns; however, their hydration and nutritional status are the first priority.
A common behavior of clients with bipolar disorder, manic phase, is to exhibit hostility when their personal desires are limited, so it is not necessary to seek this information at this time.

38
Q

A 19-year-old unmarried college student who is approximately 8 weeks pregnant asks the nurse, “If I have an abortion in the next 2 or 3 weeks, how will it be done?” The nurse instructs the client that at this gestational age, an abortion is usually performed by which technique?
a. dilatation and curettage
b. menstrual extraction
c. dilatation and vacuum extraction
d. saline induction

A

a. dilatation and curettage

When the gestation is less than 13 weeks, an elective abortion is usually performed by the dilatation and curettage method. Menstrual extraction, or suction evacuation, is the easiest method, but it is used only when the client is between 5 and 7 weeks’ gestation. Dilatation and vacuum extraction is used when clients are between 12 and 16 weeks’ gestation. Saline induction, used for clients between 16 and 24 weeks’ gestation, involves instillation of a hypertonic saline solution into the amniotic sac to initiate expulsion. Oxytocin infusion may also be used with saline induction.

39
Q

A client with gastroenteritis is admitted to an acute care facility and presents with severe dehydration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that
a. the client requires an antiviral agent.
b. enteric precautions must be continued.
c. enteric precautions can be discontinued.
d. the client’s infection may be caused by droplet transmission.

A

b. enteric precautions must be continued.

The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis. The Norwalk virus isn’t transmitted by droplets.

40
Q

The family of a client who dies lives an hour away from the facility. What should the nurse do to support the family at this time?

a. Move the client to a private room.
b. Transport the client to the facility morgue.
c. Keep the client in the bed until the family arrives.
d. Notify the family to visit the client at the mortuary.

A

c. Keep the client in the bed until the family arrives.

In a hospital or long-term care facility, the nurse should follow the facility’s procedure for preparation of the body and transportation to the facility’s morgue. However, the needs of families to remain with the deceased, to wait until other family members arrive before the body is moved, and to perform after-death rituals should be honored. The client should not be moved to a private room, transported to the facility morgue, or transported to the mortuary without the family first having an opportunity to view the body in the facility.

41
Q

An infant is diagnosed with a congenital hip dislocation. On assessment, the nurse expects to note:
a. symmetrical thigh and gluteal folds.
b. Ortolani’s sign.
c. increased hip abduction.
d. femoral lengthening.

A

b. Ortolani’s sign.

In a child with a congenital hip dislocation, assessment typically reveals Ortolani’s sign, asymmetrical thigh and gluteal folds, limited hip abduction, femoral shortening, and Trendelenburg’s sign.