TEST 6: Comprehensive Flashcards

Question 1

Q

A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage?
Lying flat without a pillow with the head turned to the right.
Lying flat with the head elevated on three pillows.
Head of the bed elevated to 30 degrees with the head in a neutral position.
Side-lying on the client’s left side.
A 57-year-old woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do?
Ask the client’s daughter to serve as an interpreter.
Ask one of the nursing assistants to serve as an interpreter.
Use the limited knowledge of the client’s language learned in high school along with nonverbal
communication.
Obtain a trained medical interpreter.
A nurse is caring for a client who has undergone a total laryngectomy for laryngeal cancer. What information is important to include in discharge teaching? Select all that apply.
Providing humidity at home.
Following a bland diet.
Learning how to suction.
Having communication rehabilitation with a speech pathologist.
Attending a smoking cessation program.
The client received electroconvulsive therapy (ECT) an hour ago and now has a headache. Which response by the nurse is best?
“A headache is common after ECT.”
“I will get some acetaminophen (Tylenol) for you.”
“A nap will help you feel better.”
“Eat your breakfast and then let me know how you feel.”
The staff nurse is reviewing how to manage the last 2 hours of the night shift on an antepartal unit and has the following prescriptions and tasks to complete prior to 7 AM . The nurse should
complete the tasks at which of the following times?
Check documentation, final check of each client.
Fetal monitor strip for 1⁄2 hour every shift.
Magnesium sulfate drawn at 6 AM .
Point of care blood glucose and sliding scale insulin due at 7, 11, 4, and bedtime.

5: 30
6: 00
6: 30
7: 00

When assessing speech development, which of the following children should the nurse refer for further examination?
A 4-month-old who laughs out loud.
A 10-month-old who says “dada” and “mama.”
A 1-year-old who says three to five words.
An 18-month-old who only says “no.”
A family has taken home their newborn and later received a call from the pediatrician that the
phenylketonuria (PKU) levels for their newborn daughter are abnormally high. Additional testing confirmed the diagnosis of phenylketonuria. The parents refuse to believe the results as no one else in their family has the disease. The nurse explains that the disease:
Is carried on recessive genes contributed by each parent.
Is caused by a recessive gene contributed by either parent.
Is cured by eliminating dietary protein for this child.
Will not impact future childbearing for the family.
During a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse
would be best?
“The hormonal changes your body is experiencing are causing you to feel this way.”
“Most new mothers feel the same way that you do. I hear that a lot from others.”
“You need to have your husband and family help you so that you can get some rest.”
“I’m concerned about what you are experiencing. Tell me more about what you are thinking and
feeling.”
A client is to receive 2 g of metronidazole (Flagyl) orally in a single dose. The medication is available in 500-mg tablets. How many tablets should the nurse administer?
_______________ tablets.
A college student is asking the nurse about the student’s grandfather, who just received a diagnosis of Huntington’s disease. The student wants to know if the student will have the disease too. What should the nurse tell the student? Select all that apply.
“Huntington’s disease affects men more than women.”
“Huntington’s disease is an autosomal dominant disease.”
“Huntington’s disease does not skip a generation.”
“Huntington’s disease is a treatable disease.”
“There is a 75% chance you will have the disease.”

Answer

A

1. The head of the bed should be elevated 30 degrees to promote venous drainage and decrease
  intracranial pressure. The client’s head should be in a midline, or neutral, position. Clients with
  supratentorial surgery should be positioned on the nonoperative side to prevent displacement of the
  cranial contents by gravity.
  CN: Reduction of risk potential; CL: Synthesize
1. A trained medical interpreter is required to ensure safety, accuracy of history data, and client
  confidentiality. The medical interpreter knows the client’s rights and is familiar with the client’s
  culture. Using the family member as interpreter violates the client’s confidentiality. Using the nursing
  assistant or limited forms of verbal and nonverbal communication do not ensure accuracy of
  interpretation and back-translation.
  CN: Management of care; CL: Synthesize
1, 3, 4, 5. Home care for a client with a total laryngectomy should include a high-humidity
environment, laryngectomy tube care and suctioning, speech rehabilitation, and smoking cessation.
The client is not restricted to a bland diet.
CN: Management of care; CL: Create
1. Administering acetaminophen to the client with a post-ECT headache is the best action.
  Stating a headache is common after ECT and that napping will help the client feel better may be true,
  but it does not offer the client pain relief. Telling the client to eat breakfast and then to let the nurse
  know how the client feels conveys a lack of understanding to the client and dismisses the client’s
  concern.
  CN: Basic care and comfort; CL: Synthesize
  5.
  5:30 2. Fetal monitor strip for 1⁄2 hour every shift.
  6:00 3. Magnesium sulfate drawn at 6 AM .
  6:30 1. Check documentation, final check of each client.7:00 4. Point of care blood glucose and sliding scale insulin due at 7, 11, 4, and bedtime.
  The two tasks/orders that have time frames associated with them are the point of care blood
  glucose and insulin, and the magnesium sulfate blood draw. The fetal monitor strip can be obtained
  when convenient. Checking documentation and seeing each client should be done so that any client
  needs can be met and documentation completed prior to the 7 AM accu-check and insulin, yet close
  enough to the end of the shift that there will be minimal changes before change of shift.
  CN: Management of care; CL: Synthesize
1. An 18-month-old child should be able to say 10 or more words. Lack of speech development
  may indicate a lack of social stimulation, a hearing deficiency, or developmental delay. Referring the
  child for an evaluation may increase the child’s chance of reaching the child’s potential. A 4-month-
  old child with a healthy central nervous system and normal mental development should be able to
  laugh out loud if the child’s environment has been caring and the child’s needs are met safely and
  consistently. Children at age 10 months should be able to say the words “dada” and “mama” in
  response to the appropriate person. A 1-year-old child should have the ability to speak three to five
  words plus “mama” and “dada.”
  CN: Health promotion and maintenance; CL: Analyze
1. Phenylketonuria is a disease that is carried on the recessive genes of each parent. In order to
  be transmitted to a newborn, the infant inherits a recessive gene from each parent. Control of the
  disease is by reduction of the amino acid phenylalanine, which is present in all protein foods. The
  disease cannot be cured, but controlled. With each pregnancy, there is a 25% chance a child will
  inherit the disease.
  CN: Reduction of risk potential; CL: Apply
1. The nurse should convey empathy and invite the client to share more about her thoughts and
  feelings so that the nurse can assess the mother for possible postpartum depression, which usually
  occurs between 2 weeks and 3 months after the baby’s birth but also can occur later. Postpartum
  depression is a mood disorder with symptoms of tearfulness, mood swings, despondency, feelings of
  inadequacy, inability to cope with the baby, and guilt about performance as a mother. Postpartum
  depression commonly goes undetected because of poor recognition and lack of knowledge. Hormonal
  changes during and after childbirth may account for some of the symptoms; however, the nurse should
  not assume that that is the case. Stating the client’s husband and family should help her is an
  assumption that they are not and dismisses the client’s concerns. Saying most new mothers feel the
  same way minimizes the client’s concerns and decreases the likelihood of further disclosure by the
  client.
  CN: Psychosocial integrity; CL: Synthesize
4 tablets
CN: Pharmacological and parenteral therapies; CL: Apply
2,3. Huntington’s disease, or Huntington’s chorea, is an autosomal dominant geneticneurologic disease that affects descendants of an affected person at a 50% rate. Huntington’s disease
does not skip generations and affects men and women equally. Huntington’s disease is genetically
transmitted on chromosome 4, and death usually results from respiratory complications related to
aspiration.
CN: Physiological adaptation; CL: Apply

Question 2

Q

The nurse notices drops of a liquid on the hallway floor of a health care facility. The nurse should do which of the following first?
Place paper towels over the drops of liquid.
Don clean gloves and wipe up the drops of liquid.
Post “wet floor” signs around the area.
Call the Environmental Services Department.
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client’s legs are numb
all the way up to the hips. The nurse should do which of the following next? Select all that apply.
Call the family to come in to visit.
Notify the health care provider of the change.
Place respiratory resuscitation equipment in the client’s room.
Check for advancing levels of paresthesia.
Have the client perform ankle pumps.
The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:
Give higher doses of pain medication.
Keep patches on the client’s eyes to prevent corneal abrasion.
Monitor the temperature of the bathwater.
Avoid turning the client.
A client with paranoia is having a delusion. While the client is having the delusion, the nurse should do which of the following?
Assist the client to relieve anxiety.
Ask the client what is causing the feelings of anxiety.
Present reality when the client asks about the delusion.
Allow the client to express anger and intense emotions in appropriate ways.
The nurse is reviewing laboratory values of a client receiving clozapine. Which of the following laboratory values should the nurse report to the health care provider?
WBC of 3,500/μL (3.5 × 10 9 /L)
Hemoglobin of 8.2 g/dL (82 g/L)
Sodium level of 136
Hyaline casts in the urinalysis
The nurse is planning care for a client who has sustained a spinal cord injury. The nurse should assess the client for:
Anesthesia below the level of the injury.
Tingling in the fingers.
Pain below the site of the injury.
Loss of vibratory sense.
A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which of the following areas that is a potential pressure point when theclient is in this position?
Sacrum.
Occiput.
Ankles.
Heels.
Which of the following is appropriate when developing a plan of care for promoting the development of a pre-schooler? Select all that apply.
Providing anticipatory guidance for parents.
Helping the parents understand their child’s behavior.
Identifying deviations from normal growth and development patterns.
Determining the child’s future development.
Sending the child to a day care center.
A neonate is to receive an IV infusion of normal saline solution at 3 mL/h. The nurse is setting the alarms on an IV infusion pump. How should the nurse set the alarms?
At 5% above and 5% below the keep-vein-open rate.
Within a 15% range of the keep-vein-open rate.
To sound when the infusion is infiltrating.
At the exact drip rate as prescribed.
A client is exhibiting pressured speech, a labile affect, euphoria, and hyperactivity. The client
states, “I am the Savior of the city.” The family states that the client has hardly slept or eaten for days. Which of the following client needs is a priority in the nurse’s plan of care?
Physical.
Social.
Spiritual.
Cultural.

Answer

A

1. Liquids found on the floor should be removed immediately. The nurse should first put on
  gloves and then wipe up the liquid. Following removal, Environmental Services should be contacted
  to thoroughly cleanse the floor with a disinfectant solution. Placing paper towels over the drops is a
  safety hazard. “Wet floor” signs will be posted after the floor is cleansed by Environmental Services.
  CN: Safety and infection control; CL: Synthesize
2,3,4. A client who has been admitted for numbness and tingling in the lower extremities that
advances upward, especially after having a viral infection, has clinical manifestations characteristic
of Guillain-Barré syndrome. The health care provider must be notified of the change immediately
because this disease is progressively paralytic and should be treated before paralysis of the
respiratory muscles occurs. The nurse must assess the client continuously to determine how fast the
paralysis is advancing. The family does not need to be called in to visit until the client is stabilized
and emergency equipment is placed at the bedside. Performing ankle pumps will not relieve the
numbness or change the course of the disease.
CN: Management of care; CL: Synthesize
1. The spinal cord connects the brain to the periphery. The thalamus is located in the midbrain
  and integrates all sensory impulses except olfaction. The afferent impulses are received and then
  transmitted from the thalamus. Destruction or interruption of the neurosensory pathway results in loss
  of communication between the two systems. Monitoring the temperature of the bathwater is important
  because the client cannot feel whether the water is too hot or too cold. Damage to the thalamus does
  not result in loss of the corneal reflex. Loss of position and vibratory sense usually occurs with
  degeneration of the posterior column of the spinal cord; therefore, turning every 2 hours is critical to
  prevent skin breakdown related to increased capillary pressure. The nurse can give only the
  prescribed dosage of pain medication.
  CN: Physiological adaptation; CL: Synthesize
1. When a client asks the nurse about the validity of a delusion, the nurse should present
  reality. The nurse should tell the client that he or she does not hear the voice, see the image, or
  experience whatever other manifestation of the delusion that the client is experiencing. The client
  with paranoia is delusional, related to anxiety states, but cannot manage the anxiety at this moment.
  Allowing expressions of anger or other intense emotions may be harmful to the client or others.
  Nurses should avoid “why” questions, because such questions tend to make the client defensive.
  CN: Management of care; CL: Synthesize
1. A side effect of clozapine is leukopenia. A WBC count is drawn every week; if it starts to
  drop, the nurse should notify the health care provider. A slightly low hemoglobin level (below 11.2
  g/dL [112 g/L]) and a normal sodium level of 136 are not significant. Hyaline casts occur because of
  protein in the urine, and a small amount is normally found in the urine, especially after exercise.
  CN: Pharmacological and parenteral therapies; CL: Synthesize16. 1. The spinal cord connects the brain to the periphery. Destruction or interruption of the
  neurosensory pathway results in loss of communication between the two systems. Transection of the
  spinal cord renders the individual in a complete state of anesthesia below the level of injury. Tingling
  in the fingers may be related to spinal cord disease or to improper positioning of the extremity. Loss
  of position and vibratory sense usually occurs when the individual has degeneration of the posterior
  column of the spinal cord.
  CN: Physiological adaptation; CL: Analyze
1. Common pressure points in the side-lying position include the ears, shoulders, ribs, greater
  trochanter, medial and lateral condyles, and ankles. The sacrum, occiput, and heel are pressure points
  in the supine position.
  CN: Basic care and comfort; CL: Analyze
1, 2, 3. Goals for promoting healthy development in preschoolers include anticipatory
guidance, helping parents understand their child’s behavior, identifying deviations from the norm, and
assessing parent-child interaction. No one can assess or determine the child’s future development and
trying to do so can limit the potential the child may achieve. Although learning to interact with others
is important, sending the child to a day care center is not essential to promote healthy development.
The nurse can encourage the parents to provide opportunities for the child to play with others.
CN: Psychosocial integrity; CL: Create
1. On pumps with infusion rate alarms, the alarms should be set at 5% above and 5% below
  the prescribed infusion rate. A wider range is not safe. The alarms must be set to indicate a change in
  the drip rate, not infiltration. Setting the alarms for the exact drip rate will cause the alarms to trigger
  when the client moves, and this exact range is not needed to alert the nurse to an unsafe rate.
  CN: Safety and infection control; CL: Apply
1. The client’s physical needs are a priority in the nurse’s plan of care. The lack of fluid and
  caloric intake can lead to dehydration and cardiac collapse. The lack of sleep and rest can lead to
  exhaustion and death. Social, spiritual, and cultural needs are important client needs but not as
  important as the physical needs during an acute manic episode.
  CN: Psychosocial integrity; CL: Synthesize

Question 3

Q

21. A neonate is receiving an IV infusion of dextrose 10% in water administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which times? Select all that
apply.
1. When the infusion is started.
2. At the beginning of each shift.
3. When the neonate returns from x-ray.
4. When the neonate moves in the crib.
5. After the parents have visited.

The nurse is caring for a critically ill client with the client’s mother and spouse in the room. The spouse begins to shout derogatory comments to the mother, blaming her for her spouse’s critical state. What should the nurse do?
Try to calm both the mother and spouse by speaking in a soft voice.
Step between the mother and spouse stating emphatically, “Stop!”
Call the hospital Security Department.
Report the details immediately to the supervisor.
The nurse is planning care for a neonate to prevent neonatal heat loss immediately after birth.
To conserve heat and help the infant maintain a stable temperature, the nurse should:
Nestle the neonate against the crib wall.
Place the infant skin to skin with the mother.
Bathe the neonate with warm water.
Position the neonate lying in an open crib with a diaper on.
The nurse observes that the client’s right eye does not close completely. Based on this finding, which of the following nursing interventions would be most appropriate?
Making sure the client wears eyeglasses at all times.
Placing an eye patch over the right eye.
Instilling artificial tears once every shift.
Cleaning the eye with a clean washcloth every shift.
The nurse is administering an intramuscular injection to an infant. Indicate the appropriate site for this injection.
A 14-year-old with rheumatic fever who is on bed rest is receiving an IV infusion of dextrose 5% in water administered by an infusion pump. The nurse should verify the alarm settings on the infusion pump at which of the following times? Select all that apply.
When the infusion is started.
At the beginning of each shift.
When the child returns from x-ray.
When the child moves in the bed.
When the child is sleeping.
A potential concern when caring for an older adult who has diminished hearing and vision is the client’s:
Feelings of disorientation.
Cognitive impairment.
Sensory overload.
Social isolation.
Which of the following children should be referred for further assessment regarding language
development?
A 2-year-old who has a vocabulary of 300 words and can combine two or three words in a phrase.
A 3-year-old who has a vocabulary of 900 words and can make a complete sentence of three
or four words.
A 2-year-old who has a vocabulary of 100 words and can point to objects.
A 1-year-old who has a vocabulary of eight words and can say “mommy” and “daddy” with
specific reference to the correct person.
A nurse is taking a medication history on a client with multiple sclerosis before administering an initial dose of baclofen (Lioresal). What should the nurse check before administering the drug? Select all that apply.
Presence of muscle weakness.
History of muscle spasms.
Serum creatinine level.
Serum potassium level.
Blood glucose.
A client has been taking carbamazepine (Tegretol) for 2 years. The nurse should assess the client for which of the following? Select all that apply.
Bruising.
Sore throat.
Urine retention.
Light-colored stool.
Hydration status.

Answer

A

1, 2, 3. The alarm settings on infusion pumps should be verified at the time the infusion is
started, at the beginning of each shift, and when the client is moved. The neonate can move in bed, but
if the alarm is triggered, the nurse should verify the settings. Unless the neonate has moved or been
taken out of the crib, it is not necessary to check alarm settings after the parents visit.
CN: Safety and infection control; CL: Apply
1. Contacting the Security Department is a proactive response in a situation that may become
  more volatile. A soft voice by the nurse may not even be heard in this situation. To state, “Stop!” in
  this situation is not helpful and does not deal with the escalating risk. Once Security has been notified,
  the nurse should also report the incident to the supervisor.
  CN: Management of care; CL: Synthesize
1. Thermoregulation of the neonate is a critical intervention for the nurse caring for neonates.
  The preferred method of thermoregulation for healthy term newborns is to place them skin to skinwith the mother. Wrapping and placing a hat on the newborn is another way to conserve heat and
  prevent heat loss. With the neonate lying against a crib wall, heat transfers away from the infant to the
  cooler surface (conduction). If the neonate is wet, the warmer water on the surface of the neonate
  evaporates to the cooler air (evaporation). If the neonate is lying in an open crib with a diaper on, the
  body naturally loses heat to the surrounding cooler air as it radiates from the warm body to the cooler
  room (radiation).
  CN: Management of care; CL: Synthesize
1. When the blink reflex is absent or the eyes do not close completely, the cornea may become
  dry and irritated. Placing a patch over the eye is the most appropriate intervention to prevent eye
  injury. Making sure the client wears her eyeglasses at all times will not help protect the eye from
  injury. A once-per-shift intervention will not adequately relieve the potential for injury from a dry and
  irritating ocular environment. A normal saline solution should be used to moisten the eye, not tap
  water.
  CN: Health promotion and maintenance; CL: Synthesize
The vastus lateralis in the thickest part of the anterolateral thigh is a safe injection site for
infants. The needle should be inserted at a 90-degree andle to the long axis of the femur.
CN: Safety and infection control; CL: Apply
1, 2, 3. The alarm settings on infusion pumps should be verified at the time the infusion is
started, at the beginning of each shift, and when the client is moved. The child can move in bed or
sleep, but if the alarm is triggered, the nurse should verify the settings.
CN: Safety and infection control; CL: Apply
1. Social isolation is a concern for an older adult who has diminished hearing and vision.Feeling disoriented may be related to cognitive problems rather than diminished hearing and vision.
  Diminished hearing and vision is related to the aging process and does not result in impairment of the
  older adult’s thought processes. The client with impaired hearing and vision is unlikely to experience
  sensory overload.
  CN: Psychosocial integrity; CL: Synthesize
1. According to the Denver Developmental Screening Examination, a child age 2 years should
  have a vocabulary of 300 words, be able to combine two or three words, and ask for what he or she
  wants by name. By age 3, the child should have a vocabulary of 900 words and can use a complete
  sentence of three or four words. A 1-year-old has a vocabulary of at least eight words and can
  reference people and objects.
  CN: Health promotion and maintenance; CL: Analyze
1, 2, 3, 5. The nurse should ask the client with multiple sclerosis about areas of muscle
weakness because baclofen may increase the weakness. The nurse should ask the client about a
history of muscle spasms. Baclofen is effective against involuntary spasms resistant to passive
movement for clients with multiple sclerosis and paralysis. Baclofen is not effective against the
spasticity of cerebral origin, such as with cerebral palsy and Parkinson’s disease. The nurse should
ask the client about the client’s liver and renal function because baclofen is metabolized and excreted
by these organs. The nurse should check the laboratory values reflecting the function of the kidneys
and liver, which include serum creatinine and blood urea nitrogen levels. The nurse should also check
blood glucose levels because baclofen can increase blood glucose. Clients with diabetes taking
antidiabetic medication may need to adjust the dosage. Potassium is not affected by the drug, so the
nurse does not need to check the serum potassium level.
CN: Pharmacological and parenteral therapies; CL: Apply
1, 2, 4. The nurse should assess the client for signs of bone marrow depression, manifested by
bruising or unusual bleeding, and signs of infection such as a sore throat. The nurse should also assess
the client for signs of hepatic dysfunction, such as light-colored stool or dark-colored urine. Although
the nurse may want to check the client’s urinary function 31. 3. The nurse uses active listening, in which the client’s feelings are reflected back to him.
Telling the client that everyone wears them does not consider the client’s feelings. Telling the client
that what he said is not what he meant discounts the validity of his statement. Interpreting the reason
for the client being upset as the rule being unreasonable does not take into account how it affects the
client personally.
CN: Psychosocial integrity; CL: Synthesize
1. The restraint should remain in position. Removing the restraint or untaping the restraint will
  risk dislodging the IV.
  CN: Safety and infection control; CL: Apply
1, 2, 3, 4. The purposes of the Pap (Papanicolaou) smear include: to detect precancerous and
cancerous cells of the cervix; to assess the effects of sex hormonal replacement; to identify viral,
fungal, and parasitic conditions; and to evaluate the response to chemotherapy or radiation therapy tothe cervix.
CN: Health promotion and maintenance; CL: Apply
2,3. The nurse should use at least two sources of identification before administering
medication to any client. The identification can include the medical record number and the client’s
date of birth. It is not necessary to check the client and dose for this drug with another nurse. It is also
not safe to use the room number or bed number as a source of identification as clients’ locations in the
hospital are frequently changed. The nurse should not assume that the child will give a correct first
name.
CN: Safety and infection control; CL: Apply
1. One of the actions of propranolol (Inderal), a drug used in the treatment of migraine
  headaches, is to decrease the heart rate. The nurse should assess the client’s blood pressure to
  evaluate overall circulatory response to the medication. Until the blood pressure value is assessed,
  there is no immediate need to contact the physician. The nurse should complete the blood pressure
  assessment before administering the drug. There is no immediate need to administer oxygen or contact
  a relative because a slowed pulse rate is an expected action of propranolol.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. During the tertiary circular reacti31. 3. The nurse uses active listening, in which the client’s feelings are reflected back to him.
  Telling the client that everyone wears them does not consider the client’s feelings. Telling the client
  that what he said is not what he meant discounts the validity of his statement. Interpreting the reason
  for the client being upset as the rule being unreasonable does not take into account how it affects the
  client personally.
  CN: Psychosocial integrity; CL: Synthesize
1. The restraint should remain in position. Removing the restraint or untaping the restraint will
  risk dislodging the IV.
  CN: Safety and infection control; CL: Apply
1, 2, 3, 4. The purposes of the Pap (Papanicolaou) smear include: to detect precancerous and
cancerous cells of the cervix; to assess the effects of sex hormonal replacement; to identify viral,
fungal, and parasitic conditions; and to evaluate the response to chemotherapy or radiation therapy tothe cervix.
CN: Health promotion and maintenance; CL: Apply
2,3. The nurse should use at least two sources of identification before administering
medication to any client. The identification can include the medical record number and the client’s
date of birth. It is not necessary to check the client and dose for this drug with another nurse. It is also
not safe to use the room number or bed number as a source of identification as clients’ locations in the
hospital are frequently changed. The nurse should not assume that the child will give a correct first
name.
CN: Safety and infection control; CL: Apply
1. One of the actions of propranolol (Inderal), a drug used in the treatment of migraine
  headaches, is to decrease the heart rate. The nurse should assess the client’s blood pressure to
  evaluate overall circulatory response to the medication. Until the blood pressure value is assessed,
  there is no immediate need to contact the physician. The nurse should complete the blood pressure
  assessment before administering the drug. There is no immediate need to administer oxygen or contact
  a relative because a slowed pulse rate is an expected action of propranolol.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. During the tertiary circular reaction stage of the sensorimotor stage (12 to 18 months of
  age), the infant comes to understand causality and object performance, recognizing that objects placed
  out of sight continue to exist. During the preoperational stage (ages 2 to 6), the child’s perception is
  based on how he views an event. The concrete operational stage (ages 6 to 12) is the beginning of
  concrete, logical thinking. During the formal operations stage (ages 13 to 18), the child is able to
  perform abstract reasoning.
  CN: Health promotion and maintenance; CL: Analyze
1. The neonate will be simultaneously dried and stimulated to cry immediately upon birth. If
  the neonate does not cry as a result of these measures, the ABCs (airway, breathing, and circulation)
  of cardiopulmonary resuscitation will be followed. Positioning the neonate and suctioning or clearing
  the airway ensure that the airway is clear so that the first breath the neonate takes is air, rather than
  fluid or particulate matter. Breathing will be stimulated once the airway is clear and then heart rate
  will be validated either apically or through the cord. The cord may be cut in order to hand the neonate
  to the mother for nursing. In many instances, the infant is placed on the mother’s abdomen before the
  cord is cut.
  CN: Health promotion and maintenance; CL: Evaluate
2 mg/minute
First, calculate the concentration of mg/mL:
Next, multiply the number of milligrams per milliliter by the pump setting in milliliters per hour:
Next, divide the milligrams per hour by 60 to obtain milligrams per minute:CN: Pharmacological and parenteral therapies; CL: Apply
1. The client may become tolerant of the antianginal effects of nitrates. Removing nitrates for
  8 hours each day is usually effective in preventing tolerance. Nitrate patches should not be used on an
  as-needed basis. Sites should be rotated daily to prevent skin irritation, but this is not related to
  tolerance. Removing the patch for only 8 hours is sufficient to prevent tolerance and skipping days
  could impact the drug’s effectiveness.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. The nurse should tell the client in a simple, matter-of-fact manner the purpose of the
  restraints to help the client understand why restraints are necessary. Long explanations and
  interactions with the acutely manic and agitated client are not appropriate or therapeutic at this time
  because the client with a high level of anxiety has difficulty focusing and processing. Saying
  “threatening others and throwing furniture is not allowed” could lead the client to believe he is being
  punished. Reminding the client that the client has “been here before and knows what the rules are”
  and “we are only doing this for your own good, so calm down” are condescending and verbalizing the
  expectation that the client can control the illness.
  CN: Psychosocial integrity; CL: Synthesizeon stage of the sensorimotor stage (12 to 18 months of
  age), the infant comes to understand causality and object performance, recognizing that objects placed
  out of sight continue to exist. During the preoperational stage (ages 2 to 6), the child’s perception is
  based on how he views an event. The concrete operational stage (ages 6 to 12) is the beginning of
  concrete, logical thinking. During the formal operations stage (ages 13 to 18), the child is able to
  perform abstract reasoning.
  CN: Health promotion and maintenance; CL: Analyze
1. The neonate will be simultaneously dried and stimulated to cry immediately upon birth. If
  the neonate does not cry as a result of these measures, the ABCs (airway, breathing, and circulation)
  of cardiopulmonary resuscitation will be followed. Positioning the neonate and suctioning or clearing
  the airway ensure that the airway is clear so that the first breath the neonate takes is air, rather than
  fluid or particulate matter. Breathing will be stimulated once the airway is clear and then heart rate
  will be validated either apically or through the cord. The cord may be cut in order to hand the neonate
  to the mother for nursing. In many instances, the infant is placed on the mother’s abdomen before the
  cord is cut.
  CN: Health promotion and maintenance; CL: Evaluate
2 mg/minute
First, calculate the concentration of mg/mL:
Next, multiply the number of milligrams per milliliter by the pump setting in milliliters per hour:
Next, divide the milligrams per hour by 60 to obtain milligrams per minute:CN: Pharmacological and parenteral therapies; CL: Apply
1. The client may become tolerant of the antianginal effects of nitrates. Removing nitrates for
  8 hours each day is usually effective in preventing tolerance. Nitrate patches should not be used on an
  as-needed basis. Sites should be rotated daily to prevent skin irritation, but this is not related to
  tolerance. Removing the patch for only 8 hours is sufficient to prevent tolerance and skipping days
  could impact the drug’s effectiveness.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. The nurse should tell the client in a simple, matter-of-fact manner the purpose of the
  restraints to help the client understand why restraints are necessary. Long explanations and
  interactions with the acutely manic and agitated client are not appropriate or therapeutic at this time
  because the client with a high level of anxiety has difficulty focusing and processing. Saying
  “threatening others and throwing furniture is not allowed” could lead the client to believe he is being
  punished. Reminding the client that the client has “been here before and knows what the rules are”
  and “we are only doing this for your own good, so calm down” are condescending and verbalizing the
  expectation that the client can control the illness.
  CN: Psychosocial integrity; CL: Synthesizeand hydration status, urine output and
  hydration are not specific monitoring needs related to long-term use of carbamazepine (Tegretol).
  CN: Pharmacological and parenteral therapies; CL: Analyze

Question 4

Q

A 12-year-old client says, “Give me my pajamas. I’m not putting your silly gown on.” An appropriate response by the nurse should be:
“I know they’re funny but everyone here wears them.”
“You don’t mean that, now. A big guy like you knows how hospitals are.”
“You’re upset because you feel awkward and embarrassed in these gowns.”
“You’re upset because you think we’re unreasonable.”
A nursing assistant is taking care of a child in the arm restraint shown below. To provide care for this child, what should the assistant do?
Unpin the restraint and perform range-of-motion exercises.
Unwrap the restraint and bathe the arm using warm water.
Leave the restraint in its current position.
Remove one tape at a time while bathing the child’s arm.
Which of the following are reasons for the nurse to encourage women to have a “Pap test” (Papanicolaou smear)? Select all that apply.
To detect precancerous and cancerous cells of the uterus.
To assess the effects of sex hormonal replacement.
To identify viral, fungal, and parasitic conditions.
To evaluate the response to chemotherapy or radiation therapy to the cervix.
To detect a diminished blood flow to the perineal mucous membrane.
The nurse is administering prednisone to a preschool child with nephrosis. To ensure that the nurse has identified the child correctly, the nurse should do which of the following? Select all that
apply.
Ask another nurse to confirm that this is the correct dose and correct client for whom the prednisone has been prescribed.
Check the child’s identification band against the medical record number.
Verify the date of birth from the medical record with the date of birth on the client’s
identification band.
Compare the room number on the bed with the number on the client’s identification band.
Ask the client to state the first name.
The nurse is administering propranolol (Inderal) to a client for control of migraine
headaches. The client’s pulse rate is 56 bpm. What should the nurse do next?
Contact the physician immediately.
Assess blood pressure.
Administer oxygen.
Ask for a relative to contact.
When a child is able to grasp the idea that a ball continues to exist even though the child’s parent placed the ball under a hat, the child is in which of the following stages in the development of logical thinking, according to Piaget?
Sensorimotor.
Preoperational.
Concrete operations.4. Formal operations.
A nurse discusses with parents the procedures that will be performed on their neonate immediately after birth. The nurse determines that the instructions have been understood when the
client states that which of the following will be done to the neonate first?
The neonate will be suctioned.
The neonate will be dried and stimulated to cry.
The neonate will be given oxygen.
The neonate’s umbilical cord will be cut.
An infusion of lidocaine hydrochloride (Xylocaine) is running at 30 mL/hour. The dilution is 1,000 mg/250 mL. What dosage is the client receiving per minute?
_______________ mg/minute.
A nurse is instructing a client about the use of nitroglycerin patches. The nurse should instruct
the client to:
Remove the patch every night.
Use the patch only when chest pain occurs.
Change the site of the patch every day.
Apply the patch only on alternate days.
The nursing staff has safely and successfully secluded and restrained a client with acute mania who threatened the nurse and threw a chair against the wall in the community room. Which
statement by the nurse is most helpful to the client at this time?
“Threatening others and throwing furniture is not allowed.”
“You have been restrained until you can manage your behavior.”
“Since you have been here before, you know what the rules are.”
“We are only doing this for your own good, so calm down.”

Answer

A

1, 2, 3. The alarm settings on infusion pumps should be verified at the time the infusion is
started, at the beginning of each shift, and when the client is moved. The neonate can move in bed, but
if the alarm is triggered, the nurse should verify the settings. Unless the neonate has moved or been
taken out of the crib, it is not necessary to check alarm settings after the parents visit.
CN: Safety and infection control; CL: Apply
1. Contacting the Security Department is a proactive response in a situation that may become
  more volatile. A soft voice by the nurse may not even be heard in this situation. To state, “Stop!” in
  this situation is not helpful and does not deal with the escalating risk. Once Security has been notified,
  the nurse should also report the incident to the supervisor.
  CN: Management of care; CL: Synthesize
1. Thermoregulation of the neonate is a critical intervention for the nurse caring for neonates.
  The preferred method of thermoregulation for healthy term newborns is to place them skin to skinwith the mother. Wrapping and placing a hat on the newborn is another way to conserve heat and
  prevent heat loss. With the neonate lying against a crib wall, heat transfers away from the infant to the
  cooler surface (conduction). If the neonate is wet, the warmer water on the surface of the neonate
  evaporates to the cooler air (evaporation). If the neonate is lying in an open crib with a diaper on, the
  body naturally loses heat to the surrounding cooler air as it radiates from the warm body to the cooler
  room (radiation).
  CN: Management of care; CL: Synthesize
1. When the blink reflex is absent or the eyes do not close completely, the cornea may become
  dry and irritated. Placing a patch over the eye is the most appropriate intervention to prevent eye
  injury. Making sure the client wears her eyeglasses at all times will not help protect the eye from
  injury. A once-per-shift intervention will not adequately relieve the potential for injury from a dry and
  irritating ocular environment. A normal saline solution should be used to moisten the eye, not tap
  water.
  CN: Health promotion and maintenance; CL: Synthesize
The vastus lateralis in the thickest part of the anterolateral thigh is a safe injection site for
infants. The needle should be inserted at a 90-degree andle to the long axis of the femur.
CN: Safety and infection control; CL: Apply
1, 2, 3. The alarm settings on infusion pumps should be verified at the time the infusion is
started, at the beginning of each shift, and when the client is moved. The child can move in bed or
sleep, but if the alarm is triggered, the nurse should verify the settings.
CN: Safety and infection control; CL: Apply
1. Social isolation is a concern for an older adult who has diminished hearing and vision.Feeling disoriented may be related to cognitive problems rather than diminished hearing and vision.
  Diminished hearing and vision is related to the aging process and does not result in impairment of the
  older adult’s thought processes. The client with impaired hearing and vision is unlikely to experience
  sensory overload.
  CN: Psychosocial integrity; CL: Synthesize
1. According to the Denver Developmental Screening Examination, a child age 2 years should
  have a vocabulary of 300 words, be able to combine two or three words, and ask for what he or she
  wants by name. By age 3, the child should have a vocabulary of 900 words and can use a complete
  sentence of three or four words. A 1-year-old has a vocabulary of at least eight words and can
  reference people and objects.
  CN: Health promotion and maintenance; CL: Analyze
1, 2, 3, 5. The nurse should ask the client with multiple sclerosis about areas of muscle
weakness because baclofen may increase the weakness. The nurse should ask the client about a
history of muscle spasms. Baclofen is effective against involuntary spasms resistant to passive
movement for clients with multiple sclerosis and paralysis. Baclofen is not effective against the
spasticity of cerebral origin, such as with cerebral palsy and Parkinson’s disease. The nurse should
ask the client about the client’s liver and renal function because baclofen is metabolized and excreted
by these organs. The nurse should check the laboratory values reflecting the function of the kidneys
and liver, which include serum creatinine and blood urea nitrogen levels. The nurse should also check
blood glucose levels because baclofen can increase blood glucose. Clients with diabetes taking
antidiabetic medication may need to adjust the dosage. Potassium is not affected by the drug, so the
nurse does not need to check the serum potassium level.
CN: Pharmacological and parenteral therapies; CL: Apply
1, 2, 4. The nurse should assess the client for signs of bone marrow depression, manifested by
bruising or unusual bleeding, and signs of infection such as a sore throat. The nurse should also assess
the client for signs of hepatic dysfunction, such as light-colored stool or dark-colored urine. Although
the nurse may want to check the client’s urinary function and hydration status, urine output and
hydration are not specific monitoring needs related to long-term use of carbamazepine (Tegretol).
CN: Pharmacological and parenteral therapies; CL: Analyze

Question 5

Q

A client is taking 600 mg of valproic acid twice daily. The nurse should assess the client for
which of the following? Select all that apply.
Tremors.
Hair loss.
Gastrointestinal upset.
Anorexia.
Weight gain.
A client has a cerclage placed at 16 weeks’ gestation. She has had no contractions and her
cervix is dilated 2 cm. The nurse is preparing the client for discharge. Which statement by the client
should indicate to the nurse that the client needs further instruction?
“I will need more frequent prenatal visits.”
“I should call if I am leaking fluid or have bleeding or contractions.”
“I can have sex again in about 2 weeks.”
“I can have nothing in my vagina until I am at term.”
Which of the following conditions is a potential consequence of a prolonged QT interval?
Serious electrolyte imbalance.
Predisposition to torsades de pointes.3. Predisposition to atrial fibrillation.
Development of orthostatic hypotension.
A mother calls the clinic after her 4-year-old choked on a peanut. The mother reports that she performed abdominal thrusts and the child is breathing normally now. The nurse should tell the mother to:
Bring the child to the emergency department to check for airway obstruction.
Test the child’s urine for blood from internal bleeding.
Call the physician if the child begins to sweat and feels dizzy.
Observe the child for difficulty breathing because the abdominal thrusts may have caused a
pneumothorax.
A client is taking nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain from rheumatoid arthritis. What instruction should the nurse give the client about NSAIDs?
Take the prescribed medication with food and fluids.
Gradually decrease the medication dosage.
Rinse the mouth with water after taking NSAIDs.
Avoid driving and using machinery while taking NSAIDs.
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart below. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart below.What should the nurse do next?

Apgar score 5 minutes after birth
HR - 100 bpm
RR - irregular
Color - pink
muscle tone - moving all extremities
Reflexes - cough

Notify the neonatologist on call.
Continue to assess the neonate.
Apply an oxygen mask.
Rub the neonate’s extremities.
Communicating with parents and children about health care has become increasingly significant because:
Consumers of health care cannot keep up with rapid advances in science.
The influence of the media and specialization have increased the complexity of managing health.
Nurse educators have recognized the value of communication.
Clients are more demanding that their rights be respected.
The most appropriate toys to give to a 5-month-old infant are:
Plastic toy cars.
Wooden puzzles.
Stuffed animals.
Soft, washable toys.
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews
the chart for pulse oximetry reading for the last 8 hours.
The pulse oximetry reading at 3:30 PM is 75%. What should the nurse do first?
Administer oxygen via mask.
Swaddle the neonate in heated blankets.3. Reassess the oximetry reading in 30 minutes.
Draw blood gases for oxygen and carbon dioxide levels.
The nurse reviews the client’s laboratory report to determine the client’s blood level of valproic acid, which is 35 mcg/mL (243 μmol/L). Based on this report, what should the nurse do
first?
Withhold the next dose of valproic acid.
Notify the physician.
Give the next dose as prescribed.
Take the client’s vital signs.

Answer

A

1, 2, 3, 5. Anorexia or loss of appetite is not associated with valproic acid. Adverse effects
include tremors, transient hair loss, gastrointestinal upset, and weight gain.
CN: Pharmacological and parenteral therapies; CL: Analyze
1. Intercourse commonly stimulates uterine contractions. The prostaglandins found in semen
  can also initiate contractions. After placement of a cerclage for advanced dilation and contractions,
  the client is considered at high risk for preterm birth and should be seen by her health care provider
  more frequently. The client should call the health care provider immediately if she sees signs of
  complications, such as leaking fluid (rupture of membranes), vaginal bleeding, and contractions
  (particularly with a cerclage in place). Anything in the vagina may initiate contractions and the labor
  process.
  CN: Reduction of risk potential; CL: Evaluate
1. A prolonged QT interval is significant because it can lead to the development of
  polymorphic ventricular tachycardia, also known as torsades de pointes. A prolonged QT interval
  may result from electrolyte imbalance but it does not lead to the development of an electrolyte
  imbalance, atrial fibrillation, or orthostatic hypotension.
  CN: Physiological adaptation; CL: Analyze
1. The nurse should instruct the mother to bring the child to the emergency department. If
  aspirated, nuts may swell leading to an airway obstruction after the initial event; endoscopy may be
  required to remove remaining fragments. Bleeding from trauma to internal organs after abdominal
  thrusts is rare. There are no signs of shock to suggest anaphylaxis. There is no indication of the
  presence of a pneumothorax.
  CN: Physiological adaptation; CL: Synthesize
1. Gastric upset is an adverse effect of NSAIDs. Taking these drugs with food and fluids
  minimizes this effect. The dosage of NSAIDs does not need to be tapered. Because NSAIDs do notcause drowsiness or stomatitis, the client does not need to restrict driving or rinse the mouth.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The neonate’s Apgar score has been improving since birth. (The birth score is 6; the current
  score is 9.) The nurse should continue to assess the neonate. There is no indication that oxygen is
  needed since the color is improving, and stimulating the baby is not necessary as the baby is now
  flexing the extremities.
  CN: Management of care; CL: Synthesize
1. Today’s health care network includes many specialized areas, such as respiratory therapy,
  medicine, laboratory, social services, and technical monitoring, to name a few. Due to expanded
  media coverage of health care issues, parents are more aware of health care issues but cannot
  understand all the ramifications of possible health care decisions. Because of this expanded media
  coverage, health care consumers are more aware of advances in the science of health care. Nurses
  have always recognized the value of communication and that all nurses are teachers. Clients are more
  aware of their rights through media exposure and information disseminated by health care facilities.
  However, respect for the client’s rights should be the nurse’s concern as well and communicating with
  parents and children should not be impacted by a client’s knowledge or demand for those rights.
  CN: Health promotion and maintenance; CL: Apply
1. Soft, washable toys are appropriate for infants, who tend to place everything in their
  mouths. These toys are not harmful. Plastic toys cannot be manipulated by a child of this age and the
  child would put the car in the mouth, which may not be safe due to small parts that may be swallowed
  or aspirated. Games and puzzles are too advanced for a 5-month-old and the child could put the
  pieces in the mouth and swallow them. Some stuffed animals have eyes that can be swallowed or
  aspirated.
  CN: Reduction of risk potential; CL: Apply
1. The oxygen levels for this neonate have dropped during the last 8 hours; the nurse should
  administer oxygen, as the neonate is not obtaining adequate oxygenation on room air. The
  recommended pulse oximetry reading in a term neonate is 95% to 100%. Keeping the neonate warm
  may improve the oxygen saturation if that is the cause of the poor gas exchange, but overheating with
  warm blankets may increase oxygen demand. Waiting to reassess the neonate could cause the neonate
  to have inadequate oxygen levels unnecessarily. While blood gases may be drawn, the first action is
  to administer the oxygen.
  CN: Management of care; CL: Synthesize
1. The nurse should give the next dose as prescribed because the blood level is 35 mcg/mL
  (243 μmol/L), which is lower than the normal range of 50 to 100 mcg/mL (347 to 693 μmol/L).
  Withholding the next dose, notifying the physician, and taking the client’s vital signs are not indicated
  in this situation.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 6

Q

After 2 days on a psychiatric unit, a client is still isolating himself or herself in his or her room, except for meals. The client says he or she is uncomfortable around crowds of people. Which
nursing intervention is the most appropriate initially?
Play a game of checkers with the client in his or her room.
Ask the client to attend a group session with the nurse.
Invite the client to go for a walk with the nurse and one other client.
Talk with the client in a corner of the crafts room.
A nurse is caring for a woman who gave birth to a term neonate at 6 AM . At 4 PM , the woman has a
distended bladder and is reporting pain of 5 on a scale of 1 to 10. The nurse reviews the client’s output record.
Apply a warm, moist towel over the bladder.
Ask the woman to sit on the toilet while the nurse runs water from the faucet.
Administer Tylenol with codeine.
Use an in-and-out catheter to empty the bladder.
The father of a 3-week-old infant who has developed sepsis says that he feels guilty because
he did not realize his infant was sick. Which of the following responses by the nurse would be most
appropriate?
“You should have realized something was wrong; he is your son.”
“Did you read the booklet on newborns that was sent home with you from the hospital?”
“What you are feeling is normal; next time, you will know what to look for.”
“Babies can get sick quickly, and parents do not always realize it.”
A mother brings a 15-month-old child to the well-baby clinic. She states the child has been taking approximately 18 to 20 oz (540 to 600 mL) of whole milk per day from a bottle with meals and at bedtime. The nurse should suggest that she begin weaning the child from the bottle to avoid risking:
Malnutrition.
Anemia.
Dental caries.
Malocclusion.
The nurse is preparing to administer furosemide (Lasix) to a 3-year-old with a heart defect. The nurse verifies the child’s identity by checking the arm band and:
Asking the child to state her name.
Checking the room number.
Asking the child to tell her birth date.
Asking the parent the child’s name.
Diuretic therapy with torsemide is started for a client with heart failure. Two days after the drug therapy is started, the nurse evaluates the torsemide as effective when the client has experienced which of the following outcomes?
Has an improved appetite and is eating better.
Weighs 6 lb (3 kg) less than she did 2 days ago.
Is less thirsty than she was before the drug therapy.
Has clearer urine since starting torsemide.
Which of the following techniques is correct for the nurse to use when inserting a rectal suppository for an adult client?
Insert the suppository while the client bears down.
Place the client in a supine position.
Position the suppository along the rectal wall.
Insert the suppository 2 inches (5.1 cm) into the rectum.
The nurse is preparing to suction a tracheostomy for a client with methicillin resistant Staphylococcus aureus (MRSA) (see figure). The nurse should:
Wear a powered air purifying respirator (PAPR) face shield.
Use goggles that include the hairline.
Change to a surgical mask.
Proceed to suction the client’s tracheostomy.
A young woman is brought from the emergency department (ED) to the psychiatric unit. ED staff report that she is not answering questions and has been sitting in the same position in the
wheelchair for 45 minutes. When her arm was extended to draw blood, she did not move her arm
back to a natural position. The client’s brother says he found her this way yesterday and couldn’t get
her to move on her own. Which nursing interventions have a high priority in this case? Select all that apply.
Ask her to describe her stressors.
Monitor her body positions to prevent injury.
Offer her nutritional shakes every 3 hours.
Encourage her to talk about her feelings.
Assist her to the bathroom every 2 hours.
Protect her from intrusions by other clients.
A client who had a total hip placement at 9 AM is receiving an autologous blood transfusion that was started at 11 AM . At the change of shift (3 PM ), the day nurse reports that there is 50 mL of the
unit of blood remaining to be infused. Which of the following is a priority action for the evening
nurse?
Keep the blood transfusing at the same rate.
Increase the rate so it will infuse by 4 PM .
Discontinue the blood transfusion at the beginning of the shift.
Maintain the current rate and discontinue the blood transfusion at 5 PM .

Answer

A

1. Going for a walk with the nurse and another client is a more gradual introduction to being
  with others. The goal is to gradually encourage interaction with others; playing games in the client’s
  room promotes continued isolation. Going to a group session and participating in crafts is exposing
  the client to large groups too rapidly.CN: Psychosocial integrity; CL: Synthesize
1. The client is not emptying her bladder after repeated attempts. The nurse should now use an
  in-and-out catheter to empty the bladder. While the other comfort measures may be helpful, this client
  has not completely emptied her bladder since giving birth and will be at risk for a urinary tract
  infection and postpartum hemorrhage.
  CN: Management of care; CL: Synthesize
1. The signs and symptoms of sepsis in a neonate, such as changes in appearance and
  behavior, are almost imperceptible. Often, the parents’ only problem is that the neonate does not look
  “right.” Fever and localized response, which are clues to infections in older children, are often absent
  in the neonate. Telling the father that he should have realized something was wrong is condescending
  and serves only to further the father’s guilt feelings. Asking the father whether he read the booklet
  from the hospital implies that the father is at fault. One experience would not necessarily ensure that
  the father would be able to detect sepsis another time.
  CN: Psychosocial integrity; CL: Synthesize
1. Nursing bottle caries occur when a child is routinely given a bottle of milk or juice at nap
  and bedtime. When teeth become coated in sugar before sleep, the lack of activity in the child’s mouth
  for several hours during sleep allows the sugar to convert to acid, leading to decay. A child drinking
  18 to 20 oz (540 to 600 mL) of whole milk in a day should not be malnourished, although she may
  lack essential vitamins and iron. Anemia may occur if she is only drinking milk because it contains no
  iron; however, the mother indicates she is eating meals. Regardless, children of this age should be
  taking no more than 16 oz (480 mL) of milk per day, and most children at this age should be drinking
  from a cup. The mother should be instructed to wean the child to a cup one feeding at a time until the
  child is completely weaned to a cup for all feedings. The last bottle-feeding to be replaced is usually
  the night bottle. Malocclusion of the teeth does not occur at 15 months. If the child were to continue to
  suck on a bottle until age 4 years or later, then malocclusion may occur.
  CN: Health promotion and maintenance; CL: Apply
1. Safety standards require the use of two identifiers prior to medication administration. A
  parent can be used as the second identifier. Many young children will only answer to a nickname that
  does not coincide with the medical identification band, or may answer to any name. It is common for
  children on a pediatric floor to go into each other’s rooms. A small child may not know their birth
  date.
  CN: Safety and infection control; CL: Apply
1. The primary reason to give a diuretic to a client with heart failure is to promote sodium and
  water excretion through the kidneys. As a result, the excessive body water that tends to accumulate in
  a client with heart failure is eliminated, which causes the client to lose weight. Monitoring the client’s
  weight daily helps evaluate the effectiveness of diuretic therapy. The client should be advised to
  weigh herself daily. An increased appetite or decreased thirst does not establish the effectiveness of
  the diuretic therapy, nor does having clearer urine after starting torsemide.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
1. The client should be placed in a side-lying position and encouraged to take a deep breath
  during the insertion of the suppository. Placing the suppository along the rectal wall promotesabsorption of the medication and helps avoid placing it into a stool mass. The nurse should insert the
  suppository 3 to 4 inches (7.6 to 10.2 cm) into the rectum of an adult client.
  CN: Reduction of risk potential; CL: Apply
1. The nurse is wearing protective personnel equipment appropriately for suctioning the
  client: goggles, gown, and respirator mask. It is not necessary to wear a PAPR face shield to suction a
  tracheostomy. A surgical mask does not provide maximum protection.
  CN: Safety and infection control; CL: Apply
2, 3, 5, 6. Safety and physiological needs are crucial initially for a client who is unable to
meet her own needs. Identifying her stressors and feelings will be important later when she is
responding to questions and her environment.
CN: Psychosocial integrity; CL: Synthesize
1. In most agencies, it is a policy to discard the autologous blood after 4 hours of transfusing,
  due to an increased risk of infection. Increasing the infusion rate could cause fluid overload.
  Monitoring blood transfusions is a serious nursing responsibility, and because it is the change of shift,
  there is increased risk of error.
  CN: Safety and infection control; CL: Synthesize

Question 7

Q

A client is admitted with fatigue, shortness of breath, pale skin, and dried, cracked lips,
tongue, and mouth. The hemoglobin is 9 g/dL (90 g/L) and red blood cell count is 3.5 million
cells/mm 3 (3.5 × 10 12 /L). Which of the following foods should the nurse teach this client to include in the diet?
Beef, beets, and cabbage.
Lamb, applesauce, and mint jelly.
Chicken, dumplings, and biscuits.
Fish, wine, and apples.
When assessing a neonate 1 hour after birth, the nurse observes that the neonate exhibits slight
cyanosis when quiet but becomes pink when crying. The nurse is unable to pass a catheter through the
left nostril. The nurse notifies the pediatrician because the neonate most likely is exhibiting signs and symptoms of which of the following?
Esophageal reflux disorder.
Unilateral choanal atresia.
Respiratory distress syndrome.
Tracheoesophageal fistula.
When developing a teaching plan for parents of toddlers about poisonous substances, the nurse should emphasize which of the following safety points? Select all that apply.
Toddlers should be adequately supervised at all times.
All poisonous substances should be kept out of the reach of children and stored in a locked
cabinet if necessary.
The difference between pediatric and adult dosages of medicines is significant and adult
dosages given to children can have serious, harmful effects.
Syrup of ipecac should be administered following all ingestions of poisonous substances.
Following any poisoning, the parents should call the Poison Control Center for instructions for appropriate treatment.
A client on a psychiatric care unit has muscle spasms in the neck, stiffness in other muscles,
and the eyes are rolling upward. The client had two PRN doses of haloperidol in the last 6 hours. Of
the drugs that have been prescribed for the client as needed (see chart), the nurse should administer:
Lorazepam.
Amantadine.
Diphenhydramine.
Benztropine.
After birth of a male neonate at 38 weeks’ gestation, the nurse dries the neonate and places
him under the radiant warmer. The nurse performs this action based on the understanding that one neonatal response to cold stress involves which of the following?
Metabolism of brown adipose tissue.
Decreased utilization of glycogen stores.
Decreased utilization of calorie stores.
Increased shivering to keep warm.
Twenty-four hours after an appendectomy, a 16-year-old adolescent of Asian ethnicity has no
pain but is frowning and has the legs drawn to the fetal position. The nurse should:
Administer pain medication.
Ask the adolescent what is troubling him.
Discuss the adolescent’s behavior with the parents.
Offer a distracting activity such as a video game.
When developing the teaching plan for a primiparous client who is bottle-feeding her term
neonate for the first feeding, which of the following instructions should the nurse include?
Fill the entire nipple of the bottle with formula.
All term babies have well-developed sucking skills.
Bubble the baby after 2 oz (60 mL) of formula have been taken.
Propping of the bottle results in too much air being taken in by the baby.
A client has back pain 10 minutes after a unit of packed red blood cells (RBCs) was started.
The client’s pulse, blood pressure, and respirations are stable, and similar to vital signs obtained
before infusing the RBCs. What should the nurse do? Select all that apply.
Turn off the infusion of the packed RBCs.
Flush the Y-tubing with normal saline to clear the line.3. Send the remaining blood to lab.
Prepare for cardiopulmonary resuscitation.
Obtain a urine specimen to send to the laboratory.
A primiparous client at 4 hours after a vaginal birth and manual removal of the placenta voids for the first time. The nurse palpates the fundus, noting it to be 1 cm above the umbilicus, slightly firm, and deviated to the left side, and notes a moderate amount of lochia rubra. The nurse notifies the physician based on the interpretation that the assessment indicates which of the following?
Perineal lacerations.
Retained placental fragments.
Cervical lacerations.
Urine retention.
While performing a gestational age assessment for a male neonate born vaginally at 37 weeks’ gestation, the nurse should assess the neonate for:
An anterior transverse crease on the soles.
Extensive rugae on the scrotum.
Some cartilage in the ear lobes.
Coarse and silky scalp hair.

Answer

A

1. The client is demonstrating signs of anemia. Beef, beets, and cabbage are good sources of
  iron. Chicken, dumplings, biscuits, fish, applesauce, jelly, and wine are not major iron sources.
  CN: Health promotion and maintenance; CL: Synthesize
1. Infants are obligatory nose breathers except when crying. The observation that the infant has
  slight cyanosis when quiet but becomes pink when crying and the inability to pass a catheter through
  the left nostril suggest that the neonate is exhibiting symptoms of unilateral choanal atresia. With this
  condition, one of the nasal passages is blocked by an abnormality of the septum. Surgical intervention
  is necessary to open the nostril. Typically, a neonate with esophageal reflux disorder exhibits
  episodes of apnea and vomiting after eating. Respiratory distress syndrome commonly occurs in
  preterm neonates who lack surfactant to maintain lung expansion. Common findings include sternal
  retractions, tachypnea, grunting respirations, nasal flaring, cyanosis, pallor, hypotonia, and
  bradycardia. A neonate with tracheoesophageal fistula commonly exhibits cyanosis during feedings
  and vomiting.
  CN: Reduction of risk potential; CL: Analyze
1, 2, 3, 5. Safety measures for poisonous substances include close supervision of children,
safely storing toxic substances, teaching proper dosages and differences between adult and child
doses, and the proper way to contact the Poison Control Center for instructions. Poison Control
should be notified as soon as the poisoning has occurred and airway and circulation have been
assessed. Poison Control will direct any further treatment. Syrup of ipecac is rarely used today in the
treatment of ingested substances due to the potential for aspiration. It is contraindicated in cases of
arsenic poisoning, seizures, and the ingestion of petroleum or corrosive substances.
CN: Safety and infection control; CL: Create
1. Dystonic adverse effects of haloperidol, especially oculogyric crises, are painful and
  frightening. IM benztropine is the fastest and most effective drug for managing dystonia. Lorazepam isan antianxiety medication and is not effective for treatment of dystonia. Although amantadine and
  diphenhydramine can be used for extrapyramidal symptoms, oral medications do not work as quickly,
  and amantadine may worsen psychotic symptoms.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Neonates burn brown adipose tissue (fat) as a response to cold stress. In addition, there is
  increased utilization of glycogen and calorie stores. Hypoglycemia may result from becoming
  stressed by a cold environment. Neonates do not have the ability to shiver.
  CN: Health promotion and maintenance; CL: Apply
1. While the adolescent is denying pain, he is displaying objective signs of pain. Adults of
  Asian ethnicity typically display stoic behavior and the 16-year-old most likely would try to conform
  to this cultural norm. The nurse should administer an analgesic and assure the client that taking
  medication will speed the recovery process. The nurse must also reassess the client after
  administering the pain medication and document the response. The reassessment is typically done 30
  minutes after a parenteral analgesic and an hour after an oral analgesic. People who identify with the
  Asian culture infrequently complain and, therefore, asking the client about what is troubling him is
  unlikely to provide the nurse with additional information. The adolescent’s behavior is consistent
  with postoperative pain. If the parents are stoic, discussing the adolescent’s behavior may not be
  productive. At this stage of treatment, distractions can be used in conjunction with medication, but
  should not be substituted for them.
  CN: Basic care and comfort; CL: Synthesize
1. Formula should fill the entire nipple of the bottle while the baby is sucking. This decreases
  the amount of air taken in by the baby; taking in too much air can lead to regurgitation. Not all babies
  at term are born with well-developed sucking skills. Some neonates are sleepy and do not suck well.
  For the first feeding, the baby should be bubbled after taking one-fourth to one-half ounce (7.5 to 15
  mL) of formula and then again when the infant has finished the feeding. Bottle propping can lead to
  aspiration, decreased infant bonding, and aspiration of formula. However, it is not associated with the
  intake of too much air.
  CN: Health promotion and maintenance; CL: Synthesize
1, 3, 4, 5. When a client begins to have back pain with administration of blood, the nurse
should suspect a hemolytic reaction, and the blood transfusion should be stopped immediately. Any
remaining blood and the tubing should be sent to the lab. The nurse should prepare for a reaction from
mild to severe, including the need for cardiopulmonary resuscitation, because even a small amount of
mismatched blood can lead to a major reaction. The nurse should obtain a urine specimen to send to
the laboratory to check for hemoglobin because RBC hemolysis filters through the kidneys from the
reaction. The nurse should stop the IV line with the Y-tubing for the blood and not flush the line with
saline so that the client does not receive any more blood. The tubing should be changed so that a tube
without blood can be used for infusions.
CN: Pharmacological and parenteral therapies; CL: Synthesize
1. At 4 hours postpartum, the fundus should be midline and at the level of the umbilicus.
  Whenever the placenta is manually removed after childbirth, there is a possibility that all of the
  placenta has not been removed. Sometimes small pieces of the placenta are retained, a common cause
  of late postpartum hemorrhage. The client is exhibiting signs and symptoms associated with retainedplacental fragments. The client will continue to bleed until the fragments are expelled. Perineal and
  cervical lacerations are characterized by bright red bleeding and a firmly contracted fundus at the
  level that is expected. Urine retention is characterized by a full bladder, which can be observed by a
  bulge or fullness just above the symphysis pubis. Also, the client’s fundus would be deviated to one
  side and boggy to the touch.
  CN: Reduction of risk potential; CL: Analyze
1. A neonate born at 37 weeks’ gestation will have some cartilage in the ear lobes, fine and
  fuzzy hair, scant to moderate rugae in the scrotum, and a breast nodule diameter of 4 mm. Neonates
  born before 36 weeks’ gestation will have only an anterior transverse crease on the soles of the feet.
  Extensive rugae on the scrotum are a typical finding in neonates born at 39 weeks’ gestation or later.
  Coarse and silky scalp hair typically is found in neonates that are born at 39 weeks or later.
  CN: Health promotion and maintenance; CL: Analyze

Question 8

Q

Two family members are visiting their father who is experiencing acute delirium. They are upset that their father is so disoriented. “He knows who we are, but that’s about it. We don’t know
what to say to him.” What should the nurse tell the family? Select all that apply.
“Answer his questions simply, honestly, slowly, and clearly.”
“Correct him when he is hearing and seeing things that are not there.”
“Occasionally remind him of the time, day, and place when he doesn’t remember.”
“Include him in your conversation, instead of talking about him while he is present.”
“Raise your voice a bit so you are sure he hears you.”
A 26-year-old is being treated for delirium due to acute alcohol intoxication. The client is restless, does not want to stay seated, and has a staggering gait. What should the nurse do first?
Place the client in a chair with a waist restraint.
Provide one-to-one supervision of the client until detoxification treatment can begin.
Ask the client to sit in a chair next to the nurses’ station.
Decrease stimuli by putting the client in bed with the room door closed.
The nurse is monitoring a client receiving a blood transfusion when the client develops a cough with shortness of breath. The client also has a headache and a racing heart. What should the nurse do first?
Slow the infusion rate.
Replace the blood with saline.
Administer an antihistamine.
Place the client flat with the feet elevated.
A nurse is obtaining an ankle-brachial index for a client with arteriosclerosis. Identify the correct order for obtaining the ankle-brachial index.
Place a Doppler probe at a 45-degree angle to the correct pulse (dorsalis pedis or posteriortibial).
Place the client in the supine position.
Record the highest systolic blood pressure readings in both arms.
Record the ankle systolic blood pressure reading when the Doppler sound returns.
A nurse is analyzing a client’s intake and output. The client has a temperature of 102°F (38.9°C) and is receiving IV fluid therapy because of the nothing-by-mouth status due to acute
pancreatitis. Before planning nursing actions, the nurse should first consider which of the following?
The client’s body mass index.
Insensible fluid loss through the lungs and skin.
When the client last ate.
The number of bags of IV fluid for the client.
Two toddlers are arguing over a toy in the playroom. The nurse should say to the children:
“If you can’t play together, I’ll have to put you back in your rooms.”
“Give the toy to me. Now neither of you will have it.”
“Let me see if I can get both of you a similar toy.”
“Let one of you play with it for awhile, and then give it to the other.”
A 9-month-old infant whose parents have emigrated from Mexico presents in the clinic with
severe dehydration from vomiting. The infant was seen in the clinic just 3 days ago for a well-childnvisit, but now the family seems very distrustful of the health care team. The nurse should ask the parents:
“Have you been speaking with a healer?”
“Did anything concern you about your last visit?”
“Has immigration been causing you problems?”
“Are you afraid your baby will be taken from you?”
A 4-year-old child continues to come to the nurses’ station after being told children are not allowed there. What behavior is the child exhibiting?
Attention-seeking behavior.
Aggressive behavior.
Resistive behavior.
Exaggerated stress behavior.
A 5-month-old infant is brought to the emergency department with vomiting and diarrhea, which the mother states started 3 days ago. The nurse should conduct a focused assessment for which of the following? Select all that apply.
Decreased or absent tearing.
Dry mucous membranes.
Sunken fontanel.
Clear, pale yellow urine.
Bounding pulse.
A neonate born to a primiparous client at 36 weeks’ gestation in a small, rural hospital is to be transferred by ambulance to a level III nursery. To prepare the parents for the transfer, which of the following should the nurse include in the plan of care?
Instruct the parents that the neonate is in critical condition.
Obtain the mother’s consent for the neonate’s transfer.
Allow the parents to touch the neonate before transfer.
Ask the father if he desires to ride in the ambulance during the transfer

Answer

A

1, 3, 4. Clear communication is crucial for a client with delirium. The family must include the
client in all conversations and keep him oriented to time and place. It is inappropriate to argue with a
client’s hallucinations because they are real to the client. Speaking more loudly will not help this
client hear more distinctly and may increase the client’s confusion.
CN: Management of care; CL: Synthesize
1. One-to-one supervision provides safety until appropriate detoxification can be given.
  Restraints are the last intervention after less restrictive alternatives have been tried. It is unlikely that
  the client can cooperate with staying in a chair. Putting the client in bed in his or her room puts the
  client at risk for falling and a closed door prevents close observation.
  CN: Safety and infection control; CL: Synthesize
1. The nurse should recognize that the client’s clinical manifestations indicate fluid overload,
  and decrease the infusion rate so the client’s circulation can handle the extra fluid. Antihistamines are
  used for allergic reactions. The nurse should place the client in an upright position with the feet down
  so that blood or fluid volume can drain to the lower extremities and relieve some of the extra fluid
  load on the heart. The nurse does not need to replace the blood with another type of fluid because the
  client’s response is not a blood transfusion reaction.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
  74.
Place the client in the supine position.
Record the highest systolic blood pressure readings in both arms.
Place a Doppler probe at a 45-degree angle to the correct pulse (dorsalis pedis or posterior
tibial).
Record the ankle systolic blood pressure reading when the Doppler sound returns.The nurse should first place the client in a supine position. Next the nurse should assess blood
pressures in both arms and record the highest systolic blood pressure as the brachial pressure. To
obtain the brachial pressure, the nurse should place the blood pressure cuff around the affected leg
just above the malleolus and then place a Doppler probe at a 45-degree angle to the dorsalis pedis or
posterior tibial pulse. The nurse should then inflate the blood pressure cuff until the Doppler sound
stops and then deflate it until the Doppler sound returns. The point when sound returns is recorded as
the ankle systolic pressure. The ankle-brachial index is the ankle (dorsalis pedis or posterior tibial)
pressure divided by the highest arm pressure. A pressure above 90 is normal; anything lower
indicates obstruction.
CN: Physiological adaptation; CL: Synthesize
1. Insensible fluid loss is invisible vaporization from the lungs and skin, and assists in
  regulating body temperature. The amount of water loss is increased by accelerated body metabolism,
  which occurs with increased body temperature. The client’s body mass index does not directly
  influence calculating fluid therapy.
  CN: Management of care; CL: Analyze
1. A toddler has not developed the concept of sharing, so two similar toys must be provided to
  prevent disagreements. Playing together in harmony is not the developmental level of a toddler. They
  play side by side, but not together. Threatening to put the children in their rooms does not solve the
  problem, nor does taking away the toy.
  CN: Health promotion and maintenance; CL: Synthesize
1. In order to reestablish trust, the nurse should first try to determine if something happened at
  the last visit that was upsetting for the family. Dislocation of a body part can be seen as a source of
  illness among persons of Mexican ethnicity. At a well-child visit the health care provider would have
  palpated the fontanel. If it is now sunken from dehydration, the parents may blame the provider for the
  illness. This belief is referred to as Caida de la mollera. The family may have talked with a
  traditional healer, but following this line of questioning first may appear that the nurse considers the
  healer as an adversary. Asking about immigration makes a stereotypical assumption. Asking if the
  family is afraid the baby will be taken from them may be suggesting something the family has never
  considered and may cause unnecessary distress.
  CN: Psychosocial integrity; CL: Synthesize
1. The child wants attention from the nurse, even if the behavior is met by a negative response.
  Aggression, resistance against authority, and exaggerated stress are behaviors that can be associated
  with a 4-year-old. However, coming to the nurses’ station after being told not to do so is not an
  example of these behaviors.
  CN: Psychosocial integrity; CL: Analyze
1, 2, 3. Clinical manifestations of dehydration include decreased tearing; dry mucous
membranes; sunken fontanelles; weight loss; behavioral changes; scanty, concentrated urine; and a
thready, fast pulse. Clear, pale yellow urine would indicate adequate hydration. A bounding pulse
would indicate fluid volume excess.
CN: Physiological adaptation; CL: Analyze
1. When a neonate is being transferred to a neonatal care center (level III nursery), the parentsshould be allowed to see and touch the neonate, if possible, before transfer. The parents should be
  given the location and telephone number of the unit to which the neonate is being transferred. This
  helps to keep the parents informed. The parents are already aware of the neonate’s condition and
  should recognize that it is critical if the neonate is being transferred to a neonatal care center. Consent
  would have been obtained on admission, and further consent is not likely necessary. Asking whether
  the father would like to ride in the ambulance with the neonate during the transfer is inappropriate.
  Most ambulances or transferring vehicles (eg, helicopters, airplanes) do not allow family members to
  accompany the ill client. Space in the motor vehicle, helicopter, or plane is limited.
  CN: Management of care; CL: Synthesize

Question 9

Q

A multiparous client gives birth to a neonate at 24 weeks’ gestation. After 12 hours, the neonate’s condition deteriorates, and death appears likely within the next few minutes. The parents are Roman Catholic, and they request that the neonate be baptized. Which of the following actions
would be most appropriate?
Contact the hospital chaplain to perform the baptism.
Alert the hospital’s director that a neonatal death is imminent.
Find a health care provider who is Roman Catholic to perform the baptism.
Baptize the neonate, regardless of the nurse’s own religious beliefs.
A client has bursitis in the subacromial bursa. A nurse determines that the client understands teaching when the client says which of the following?
“I will apply moist heat to my shoulder for 20 minutes three times each day.”
“I will lift 30-lb (13.5-kg) weights at least three times each day.”
“I will apply dry ice to my shoulder for 20 minutes three times each day.”
“I will perform 360-degree circles with my arms extended at least three times daily.”
A client has just undergone a lumbar puncture (LP). Which finding should the nurse immediately report to the physician?
The client’s oral intake was 1,200 mL in the past 8 hours.
The client required analgesia for headache.
A moderate amount of serous fluid was noted on the lumbar dressing.
The client is concerned about the test results.
The nurse is reviewing the lab report below for a client with breast cancer and brain metastasis. According to the information in the chart, what should the nurse do next?
Document these results on the medical record.
Report the elevated potassium level immediately.
Report the elevated calcium level immediately.
Refrain from reporting the results because the client is in hospice care.
The nurse on the postpartum unit has delegated the care of a multiparous client and her term neonate at 4 hours postpartum to the licensed practical nurse (LPN). Which of the following findings
should the LPN report to the nurse immediately?
Neonatal regurgitation of one tablespoon after a feeding.
Maternal pulse rate of 100 bpm at rest.
Neonatal heart rate of 140 bpm while at rest.
Increased maternal lochia rubra with initial ambulation.
A child with a cardiac defect assumes a squatting position. The nurse should determine that the position is effective for the child by noting:
Less energy required to play with toys on the floor.
Less dyspnea.
Relief of abdominal pressure.
Improved muscle tone.
A client was brought to the emergency department following a motor vehicle accident, and has phrenic nerve involvement. The nurse should asses the client for:
Alteration in level of consciousness.
Altered cardiac functioning.
Ineffective breathing pattern.
Alteration in urinary elimination.
A primigravid client is seen for her first visit in the antenatal clinic and tells the nurse that her brother was born with cystic fibrosis (CF). When teaching the client about this disorder, the nurse
should include which of the following? Select all that apply.
Asian Americans have the highest inheritance rates.
To inherit CF, each parent must carry a recessive trait for the disease.
If both parents carry the trait, each offspring has a 25% chance of inheriting the disease.
Fetal testing can occur by checking the shape of the red blood cells.
Chorionic villi sampling (CVS) can identify prenatally if their child carries the trait or has the
disease.
A client with a peritonsillar abscess has been hospitalized. Upon assessment, the nurse
determines the following: a temperature of 103°F (39.4°C), body chills, and leukocytosis. The client
begins to have difficulty breathing. In what order should the nurse perform the following actions?
Call the physician.
Open the airway.
Start an IV access site.
Explain the situation to the family.
The nurse is teaching a client who has deep vein thrombosis caused a pulmonary embolus,
which has now resolved. Which of the following instructions should the nurse give to this client?
“Report such signs as leg swelling, discomfort, redness, or warmth.”
“Sit with your legs lower than the rest of your body.”
“Walk at least every other day.”
“Limit your fluids to 1 L each day.”

Answer

A

1. Tenets of the Roman Catholic Church hold that it is acceptable for anyone, regardless of
  religious belief, to baptize a neonate. For Roman Catholic families, baptism ensures entry into
  heaven. Local practice may vary, and in some situations the parents may prefer to have a Roman
  Catholic person perform the rites; however, this person may not be available until after the death. The
  parents may wish to have a priest contacted for grief support. Notification of the hospital’s director is
  not necessary.
  CN: Management of care; CL: Synthesize
1. Moist heat is a nonpharmacologic pain management strategy that may alleviate pain and
  reduce the dose of analgesic, if required. Heat dilates blood vessels, and decreases inflammation.
  Lifting and circular exercises will aggravate the already-inflamed joint. Cold constricts blood
  vessels, and dry ice is not used on the body.
  CN: Basic care and comfort; CL: Evaluate
1. For a LP, a needle is inserted into the subarachnoid space to obtain a specimen of spinal
  fluid for diagnostic testing. Fluid on the lumbar dressing indicates cerebrospinal fluid (CSF) leakage,
  and must be reported to the physician immediately. The client should be encouraged to drink fluids
  after an LP to facilitate production of CSF. It is normal to have a mild headache due to the removal of
  CSF samples for laboratory analysis. Although the concerns of the client should be discussed with the
  physician at some point, the CSF leakage is a priority and should be reported immediately.
  CN: Reduction of risk potential; CL: Analyze
1. The normal calcium level is 9.0 to 10.5 mg/dL (2.3 to 2.6 mmol/L). Hypercalcemia is
  commonly seen with malignant disease and metastases. The other laboratory values are normal.
  Hypercalcemia can be treated with fluids, furosemide, or administration of calcitonin. Failure to treat
  hypercalcemia can cause muscle weakness, changes in consciousness, nausea, vomiting, abdominal
  pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment.
  Comfort and risk reduction are components of hospice care.
  CN: Reduction of risk potential; CL: Synthesize
1. The LPN should report a maternal pulse rate of 100 bpm at rest because it could potentially
  indicate shock or hemorrhage. Typically, the pulse rate of a postpartum client slows after childbirth
  and continues to be slow for about 1 week because of an increase in central circulation that results in
  increased stroke volume to provide adequate maternal circulation. The normal pulse rate is 60 to 70
  bpm. Neonatal regurgitation of one tablespoon after a feeding, a neonatal heart rate of 140 bpm at
  rest, and increased maternal lochia rubra when the mother initially ambulates are normal findings.CN: Management of care; CL: Analyze
1. A child with a cardiac defect finds that squatting decreases venous return and workload to
  the heart and increases comfort and blood flow to the lungs. Squatting traps blood in the lower
  extremities so less blood is returned to the right atrium. Squatting does not make it easier for the child
  to play with toys. Squatting does not relieve abdominal pressure; it may even increase it slightly.
  Squatting has no effect on muscle tone. When done by a child with a cardiac defect, it is not meant as
  an exercise but is a compensatory process used to reduce dyspnea.
  CN: Physiological adaptation; CL: Evaluate
1. The diaphragm is the major muscle of respiration; it is made up of two hemidiaphragms,
  each innervated by the right and left phrenic nerves. Injury to the phrenic nerve results in
  hemidiaphragm paralysis on the side of the injury and an ineffective breathing pattern. Consciousness,
  cardiac function, and urinary elimination are not affected by the phrenic nerve.
  CN: Management of care; CL: Analyze
2, 3, 5. Cystic fibrosis is most common in those of the Caucasian race. As an autosomal
recessive disease, for an infant to be affected, each parent must carry a recessive trait. If both parents
carry the trait, each offspring has a 25% chance of inheriting the disease, a 50% chance of being a
carrier, and a 25% chance of being unaffected. The shape of red blood cells is altered with sickle cell
disease rather than CF. CVS testing can identify whether a fetus is or is not affected.
CN: Health promotion and maintenance; CL: Create
89.
Open the airway.
Start an IV access site.
Call the physician.
Explain the situation to the family.
An open airway is essential to survival. The nurse should first ensure an open airway. Next, the
nurse should start an IV and then notify the physician. Finally, the nurse should inform the family of
the situation and, if appropriate, allow them to remain with the client.
CN: Management of care; CL: Synthesize
1. Prevention of another pulmonary embolus is important; the nurse should teach the client to
  observe for signs of clot formation to prevent a potentially fatal episode and maintain
  cardiopulmonary integrity and adequate ventilation and perfusion. Elevation of the lower extremities,
  not lowering them, promotes venous return to the heart. Ambulation must be done several times each
  day. Limiting fluid intake increases blood viscosity, promoting clot formation.
  CN: Health promotion and maintenance; CL: Synthesize

Question 10

Q

A multiparous client and her neonate, who has been cared for in the intensive care nursery for the past 3 days because of being small for gestational age, are to be discharged. Before their release, the mother tells the nurse, “I’ve been living in my car for the past 2 weeks.” Which of the following
should the nurse do next?
Notify the director of the birthing unit.
Contact the hospital’s social worker.
Contact the client’s physician.
Notify the client’s family members.
A nurse is assessing a client who is having her 14th laser surgery for removal of a birthmark from her left cheek. The nurse should ask this client about which food allergy associated with a
surgery risk given the circumstance of multiple surgeries?
Canned peas.
Frozen carrots.
Tomatoes.
Organ meats.

Answer

A

1. When a client is being released from the hospital with her neonate and the nurse learns that
  the client is homeless, the nurse should contact the hospital’s or unit’s social worker. Social workers
  have access to resources to assist the client to find temporary shelter in emergencies. The director of
  the birthing unit does not need to be notified. The director’s responsibilities are primarily
  administrative. The client’s physician can be notified once the social worker has offered assistance to
  the client. The physician may cancel the release of the neonate until temporary housing is located.
  Notifying the client’s family is inappropriate. The client may not have any immediate family members,
  or there may be some stress between the client and family.
  CN: Management of care; CL: Synthesize
1. A client who has had numerous surgical or medical procedures is more prone to latex
  exposure and thus latex sensitivity or allergy. People who are allergic to latex may also have an
  allergy to fresh fruits and vegetables such as tomatoes. If a client denies a latex allergy, the nurse
  should ask about food allergies to fresh fruits and vegetables as well as for latex allergies and
  shellfish for iodi
  ne allergies. The client with one allergy commonly has more than one allergy, so the
  nurse must specifically ask the client about food allergies related to other allergies.
  CN: Reduction of risk potential; CL: Analyze
1. The teenage girl has scoliosis, the lateral deviation of the spine. Kyphosis is noted by a
  forward curvature of the shoulders. Arthritis is diagnosed by radiographs. Hip dysplasia is noted in
  older children by pain, but is usually diagnosed before the child walks by noting excessive gluteal
  folds and limited hip abduction.
  CN: Health promotion and maintenance; CL: Analyze
1, 3, 4, 5. The nurse is responsible for the client’s safety in the operating room. The nurse
should call a time-out if the client is not properly identified with an identification band. In addition,
an IV line and oxygen should always be established when an ET tube is placed. This practice applies
whenever a client’s airway is compromised enough for intubation to occur, not only in the operating
room environment. An anesthesiologist should be present during surgery to manage the airway.
Postoperative pain medication is administered in the recovery room.
CN: Safety and infection control; CL: Synthesize
1. Anencephaly is a neural tube defect that is not compatible with life, although some infants
  with anencephaly live for several days before death occurs. When the client has decided to continue
  the pregnancy and donate the neonatal organs after the death of the neonate, the nurse should remain
  nonjudgmental. The nurse should explore his or her feelings about the issue of anencephaly and organ
  donation. The nurse should not make judgments about the client’s position, nor should the nurse try to
  persuade the client to terminate the pregnancy. Contacting the client’s minister to explore the client’s
  options is not appropriate. As a devout Baptist, the client probably has already discussed the matter
  with her minister. Telling the client that the neonatal death will be prolonged and painful to her is not
  helpful. Death may occur very soon after birth. Contacting the client’s family members is not
  appropriate. The client may wish to maintain confidentiality and privacy related to the birth.
  CN: Management of care; CL: Synthesize
2, 3, 4, 5. Anorexia is commonly the first indication of digoxin toxicity. Arrhythmias are also
common with digoxin toxicity. Although bradycardia is the most common sign of toxicity, other
tachycardic arrhythmias can occur. A normal pulse rate for a 3-month-old child at rest is about 120bpm. Blurred vision can be associated with digoxin toxicity and may be detected in an infant if he
stops following moving objects. Sudden vomiting or drowsiness can be associated with digoxin
toxicity. Constipation is not associated with digoxin toxicity and is not an adverse effect of digoxin.
CN: Pharmacological and parenteral therapies; CL: Synthesize
1. If the specimen was from a fingerstick and not a venous sample, the potassium level can be
  falsely elevated. Because the finger is squeezed to obtain the sample, cells may have been broken
  from the pressure of squeezing. When the cells break, they release potassium, which will falsely
  elevate the potassium level in the result. Calling the physician without first checking the source of the
  sample would not give the physician accurate and complete information. A cardiac monitor would not
  be necessary if the potassium level is falsely elevated. The last 24-hour output would only indicate
  that the infant is voiding in an adequate amount. This may or may not have an influence on the infant’s
  potassium level.
  CN: Reduction of risk potential; CL: Synthesize
1. The level of lethality of a client’s suicidal thoughts depends on the presence or absence of a
  plan. If the client has a plan, the nurse must know what it is and whether or not the client has access to
  the means to complete suicide. The initiation of suicide precautions is necessary whenever a client
  threatens suicide, but first it is important to discover more information about what the client is
  thinking and planning. Unless the client has at his or her disposal the means to harm himself or herself
  or is constantly trying to harm himself or herself with objects on the unit, placing the client on a
  suicide watch or confining the client to his or her room is an overreaction to the client’s disclosure of
  suicidal ideation.
  CN: Safety and infection control; CL: Synthesize
1, 2, 4, 5.The safest position for a hospital bed is in the low position if the client is not being
attended by the nurse. All IV rates should be running at the prescribed level or changed to that level.
The laboring client should be able to determine who is with her during the labor process and nursing
serves as the advocate for the client if the client wishes to have changes made. Laboring mothers
should not be lying flat on their backs as this creates compression of the vena cava and decreases
oxygenation to both the mother and the infant at a time when the best perfusion is desired. Pain should
be relieved or expressed to be tolerable at any point in the labor process. It is not necessary to use
continuous fetal monitoring in the early stages of a low risk pregnancy and labor.
CN: Safety and infection control; CL: Evaluate
1. Due to the client’s psychosis and difficulties coping, a positive, supportive environment is
  essential to limit further regression and help the client engage in her own treatment. Confrontation and
  peer pressure are the type of milieu more suited to a chemically dependent client. While involvement
  in self-governance can be therapeutic, forcing a psychotic client to participate in self-governance
  before she is ready could actually hinder treatment and recovery. Although group activities are
  commonly required in treatment programs, a client who is very disturbed or confused is not forced to
  attend. Also, the client must participate when and how she feels comfortable, rather than mandating a
  specific amount of participation. Equal participation by clients does not ensure a therapeutic milieu
  or speed the client’s recovery.
  CN: Psychosocial integrity; CL: Synthesize

Question 11

Q

Assessment of a primigravid client in active labor reveals cervical dilation at 9 cm withb complete effacement and the fetus at +1 station. Which of the following should the nurse do when the
physician prescribes meperidine 50 mg IM for the client?
Administer the medication in the left ventrogluteal muscle.
Be certain that naloxone is at the client’s bedside.
Ask the physician to validate the dosage of the drug.
Refuse to administer the medication to the client.
A client has been hospitalized with a diagnosis of myasthenia gravis. A friend is visiting the client during lunch. The nurse enters the room after the client recovered from choking on lunch. What
should the nurse do next?
Instruct the client to sit at a 30-degree angle in bed when eating.
Tell the client to swallow when her chin is tipped down on her chest.
Remind the client to rest after eating.
Encourage the client to eat alone.
A nurse is assessing a client with a brain injury. What is a client’s cerebral perfusion pressure (CPP) when the blood pressure (BP) is 90/50 mm Hg and the intracranial pressure (ICP) is 21?_______________ mm Hg.
A client with a T2-to-T3 spinal cord injury suddenly has a throbbing headache and blurred vision. The client is flushed and sweating on the upper trunk and face, and the hairs on the arms are raised. What should the nurse do first?
Raise the head of the bed.
Assess for hypotension.
Check the client for a distended bladder.
Logroll the client to see if the client is lying on a foreign object.
A 17-year-old unmarried primigravida client at 10 weeks’ gestation tells the nurse that her family doesn’t have much money and her dad just got laid off from his job. Which of the following
would be the nurse’s most appropriate action?
Instruct the client in methods for low-cost, highly nutritious meal preparation.
Determine whether the client qualifies for local assistance programs.
Refer the client to a social worker for enrollment in a food assistance program.
Ask the client if she has a job and the amount of income earned.
A client has impairments in immediate recall and short-term memory. A nurse is planning for the client’s daily activities. Which action by the nurse would be most effective?
Write out the client’s schedule in large print, and show the client where the schedule is placed.
Describe each activity and the time of the events at the beginning of the day.
Lead the client to each activity if he does not attend on time.
Tell the client about each activity 10 minutes before it begins.
A 17-year-old male client is being admitted to the adolescent psychiatric unit. He was brought in by the police after beating up two male peers. The client says, “They said I was gay because I had sex with an older neighbor when I was 8 years old. I am not gay!” Which of the
following nursing interventions would be appropriate? Select all that apply.
Monitor the client’s level of anger and potential aggression.
Help the client express anger safely.
Assist the client in processing his feelings about the sexual abuse.
Ask the client if he would like to attend a support group.
Discuss the client’s attitude about going to jail after discharge.
The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which of the following clients should the nurse assess first?
A multiparous client at 48 hours postpartum who is being discharged.
A primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate.
A multiparous client at 24 hours postpartum whose infant is in the special care nursery.
A primiparous client at 48 hours after cesarean birth of a term neonate.
A client is admitted to the hospital with malaise, headache, and cough followed by fever, chills, dyspnea, chest discomfort, myalgia, anorexia, vomiting, and diarrhea. The physician makes the
diagnosis of legionellosis (legionnaires’ disease). The client asks, “How did I get this?” Which response by the nurse is the most accurate?
“The bacteria thrive in warm water environments and are inhaled from contaminated water droplets.”
“You inhaled the bacteria from secondary smoke.”
“As ceiling fans circulate, bacteria are dispersed into the air.”
“You may have swallowed contaminated water.”
A client is scheduled to undergo an upper gastrointestinal (GI) series. Which of the following instructions should the nurse give the client in preparation for the test? Select all that apply.
“You will need to take a stool softener before the test to promote evacuation of the barium.”
“Do not eat or drink for 8 hours before the test.”
“You can expect white stools for about 48 hours after the test.”
“You will experience mild stomach pain during the test.”
“It is okay for you to smoke before the test.”

Answer

A

1. The nurse should refuse to administer the medication to the client because of the risk ofrespiratory depression in the neonate. Meperidine, given IM, peaks in 30 to 60 minutes and lasts 2 to
  4 hours. Based on the assessment findings, the client most likely will be giving birth within that time
  frame, increasing the risk of respiratory depression in the neonate, a serious consequence. Therefore,
  the nurse should not administer the drug. Naloxone should be readily available whenever opioids that
  can result in respiratory depression are used. Asking the physician to validate the dosage is not
  necessary. For clients in early labor, meperidine can be given IM in dosages ranging from 50 to 100
  mg.
  CN: Management of care; CL: Synthesize
1. Bending the chin down toward the chest decreases the risk of food entering the trachea and
  causing aspiration into the lungs. The client should sit up at a 90-degree angle when eating. Although
  eating and talking increase the risk of aspiration as well as muscle fatigue, the nurse should encourage
  the client to have visitors but avoid talking while chewing and swallowing. The client should rest
  before eating because muscle fatigue can contribute to choking.
  CN: Reduction of risk potential; CL: Synthesize
42.3 mm Hg
To obtain CPP, use this formula:
CPP = mean arterial pressure (MAP) − ICP. To obtain the MAP, use this formula:
To obtain the MAP, use this formula:
CN: Physiological adaptation; CL: Apply
1. The client with a spinal cord injury above T6 who suddenly experiences clinical
  manifestations of autonomic stimulation, such as flushing, sweating, and piloerection, is
  demonstrating life-threatening autonomic dysreflexia. The cluster of manifestation results from
  noxious stimuli, such as a full bladder, or lying on a foreign object, such as a plastic cap or crinkled
  paper, which the client cannot feel. As soon as the noxious stimulus is removed, the manifestations
  begin to subside. When the client demonstrates clinical manifestations of autonomic dysreflexia, the
  nurse should first elevate the head of the bed immediately to decrease the intracerebral pressure
  caused by the hypertension that developed from autonomic stimulation. The nurse can next check for a
  distended bladder or foreign object. The client’s blood pressure will be elevated; the nurse should
  assess vital signs frequently.
  CN: Management of care; CL: Synthesize
1. The nurse should refer the client to a social worker for assistance in enrolling in a food
  assistance program. Instructing the client in low-cost, highly nutritious meal preparation will not meet
  the client’s need for additional funds for food. Determining whether the client qualifies for assistance
  is part of the role of the social worker, not the nurse. Asking the client if she has a job and the amount
  of income earned is not within the role of the nurse. The social worker can determine whether the
  family income guidelines are met for assistance.
  CN: Management of care; CL: Synthesize
1. Telling the client about one activity at a time with 10 minutes’ notice gives the client timeto prepare for that activity. Writing out the schedule does not ensure that the client will remember to
  look at it. It is overwhelming to explain an entire day’s schedule all at once to a client diagnosed with
  dementia. Leading a client to an activity after the fact doesn’t allow the client to prepare.
  CN: Psychosocial integrity; CL: Synthesize
1, 2, 3, 4. Safety of others is a priority and the nurse must monitor the client’s anger and
potential for aggression. The nurse should also find safe ways for the client to express the client’s
anger and any other feelings about the abuse. A referral to a support group is appropriate because
anger management groups are one way to assist the client in learning to manage anger. Nothing about
jail is mentioned in the question. Discussion of jail does not help the client address the client’s issues
with anger and the abuse causing the anger.
CN: Management of care; CL: Synthesize
1. The primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate
  should be assessed first because this client is at risk for postpartum hemorrhage. Early postpartum
  hemorrhage typically occurs during the first 24 hours postpartum. Once the nurse has assessed the
  client’s fundus, lochia, and vital signs, a determination about the stability of the client can be made.
  After this assessment, the nurse can provide care to the other clients, who are of lesser priority than
  the newly postpartum primiparous client.
  CN: Management of care; CL: Synthesize
1. Legionellosis is a pneumonia caused by the bacterium Legionella pneumophila that
  thrives in water that is 95° to 115°F (35° to 46°C). When a building’s hot water plumbing has water at
  this temperature, the bacteria thrive; then they may be transmitted via inhalation from air conditioning,
  showers, spas, and whirlpools. The bacteria are not transmitted via smoke or ceiling fan blades or by
  swallowing contaminated water.
  CN: Health promotion and maintenance; CL: Synthesize
2, 3. The client should be instructed not to eat or drink for 8 to 12 hours before the test.
Stools will be white for up to 72 hours following the procedure as the barium is eliminated from the
body. Laxatives and fluids will be encouraged after the procedure to help prevent barium impaction,
but the client will not be given stool softeners or laxatives before the procedure. The client should not
experience pain during the procedure. The nurse should also instruct the client to stop smoking at
midnight the night before the test.
CN: Reduction of risk potential; CL: Apply

Question 12

Q

Which of the following are appropriate identifiers to use when providing care or
administering medications or treatments? Select all that apply.
Room number.
Bed number.
Medical record number.
Name band.
Social security (social insurance) number.
A client with metastatic cancer of the liver is concerned about the progress. Which of the
following nursing interventions is most appropriate?
Provide information for the client to consider a liver transplantation.
Assure the client that the prescribed medications will shrink all tumor sites.
Explain the effects of chemotherapy.
Place emphasis on providing symptomatic and comfort measures.
The nurse is preparing to give an IM injection. Which of the following sites has the least amount of blood vessels and major nerves located in the area?
Deltoid.
Dorsogluteal.
Vastus lateralis.
Triceps.
The nurse is planning to teach the client how to properly use a metered-dose inhaler to treat asthma. Which of the following instructions should the nurse include in the teaching plan?
Rinse the mouth after each use of a steroid inhaler.
Inhale quickly when administering the medication.
Inhale the medication and then exhale through the nose.
Cough and deep-breathe before inhaling the medication.
A client is receiving a transfusion of packed red blood cells. Which of the following actions should the nurse implement to safely administer the blood?
Keep the blood refrigerated on the nursing unit until ready to administer.
Stay with the client during the first 15 minutes to detect signs or symptoms of a reaction.
Do not infuse blood that has been hanging for more than 6 hours.
Administer the blood quickly to prevent wasting it if the client develops a fever.
A client who is receiving a blood transfusion begins to have difficulty breathing. The nursenotes an elevated blood pressure and a cough. Based on these signs, the nurse should prepare to
manage which of the following complications?
Anaphylactic reaction.
Circulatory overload.
Sepsis.
Acute hemolytic reaction.
A client has had sucralfate prescribed as treatment for peptic ulcer disease. Which of the
following statements indicates that the client understands how to take the medication?
“I should take the sucralfate every evening at bedtime.”
“It is important that I take this drug on an empty stomach.”
“I should avoid milk products while taking this drug.”
“I should have my hemoglobin checked monthly while taking sucralfate.”
During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that when she has flashbacks of this abuse she cuts her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing
intervention is most important?
Assist the client with finding safe ways to express her anger.
Talk with the client about confronting her uncle and cousin directly.
Defer talking about the abuse to prevent further self-mutilation.
Discuss the possibility of the client suing her relatives for their abuse.
An adult client has bacterial conjunctivitis. What should the nurse teach the client to do? Select all that apply.
Use warm saline soaks four times per day to remove crusting.
Apply topical antibiotic without touching the tip of the tube to the eye.
Wash the hands after touching the eyes.
Avoid touching the eyes.
Observe isolation procedures by staying in the bedroom until the redness in the eye disappears.
Which of the following actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply.
Have the client state his or her name.
Check the name on the arm band with the name on the medication.
Learn to recognize the client.
Check the client’s room number.
Compare the date of birth on the client’s chart to the date of birth on the client’s armband.

Answer

A

3, 4. A National Patient Safety Goal of The Joint Commission and the Canadian Patient
Safety Institute is to improve the accuracy of client identification; to attain that goal, health care
personnel must use at least two client identifiers when providing care, treatment, or services. The
medical record number and name as printed on the client’s name band are appropriate identifiers.
Because the client can change rooms and beds, these are not to be used as identifiers. Social security
or social insurance number is not used as an identifier for health care or treatment purposes.
CN: Safety and infection control; CL: Apply
1. There is no cure for metastatic cancer of the liver; palliative nursing care is required.
  Liver transplants are not recommended for the client with widespread malignant disease. Prescribed
  medications will not make metastatic lesions shrink. There is nothing to indicate that the client isreceiving chemotherapy; therefore, explaining its effects would not be helpful.
  CN: Physiological adaptation; CL: Synthesize
1. The vastus lateralis site is the preferred IM site for all ages because it does not have any
  major nerves or blood vessels located near it. The deltoid and dorsogluteal muscles have major
  nerves and blood vessels located nearby. The triceps is not an acceptable muscle for IM injections
  because it is not well developed in most clients.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Clients should be instructed to rinse their mouths after using a steroid inhaler to avoid
  developing thrush. Clients should also be instructed to inhale slowly through the mouth and then hold
  the breath as they count to 10 slowly. It is not necessary for the client to cough and deep-breathe
  before using the inhaler.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The nurse should stay with the client during the first 15 minutes of a blood transfusion
  because this is when reactions are most likely to occur. Blood products should never be refrigerated
  on the nursing unit. Blood that has not been infused after 4 hours should not be infused. The blood
  should be infused over the specific time prescribed by the physician. If a fever develops, the
  transfusion should be stopped immediately and the blood reaction policy of the facility should be
  followed.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The symptoms of difficulty breathing, elevated blood pressure, and cough are indicative of
  circulatory overload. Circulatory overload occurs when blood is infused more rapidly than the
  circulatory system can accommodate. Anaphylactic reactions are manifested by urticaria, wheezing,
  and shock. Sepsis begins with a rapid onset of chills and fever. Acute hemolytic reaction is typically
  manifested by chills, fever, low back pain, and flushing.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. Sucralfate should be taken on an empty stomach 1 hour before or 2 hours after meals, and
  at bedtime. It is usually taken four times a day. There is no need to avoid milk products while taking
  the drug. Sucralfate does not affect hemoglobin levels.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
1. Anger is a common feeling that may lead to self-mutilation. Anger must be expressed in
  safe ways to diminish self-mutilation. Confronting the abusers directly is rarely successful and must
  be done with much preparation. Talking about the abuse typically decreases, not increases, self-
  mutilation. Civil suits are possible, but should only be undertaken after significant recovery from the
  abuse.
  CN: Psychosocial integrity; CL: Synthesize
1, 2, 3, 4. The client with conjunctivitis can use warm soaks to remove crusting. The nurse
should teach the client to dispose of the soaks by wrapping them in a separate bag to avoid spreading
bacteria. Topical antibiotics are used to treat the infection. The client should avoid contaminating the
tip of the medication dispenser. Bacterial conjunctivitis requires containing the spread of the
infection. The client should wash the hands after touching the eyes but does not need to be isolated.CN: Reduction of risk potential; CL: Create
2, 5. Two sources of identification must be confirmed before administering medication to a
client. A source of information can be the client’s record number, name, or date of birth, as noted on
the client’s armband. A client may be confused or hard of hearing and may give a wrong name or
answer to a wrong name, thus having the client state his or her name or respond to his or her name is
not safe practice. Client recognition is not sufficient identification for administering medication.
Clients change rooms frequently, so a room number is not a source of identification for administering
medication.
CN: Pharmacological and parenteral therapies; CL: Apply

Question 13

Q

A nurse is counseling a mother with young children after the mother left her abusive husband 6 months ago. The mother says, “My 6-year-old, Kevin, is starting to act just like his father. I just
don’t know how to handle this.” Which response by the nurse is most appropriate?
“You’ll have to limit Kevin’s contact with his father.”
“Counseling for Kevin would be helpful.”
“Most boys outgrow these behaviors.”
“Setting limits on his behavior is all you need to do now.”
The nurse manager is developing a “read-back” procedure to reduce medication administration errors. Which of the following are purposes of the “read-back” requirement? Select all
that apply.
To prohibit prescriptions and test results from being communicated verbally or by telephone.
To make sure that prescriptions and test results that are communicated verbally or by telephone
are clear to the receiver of the information.
To make sure that prescriptions and test results that are communicated verbally or by telephone
are confirmed by the individual giving the information.
To minimize the risk of nonauthorized personnel from giving prescriptions which are communicated verbally or by telephone.
To encourage the use of electronic medical records.
A 13-year-old male was kidnapped and held for ransom by two criminals. His parents asked to have him admitted to the adolescent psychiatric unit. He is sleep-deprived, filthy, alternating
between sobbing and making threats to kill his captors, suspicious, and easily startled. He signs a no
harm contract and then asks to go to sleep. What is the best initial plan for this client?
Encourage him to talk with the police about the crime details.
Develop trust and allow him to talk about his memories and feelings.
Help him and his parents prepare for the future trial.
Discourage him from making threats toward his captors.
A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, “I want to see the baby one last time.”
Which of the following should the nurse do?
Tell the client that it would be best if she didn’t see the baby.
Allow the client to see the baby through the nursery window.
Contact the physician for advice related to the client’s visitation.
Allow the client to see and hold the baby for as long as she desires.
A 10-year-old child is admitted with a brain tumor. Which assessment made by the nurse is most critical to report to the child’s physician?
Vomiting after lunch.
Difficulty in recalling the day of the week.
Blood pressure of 102/62 mm Hg.
100 mL of concentrated urine voided at one voiding.
The nurse is teaching a 17-year-old girl who has a severe gonorrheal infection. The nurse realizes that the girl understands the implications of her disease when she tells the nurse:
“Once I’m treated, I’ll have immunity.”
“My partner doesn’t need treatment.”
“I won’t have any more problems once I learn to protect myself.”
“I could have trouble getting pregnant.”
The nurse-manager is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply.
Admission to the hospital.2. Transfer to the nursing home.
Transfer of a client from surgery to the surgical unit.
Admission to a home health agency from the hospital.
Move from a double room to a single room on the same unit.
A client was treated for a streptococcal throat infection 2 weeks ago. The client now has been diagnosed with acute poststreptococcal glomerulonephritis. The client asks the nurse how he
could have prevented this condition. What should the nurse tell the client?
“See your physician for an early diagnosis and treatment of a sore throat.”
“As long as you do not have a fever, it is sufficient to gargle daily with an antibacterial
mouthwash.”
“You may continue to utilize the previously prescribed antibiotics until they are gone.”
“Unscented bar soap may be used in showers.”
Assessment of a primigravid client in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at −1 station. The client has indicated that she wants a “natural childbirth” with no analgesia or anesthesia. The physician enters the room and tells the client that it is
time for an epidural anesthetic. Which of the following would be the nurse’s best action at this time?
Ask the client if she desires an epidural anesthetic.
Tell the physician that the client desires a “natural childbirth.”
Tell the client that her labor will be more comfortable with an anesthetic.
Ask the client to discuss this with her husband and then make a decision.
A client is ready to be discharged following an inguinal hernia repair. Which criteria must
the client meet before the nurse can discharge the client?
The client has transportation home via a taxicab.
The client has pain no greater than 5 on a scale of 1 to 10.
The client can walk to the bathroom unassisted.
The client will urinate later after drinking more fluids.

Answer

A

1. Children who witness domestic violence commonly grow up to be victims or abusers.
  Counseling helps interrupt the pattern of violence in families. Limiting contact between the father and
  child does not address the child’s behavior, and outgrowing violent behaviors is not likely without
  other interventions. Setting limits on violent behaviors alone does not address the child’s feelings and
  needs.
  CN: Psychosocial integrity; CL: Synthesize
2, 3. A National Patient Safety Goal of The Joint Commission is to improve the effectiveness
of communication among caregivers. The requirement for verbal or telephone prescriptions, or for
telephonic reporting of critical test results, is to verify the complete prescription or test result by
having the person receiving the information record and “read-back” the complete prescription or test
result. Effective communication which is timely, accurate, complete, unambiguous, and understood by
the recipient reduces error and results in improved client safety. “Read-back” procedures are not
intended to discourage or prohibit telephone communications among health care providers or to
promote use of electronic medical records. Safety procedures, such as provider identification codes,
are in place for health care providers to give verbal or telephone prescriptions.
CN: Safety and infection control; CL: Apply
1. After such a crime, talking about his memories and feelings is an early part of the
  emotional recovery process. Encouraging him to talk to the police and helping him prepare for the
  trial may be appropriate later as he reorganizes his life for a trial. It is important for him to express
  his anger, even fantasies of revenge, rather than repress it.
  CN: Psychosocial integrity; CL: Synthesize
1. The nurse should allow the client to see and hold the baby for as long as she desires. Such
  activities provide memories for the mother and assist in the grieving process. There is a possibility
  that the client may change her mind about the adoption. If the client changes her mind about the
  adoption, the nurse should accept the client’s decision and notify the physician and social worker.
  Telling the client that it would be best if she didn’t see the baby is imposing the nurse’s value system
  on the client. Allowing the client to see the baby through the nursery window is inappropriate because
  the client should be allowed to touch and hold the baby. Contacting the physician for advice related to
  the client’s visitation is not necessary.
  CN: Management of care; CL: Synthesize
1. A decrease or change in the level of consciousness is an early indication of increased
  intracranial pressure (ICP) and should be reported to the child’s physician as soon as possible to tryand control the pressure so it doesn’t increase further. Vomiting can be a sign of increased ICP that
  occurs with a brain tumor, but it usually occurs unrelated to food and in the morning upon arising.
  Blood pressure increases with a brain tumor due to pressure on the brain stem. Concentrated urine is
  a sign of dehydration and is not related to the signs of a brain tumor.
  CN: Physiological adaptation; CL: Analyze
1. With a severe gonorrheal infection, scarring of the fallopian tubes may occur, and
  becoming pregnant may be difficult or impossible. If the girl’s partner is not treated, she can be
  reinfected. There is no immunity against gonorrhea and, if exposed again, the girl can again become
  infected. Although a condom may provide some protection against contracting gonorrhea, it is not an
  adequate protection against the condition and will not help clear up an existing infection. It is only
  with proper antibiotic administration that the condition can be eradicated.
  CN: Safety and infection control; CL: Evaluate
1, 2, 3, 4. The goal of “medication reconciliation” is to ensure that clients are on the right
medication after any transfer, admission, or going in and out of a health care facility. It is not
necessary to reconcile the medications if the client moves to a different room on the same floor. It is
estimated that more than half of medication errors occur during these transitions, and medication
reconciliation can reduce errors by 70% or more. The Joint Commission and Health Canada
requirements mandate medication reconciliation programs.
CN: Pharmacological and parenteral therapies; CL: Apply
1. Acute poststreptococcal glomerulonephritis usually follows a streptococcal throat or skin
  infection by 1 to 2 weeks. Streptococcus-type infections require medical intervention with antibiotics.
  Antibacterial mouthwashes do not kill streptococci. Previously prescribed antibiotics may not be
  effective against streptococci, and may also be expired. Bar soap fragrance has no impact on its
  ability to kill bacteria that reside on skin.
  CN: Health promotion and maintenance; CL: Synthesize
1. To be a true client advocate, the nurse should ask the client if she desires an epidural
  anesthetic even though the client has indicated a desire for “natural childbirth.” The client has a right
  to change her mind and also a right to refuse treatment. The client, not the nurse, should be the one to
  tell the physician that she does not want an epidural anesthetic; the nurse should support the client’s
  decision. Although telling the client that her labor will be more comfortable with an anesthetic
  provides the client with information, a statement such as this can be viewed as an attempt to change
  the client’s mind. The client may wish to discuss this situation with her husband, but she does not have
  to do so.
  CN: Management of care; CL: Synthesize
1. In order to meet the criteria for discharge from same-day surgery, the postoperative client
  must be able to take fluids by mouth, walk without hypotension, void, and be escorted by a
  responsible adult who will drive him home. Transportation home via a taxicab is not a sufficient
  escort to assist a client home after surgery. The client may be discharged with severe pain. The nurse
  should make sure the client has a prescription for pain medication. Because a client has been on
  nothing-by-mouth status and thinks he is dry is not a sufficient reason for being unable to urinate
  postoperatively. The inability to void in the first 8 hours after surgery is one of the potential
  complications for all surgical clients and is related to the stress response.CN: Safety and infection control; CL: Evaluate

Question 14

Q

The nurse is administering eyedrops to a client with glaucoma. Which of the following is a
correct technique for instilling the eyedrops? The eyedrops are placed:
In the lower conjunctival sac.
Near the opening of the lacrimal ducts.
On the cornea.
On the scleral surface.
Which of the following interventions will best prevent falls in older adults?
Turn on bright lights in the room so the client can see items in the room.
Instruct the client to rise slowing from a supine position.
Encourage the client not to use assistive devices as they reduce independence.
Instruct the client not to exercise painful joints.
The nurse is designing a benchmarking study to gather information about nursing care
practices for wound care. Which of the following sources of information are used for benchmarking?
Select all that apply.
Government reports.
Literature reviews.3. Standard-setting organizations.
Databases.
Clinical organization recommendations.
A client is using an over-the-counter nasal spray containing pseudoephedrine to treat
allergic rhinitis. Which instruction about this medication would be most appropriate for the nurse to
provide for the client?
Prolonged use of nasal spray can lead to nasal infections.
Pseudoephedrine is an addictive drug and must be used cautiously.
Overuse of pseudoephedrine can lead to increased nasal congestion.
A common side effect of pseudoephedrine nasal spray is thrush.
A 6-year-old child is admitted for an appendectomy. What is the most appropriate way for
the nurse to prepare the child for surgery?
Explain how to use a patient-controlled analgesia (PCA) pump for pain control.
Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a
face mask.
Show the child a video about the surgery.
Show the child a visual analog scale (VAS) based on a scale from 0 to 10.
The nurse is working on a hospital’s birthing unit when a primigravid client in active labor
is to receive meperidine (Demerol) 75 mg IM. As the nurse enters the medication room, the nurse
observes a female coworker slipping a vial of morphine into the side pocket of the uniform. Which of
the following actions would be most appropriate?
Contact the hospital’s security chief.
Notify the supervisor of the unit.
Tell the coworker of the incident.
Notify the federal drug agents about the incident.
Which of the following should the nurse include when teaching the family and a client who
was prescribed benztropine (Cogentin), 1 mg PO twice daily, about the drug therapy?
The drug can be used with over-the-counter cough and cold preparations.
The client should not discontinue taking the drug abruptly.
Antacids can be used freely when taking this drug.
Alcohol consumption with benztropine therapy need not be restricted.
Which of the following should the nurse include in a teaching plan that addresses the
adverse effects of antipsychotic medication?
Information about all potential adverse effects.
Research data about rare adverse effects.
Adverse effects that can be seen or felt.
Percentages associated with each adverse effect.
A client has nephrotic syndrome. To aid in the resolution of the client’s edema, the physician
prescribes 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for
which expected outcome?
Crackles in the lung bases.
Blood pressure elevation.3. Cerebral edema.
Cool skin temperature in lower extremities.
A client has polycystic kidney disease. The client asks the nurse, “How did I get these fluid-
filled bubbles on my kidneys? I have not had any x-ray type tests.” How should the nurse respond to
help the client understand risk factors for this disease process?
“Second-hand smoke puts you at greater risk for developing cysts.”
“Exposure to dyes used to color fruits and vegetables increases the risk of polycystic kidney
disease.”
“There is a higher incidence of polycystic kidney disease among blood relatives.”
“Drinking alcohol daily allows the kidneys to develop cysts.”

Answer

A

1. Eyedrops are correctly instilled by placing them in the lower conjunctival sac. Eyedrops
  should not be placed near the lacrimal ducts, to decrease the chance of the medication’s being
  systemically absorbed. Placing the drops on the cornea or sclera is uncomfortable for the client and
  may cause the medication to run out of the eye socket instead of being absorbed.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
1. Normal age-related changes can predispose older adults to falling and include vision,
  hearing, cardiovascular, musculoskeletal, and neurological changes. One of the most common
  problems facing older adults is the loss of tissue elasticity that affects the arteries. This loss of
  elasticity results in a decrease in tissue recoil and leads to changes in blood pressure with position
  changes. When they rise too quickly from a supine position, they feel light-headed and dizzy and can
  fall. Instruct your clients to change positions slowly and to dangle the legs a few minutes when arising
  from a supine position. When aging, the lens of the eye becomes sensitive to bright light and causes a
  glare and visual disturbances. Neurological changes are seen in impaired reflexes and thus postural
  instability. This loss of postural stability leads to falls. The need of assistive devices (hand rails,
  cane, walkers) helps reduce falls and promote independence. If joint pain develops and remains
  untreated, it can cause older adults to become sedentary or immobile. This disuse of muscles
  contributes to muscle weakness and falls. Nursing interventions should be directed at encouraging
  regular ambulation and joint movement (range of motion).
  CN: Reduction of risk potential; CL: Synthesize
1, 2, 3, 4. Benchmarking is a technique for learning from the success of others in an area
where care improvement is desired by comparing the data from others with the data about the nursing
problem for which improvement is sought. Sources of information for benchmarking include:
literature reviews, databases, unions, standard-setting organizations, local organizations, universities,
the government, staff or customer interviews, and questionnaires. A recommendation from a clinical
organization does not necessarily indicate that success has been attained.
CN: Management of care; CL: Apply
1. Overuse of nasal spray containing pseudoephedrine can lead to rhinitis medicamentosa,
  which is a rebound effect causing increased swelling and congestion. Use of pseudoephedrine nasal
  spray does not cause infections or thrush. Pseudoephedrine is not addictive.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The best way to teach a child about surgery is through play. The nurse can let the child
  handle the items that will be used for monitoring, such as the blood pressure cuff and the ECG pads.
  The child will become more familiar with the face masks he sees the surgical team wearing in the
  operating room after playing with one and wearing it before surgery. A child of this age-group does
  not understand detailed explanations of how to use equipment, such as a PCA, a VAS, or even a
  video. The pain scale that should be used for children is the FACES scale.
  CN: Basic care and comfort; CL: Synthesize
1. When a nurse observes the theft of an opioid, it is the responsibility of the nurse to report
  the incident to the supervisor of the unit. The supervisor of the unit can confront the coworker and
  notify the hospital’s chief of security about the incident. In some situations, the drug-abusing coworkermay be offered drug counseling. In situations in which the drugs are being sold, the police should be
  notified. The nurse should not confront the coworker because this may put the nurse in danger. It is not
  the responsibility of the nurse to notify federal drug agents about the incident.
  CN: Management of care; CL: Synthesize
1. The nurse should teach the client and family the importance of not discontinuing
  benztropine abruptly. Rather, the drug should be tapered slowly over a 1-week period. Benztropine
  should not be used with over-the-counter cough and cold preparations because of the risk of an
  additive anticholinergic effect. Antacids delay the absorption of benztropine, and alcohol in
  combination with benztropine causes an increase in central nervous system depression; concomitant
  use should be avoided.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The nurse needs to focus on adverse effects that can be seen or felt, using a simple, brief,
  written description of the benefits of the medication and a list of common adverse effects and how to
  cope with them. The written format helps the client and family feel more in control by participating in
  treatment. They also can use the written information as a helpful resource for review. Information
  about all potential adverse effects, including percentages associated with each, will cause undue
  anxiety in the client and possibly overwhelm the client and family, negatively affecting compliance.
  The nurse should use discretion in selecting the content of educational sessions.
  CN: Health promotion and maintenance; CL: Synthesize
1. Albumin is a colloid that remains in the intravascular space, pulling fluid out of the
  intracellular and interstitial space. The client with nephrotic syndrome loses excessive amounts of
  protein, mainly albumin, in the urine. Because fluid is drawn into the intravascular space, blood
  pressure will increase. Crackles in the lung bases and cerebral edema are signs of circulatory
  overload or fluid volume excess. When edema is present in lower extremities, the skin feels cool to
  the touch unless an infection is present.
  CN: Physiological adaptation; CL: Evaluate
1. Although inherited, it is not clearly understood why cysts form in polycystic kidney
  disease. Environmental exposures promote development of bladder cancer. Although drinking alcohol
  requires the kidneys to excrete the alcohol, it is not thought to cause the kidneys to develop cysts.
  CN: Physiological adaptation; CL: Synthesize

Question 15

Q

A nurse is administering IV fluids to a dehydrated client. When administering an IV solution
of 3% sodium chloride, what should the nurse do? Select all that apply.
Measure the intake and output.
Inspect the jugular veins for distention.
Evaluate the client for neurologic changes.
Force fluids, especially water.
Insert an indwelling urinary catheter.
The nurse is working on a birthing unit that has several unlicensed assistive personnel
(UAP). The nurse determines that the UAP understands the type of information to report to the nurse
when the UAP reports which of the following about one of the clients?
An episode of nausea after administration of an epidural anesthetic.
Contractions 3 minutes apart and lasting 40 seconds.
Evidence of spontaneous rupture of the membranes.
Sleeping after administration of IV nalbuphine (Nubain).
A 9-year-old child is scheduled for an electromyelogram. To prepare the child for this
procedure, what should the nurse do?
Wait until just before the test to tell the child what will be done.
Ask the child to draw a picture of the body structures involved.
Show the child the equipment that will be used in the test.
Verbally explain what will be done during the test.
The nurse is planning a program about women’s health and cancer prevention for a
community health fair. The nurse should include information about which of the following? Select all
that apply.
Regular self-exams of the breast and vulva are important self-care activities.
Cancer can be prevented by removing precancerous lesions of the vulva, cervix, or
endometrium.
Girls, age 11 to 12, should receive immunization for human papilloma virus (HPV) to prevent
cervical cancer.
Smoking cessation reduces the risk of cervical cancer.
There is limited evidence that cancer in women is inherited.
A 10-year-old client with rheumatic fever is on bed rest. Which of the following would be
an appropriate diversional activity for the nurse to encourage?1. Watching television with the roommate.
Coloring picture books with the brother.
Keeping up with the school work.
Building a bird house.
Clients who are receiving total parenteral nutrition (TPN) are at risk for development of
which of the following complications?
Hypostatic pneumonia.
Pulmonary hypertension.
Orthostatic hypotension.
Fluid imbalances.
The nurse is to administer a bolus starting dose of heparin to a child who is taking
penicillin. What should the nurse do? Select all that apply.
Check that the dose is appropriate for the child’s weight.
Note that the onset of the medication will be immediate.
Follow the administration of the bolus of heparin with an IV infusion of heparin 10 units/kg/h.
Monitor partial thromboplastin time (PTT).
Discontinue the penicillin until the PTT is at a therapeutic level.
The client is receiving propantheline bromide (Pro-Banthine) to treat cholecystitis. The
nurse should evaluate the client’s response to the medication by observing for which of the following
adverse effects?
Urine retention.
Diarrhea.
Hypertension.
Diaphoresis.
The nurse is preparing to start an IV infusion. Before inserting the needle into a vein, the
nurse should apply a tourniquet to the client’s arm to accomplish which of the following?
Distend the veins.
Stabilize the veins.
Immobilize the arm.
Occlude arterial circulation.
Prochlorperazine is prescribed postoperatively. The nurse should evaluate the drug’s
therapeutic effect when the client expresses relief from which of the following?
Nausea.
Dizziness.
Abdominal spasms.
Abdominal distention.151. 1, 2, 3, 4. Cough and dyspnea can be present at the time of diagnosis of bone cancer,
indicating that the cancer has metastasized to the lungs. About one-quarter of all adolescents with
bone cancer have lung metastasis at the time of diagnosis. Pain and swelling result from the
inflammation caused by the bone tumor and the increased vascularity of the tumor. At the time of
diagnosis, fever, anorexia, and decreased range of motion have not occurred. The tumor involves the
bone, so there is pain when pressure is exerted on the involved bone, but range of motion is not
affected. Fever and anorexia can occur if extensive metastasis has occurred.
CN: Health promotion and maintenance; CL: Analyze
1. The priority assessment is that the client has a firm fundus when gentle massage is used.
  This indicates that the client’s fundus may be soft or “boggy” when it is not massaged. The receiving
  nurse should assess the client’s fundus soon after admission and continue to monitor the client’s
  fundus, lochia, and pulse rate. Postpartum hemorrhage is associated with uterine atony. Maternal-
  infant bonding is a process that usually starts on day 2 and ends at week 1. A 12-hour labor is normal.
  The temperature and pulse are within normal limits.
  CN: Management of care; CL: Analyze
1. Assuming cultural appropriateness of eye contact with the client and his wife, this body
  language would make the nurse’s nonverbal message congruent with the nurse’s verbal message and
  demonstrate empathy. Directing the eyes only toward the client, rather than including the wife, ignores
  the wife. Avoiding eye contact with the client and wife or shifting the gaze between the client and
  wife conveys a lack of assurance about the nurse’s focus and comments.
  CN: Psychosocial integrity; CL: Apply
1. Colleagues can be a source of suggestions and validation of communication strategies.
  The nurse has identified difficulty with the relationship and should seek assistance before discussing
  improved involvement with the client because improved involvement may not be the most appropriate
  approach. Positive and negative interactions occur in relationships. The frequency of both types of
  interactions determines the quality of an interpersonal relationship. In a therapeutic relationship, both
  parties contribute to the relationship; neither one should dominate or be submissive.
  CN: Psychosocial integrity; CL: Synthesize
1. The nurse on the postpartum unit should discuss with the client what her wishes are and
  mutually agree on a location. The charge nurse better understands the current and future needs of the
  client experiencing this type of loss as the client may or may not be thinking well or clearly at themoment. The postpartum unit is full of sounds of infants, and although being in a room by herself may
  support the need for separation, it is often in the best interest of the client to locate her away from the
  noise of the babies. Placing the client on another unit will remove her from the support she is seeking.
  On the other hand, she will not be hearing crying infants. This has often been the location for someone
  experiencing a loss. Discharging the mother home as soon as she is stable physically is also a
  possibility, but the nurse must also assess the client’s emotional stability and preferences for grieving.
  CN: Management of care; CL: Synthesize
1. Confidentiality and privacy are critical developmental needs for the adolescent. These
  needs are important to enable the nurse to establish a relationship of trust with the adolescent. A
  sexual history should be conducted with a teen without parents. Therefore, the nurse should not ask
  the mother to provide information or put the daughter in a position of having to make a decision about
  her mother remaining in the room. Inform the adolescent that this information is confidential, and will
  not be shared with the parent. Inform the adolescent that issues of abuse or life-threatening issues are
  required by law to be disclosed to the authorities, and all other information is private.
  CN: Management of care; CL: Synthesize
1. It is critical for medication safety to know the name, dosage, and times of administration
  of the medication taken at home. The family should bring the medication bottles to the hospital. The
  nurse should document the medication on the medical record from the bottles to ensure accuracy
  before the medication is prescribed and administered. The pharmacist is a helpful resource, but the
  safest way to identify the medication is in its original container. It is not safe to assume the client
  could correctly identify the medications from a drug book. The medication regimen may have changed
  since the record 2 years ago.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
3, 4, 5. The additional fluids should run through a separate line using a Y connector. The
nurse must contact the surgeon to clarify if the client should receive the additional 100 mL/h of IV
fluids containing potassium chloride during the bolus infusion. Rapid infusion of potassium chloride
can cause hyperkalemia with adverse cardiac outcomes such as arrhythmias. Bolus infusions of IV
fluids should be run via an infusion pump to avoid excess fluid administration. Increasing the current
IV infusion rate or adding additional fluids to the existing infusion is not safe because the current
infusion contains potassium.
CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The nurse should notify the hospital’s security staff about anyone who appears unusual.
  Typically the abductor is an older woman who wishes to have a baby. The nurse should take only one
  baby at a time to a mother to prevent the neonate being taken to the wrong mother. Infants should never
  be left in the hallway. When in the mother’s room, the infant should be placed away from the doorway
  to prevent or minimize the risk of abduction of the neonate. If an exit alarm is triggered, it is possible
  that an abductor is running away with an infant. Staff members should investigate the alarm
  immediately and stop the potential abductor. Hospital security can be alerted if someone is seen
  exiting the unit carrying a large bag or an infant.
  CN: Management of care; CL: Apply
1. The client needs specific information about the effects of the drug, specifically its effect
  on the blood. The statement about weekly blood tests to determine safe dosage and monitoring foreffects on the blood gives the client specific information to ensure follow-up with the required
  protocol for clozapine (Clozaril) therapy. Lack of accurate knowledge can lead to noncompliance
  with necessary follow-up procedures and noncompliance with medication. The supply of medication
  is not dependent on blood testing. Telling the client that the physician wants to know the progress
  does not provide specific information for this client. The blood tests are not required by the drug
  company.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Answer

A

1, 2, 3. A 3% sodium chloride solution is hypertonic; it will pull fluid into the intravascular
compartment and may increase renal perfusion, so intake and output should be monitored. As fluid is
pulled into the vasculature, the client may demonstrate signs of fluid overload such as jugular vein
distention. Hypernatremia and hyperchloremia will produce neurologic signs and symptoms. Fluids
should not be forced in a client with fluid overload. There is no need for an indwelling urinary
catheter.
CN: Reduction of risk potential; CL: Apply
1. The nurse expects the UAP assigned to several clients in labor to notify the nurse if the
  UAP observes that one of the clients has evidence of spontaneous rupture of the membranes. When the
  membranes rupture spontaneously, there is danger of a prolapsed cord, a medical emergency
  requiring a cesarean birth. Nausea may occur after administration of an epidural anesthetic, but this isnot a priority or emergency. Having contractions that are 3 minutes apart and last for 40 seconds is
  normal during active labor. Because nalbuphine (Nubain) is an analgesic, it is normal for a client to
  fall asleep after IV administration of this drug.
  CN: Management of care; CL: Evaluate
1. Before teaching a school-age child about a medical or nursing procedure, it is best to
  become familiar with the child’s knowledge level. The nurse can then begin by explaining about the
  body structure involved in the procedure. Children of this age should be told about the unknown
  procedures far enough in advance for them to prepare for what is going to happen to them. Showing
  the child the equipment and explaining what is going to be done during the test should be done after
  the child is allowed to express what he knows about what is going to happen to him.
  CN: Psychosocial integrity; CL: Synthesize
1, 2, 3, 4. Educating women about risk factors for cancers of the reproductive system is
important. The nurse should encourage women to do breast and vulva self-exams. Limiting sexual
activity during adolescence, using condoms, having fewer sexual partners, and not smoking reduces
the risk of cervical cancer. Cancer can be prevented from occurring when screening reveals
precancerous conditions of the vulva, cervix, or endometrium. Also, routine screening increases the
chance that a cancer will be identified in its early stage. Immunization against HPV is recommended
for preteen girls to prevent cervical cancer. Many cancers in women, particularly breast cancer, have
a genetic basis and the woman’s genetic history is an important tool in identifying risk.
CN: Health promotion and maintenance; CL: Create
1. The client should be encouraged to keep up with the school work. The developmental task
  of the school-age child is industry versus inferiority. Keeping up with the peers is very important to
  this age-group. Watching television does provide rest, but it does not lead to a feeling of
  accomplishment. Coloring pictures is not an appropriate pastime for this age-group. Making crafts
  may be too strenuous of an activity for a client on bed rest.
  CN: Health promotion and maintenance; CL: Synthesize
1. Clients receiving TPN are at risk for a number of complications, including fluid
  imbalances such as fluid overload and hyperosmolar diuresis. Other common complications include
  hyperglycemia, sepsis, pneumothorax, and air embolism. Hypostatic pneumonia, pulmonary
  hypertension, and orthostatic hypotension are not complications of TPN.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1, 2, 4. Heparin dosage in children is based on the 141. 1, 2, 3. A 3% sodium chloride solution is hypertonic; it will pull fluid into the intravascular
compartment and may increase renal perfusion, so intake and output should be monitored. As fluid is
pulled into the vasculature, the client may demonstrate signs of fluid overload such as jugular vein
distention. Hypernatremia and hyperchloremia will produce neurologic signs and symptoms. Fluids
should not be forced in a client with fluid overload. There is no need for an indwelling urinary
catheter.
CN: Reduction of risk potential; CL: Apply
1. The nurse expects the UAP assigned to several clients in labor to notify the nurse if the
  UAP observes that one of the clients has evidence of spontaneous rupture of the membranes. When the
  membranes rupture spontaneously, there is danger of a prolapsed cord, a medical emergency
  requiring a cesarean birth. Nausea may occur after administration of an epidural anesthetic, but this isnot a priority or emergency. Having contractions that are 3 minutes apart and last for 40 seconds is
  normal during active labor. Because nalbuphine (Nubain) is an analgesic, it is normal for a client to
  fall asleep after IV administration of this drug.
  CN: Management of care; CL: Evaluate
1. Before teaching a school-age child about a medical or nursing procedure, it is best to
  become familiar with the child’s knowledge level. The nurse can then begin by explaining about the
  body structure involved in the procedure. Children of this age should be told about the unknown
  procedures far enough in advance for them to prepare for what is going to happen to them. Showing
  the child the equipment and explaining what is going to be done during the test should be done after
  the child is allowed to express what he knows about what is going to happen to him.
  CN: Psychosocial integrity; CL: Synthesize
1, 2, 3, 4. Educating women about risk factors for cancers of the reproductive system is
important. The nurse should encourage women to do breast and vulva self-exams. Limiting sexual
activity during adolescence, using condoms, having fewer sexual partners, and not smoking reduces
the risk of cervical cancer. Cancer can be prevented from occurring when screening reveals
precancerous conditions of the vulva, cervix, or endometrium. Also, routine screening increases the
chance that a cancer will be identified in its early stage. Immunization against HPV is recommended
for preteen girls to prevent cervical cancer. Many cancers in women, particularly breast cancer, have
a genetic basis and the woman’s genetic history is an important tool in identifying risk.
CN: Health promotion and maintenance; CL: Create
1. The client should be encouraged to keep up with the school work. The developmental task
  of the school-age child is industry versus inferiority. Keeping up with the peers is very important to
  this age-group. Watching television does provide rest, but it does not lead to a feeling of
  accomplishment. Coloring pictures is not an appropriate pastime for this age-group. Making crafts
  may be too strenuous of an activity for a client on bed rest.
  CN: Health promotion and maintenance; CL: Synthesize
1. Clients receiving TPN are at risk for a number of complications, including fluid
  imbalances such as fluid overload and hyperosmolar diuresis. Other common complications include
  hyperglycemia, sepsis, pneumothorax, and air embolism. Hypostatic pneumonia, pulmonary
  hypertension, and orthostatic hypotension are not complications of TPN.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1, 2, 4. Heparin dosage in children is based on the child’s weight. A bolus of heparin is
administered by the IV route and the onset of action is immediate. The PTT is an indicator of the
effectiveness of heparin. Following the heparin with a continuous infusion of heparin would cause
life-threatening anticoagulation in this child. Penicillin and cephalosporins potentiate the effects of
heparin, so the heparin must be carefully titrated to obtain maximum effect without causing an
overdose. However, the antibiotic should not be discontinued.
CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Propantheline bromide (Pro-Banthine) is an anticholinergic drug. Common adverse effects
  include urine retention and constipation; flushed, dry skin; and dry mouth, nose, and throat. Orthostatic
  hypotension may also occur. Diarrhea and diaphoresis are adverse effects of cholinergic drugs.CN: Pharmacological and parenteral therapies; CL: Analyze
1. Applying a tourniquet obstructs venous blood flow and, as a result, distends the veins. A
  tourniquet does not stabilize veins or immobilize the arm, nor is it applied to occlude arterial
  circulation.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Prochlorperazine is administered postoperatively to control nausea and vomiting.
  Prochlorperazine is also used in psychotherapy because of its effects on mood and behavior. It is not
  used to treat dizziness, abdominal spasms, or abdominal distention.
  CN: Pharmacological and parenteral therapies; CL: Evaluate141. 1, 2, 3. A 3% sodium chloride solution is hypertonic; it will pull fluid into the intravascular
  compartment and may increase renal perfusion, so intake and output should be monitored. As fluid is
  pulled into the vasculature, the client may demonstrate signs of fluid overload such as jugular vein
  distention. Hypernatremia and hyperchloremia will produce neurologic signs and symptoms. Fluids
  should not be forced in a client with fluid overload. There is no need for an indwelling urinary
  catheter.
  CN: Reduction of risk potential; CL: Apply
1. The nurse expects the UAP assigned to several clients in labor to notify the nurse if the
  UAP observes that one of the clients has evidence of spontaneous rupture of the membranes. When the
  membranes rupture spontaneously, there is danger of a prolapsed cord, a medical emergency
  requiring a cesarean birth. Nausea may occur after administration of an epidural anesthetic, but this isnot a priority or emergency. Having contractions that are 3 minutes apart and last for 40 seconds is
  normal during active labor. Because nalbuphine (Nubain) is an analgesic, it is normal for a client to
  fall asleep after IV administration of this drug.
  CN: Management of care; CL: Evaluate
1. Before teaching a school-age child about a medical or nursing procedure, it is best to
  become familiar with the child’s knowledge level. The nurse can then begin by explaining about the
  body structure involved in the procedure. Children of this age should be told about the unknown
  procedures far enough in advance for them to prepare for what is going to happen to them. Showing
  the child the equipment and explaining what is going to be done during the test should be done after
  the child is allowed to express what he knows about what is going to happen to him.
  CN: Psychosocial integrity; CL: Synthesize
1, 2, 3, 4. Educating women about risk factors for cancers of the reproductive system is
important. The nurse should encourage women to do breast and vulva self-exams. Limiting sexual
activity during adolescence, using condoms, having fewer sexual partners, and not smoking reduces
the risk of cervical cancer. Cancer can be prevented from occurring when screening reveals
precancerous conditions of the vulva, cervix, or endometrium. Also, routine screening increases the
chance that a cancer will be identified in its early stage. Immunization against HPV is recommended
for preteen girls to prevent cervical cancer. Many cancers in women, particularly breast cancer, have
a genetic basis and the woman’s genetic history is an important tool in identifying risk.
CN: Health promotion and maintenance; CL: Create
1. The client should be encouraged to keep up with the school work. The developmental task
  of the school-age child is industry versus inferiority. Keeping up with the peers is very important to
  this age-group. Watching television does provide rest, but it does not lead to a feeling of
  accomplishment. Coloring pictures is not an appropriate pastime for this age-group. Making crafts
  may be too strenuous of an activity for a client on bed rest.
  CN: Health promotion and maintenance; CL: Synthesize
1. Clients receiving TPN are at risk for a number of complications, including fluid
  imbalances such as fluid overload and hyperosmolar diuresis. Other common complications include
  hyperglycemia, sepsis, pneumothorax, and air embolism. Hypostatic pneumonia, pulmonary
  hypertension, and orthostatic hypotension are not complications of TPN.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1, 2, 4. Heparin dosage in children is based on the child’s weight. A bolus of heparin is
administered by the IV route and the onset of action is immediate. The PTT is an indicator of the
effectiveness of heparin. Following the heparin with a continuous infusion of heparin would cause
life-threatening anticoagulation in this child. Penicillin and cephalosporins potentiate the effects of
heparin, so the heparin must be carefully titrated to obtain maximum effect without causing an
overdose. However, the antibiotic should not be discontinued.
CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Propantheline bromide (Pro-Banthine) is an anticholinergic drug. Common adverse effects
  include urine retention and constipation; flushed, dry skin; and dry mouth, nose, and throat. Orthostatic
  hypotension may also occur. Diarrhea and diaphoresis are adverse effects of cholinergic drugs.CN: Pharmacological and parenteral therapies; CL: Analyze
1. Applying a tourniquet obstructs venous blood flow and, as a result, distends the veins. A
  tourniquet does not stabilize veins or immobilize the arm, nor is it applied to occlude arterial
  circulation.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Prochlorperazine is administered postoperatively to control nausea and vomiting.
  Prochlorperazine is also used in psychotherapy because of its effects on mood and behavior. It is not
  used to treat dizziness, abdominal spasms, or abdominal distention.
  CN: Pharmacological and parenteral therapies; CL: Evaluatechild’s weight. A bolus of heparin is
  administered by the IV route and the onset of action is immediate. The PTT is an indicator of the
  effectiveness of heparin. Following the heparin with a continuous infusion of heparin would cause
  life-threatening anticoagulation in this child. Penicillin and cephalosporins potentiate the effects of
  heparin, so the heparin must be carefully titrated to obtain maximum effect without causing an
  overdose. However, the antibiotic should not be discontinued.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Propantheline bromide (Pro-Banthine) is an anticholinergic drug. Common adverse effects
  include urine retention and constipation151. 1, 2, 3, 4. Cough and dyspnea can be present at the time of diagnosis of bone cancer,
  indicating that the cancer has metastasized to the lungs. About one-quarter of all adolescents with
  bone cancer have lung metastasis at the time of diagnosis. Pain and swelling result from the
  inflammation caused by the bone tumor and the increased vascularity of the tumor. At the time of
  diagnosis, fever, anorexia, and decreased range of motion have not occurred. The tumor involves the
  bone, so there is pain when pressure is exerted on the involved bone, but range of motion is not
  affected. Fever and anorexia can occur if extensive metastasis has occurred.
  CN: Health promotion and maintenance; CL: Analyze
1. The priority assessment is that the client has a firm fundus when gentle massage is used.
  This indicates that the client’s fundus may be soft or “boggy” when it is not massaged. The receiving
  nurse should assess the client’s fundus soon after admission and continue to monitor the client’s
  fundus, lochia, and pulse rate. Postpartum hemorrhage is associated with uterine atony. Maternal-
  infant bonding is a process that usually starts on day 2 and ends at week 1. A 12-hour labor is normal.
  The temperature and pulse are within normal limits.
  CN: Management of care; CL: Analyze
1. Assuming cultural appropriateness of eye contact with the client and his wife, this body
  language would make the nurse’s nonverbal message congruent with the nurse’s verbal message and
  demonstrate empathy. Directing the eyes only toward the client, rather than including the wife, ignores
  the wife. Avoiding eye contact with the client and wife or shifting the gaze between the client and
  wife conveys a lack of assurance about the nurse’s focus and comments.
  CN: Psychosocial integrity; CL: Apply
1. Colleagues can be a source of suggestions and validation of communication strategies.
  The nurse has identified difficulty with the relationship and should seek assistance before discussing
  improved involvement with the client because improved involvement may not be the most appropriate
  approach. Positive and negative interactions occur in relationships. The frequency of both types of
  interactions determines the quality of an interpersonal relationship. In a therapeutic relationship, both
  parties contribute to the relationship; neither one should dominate or be submissive.
  CN: Psychosocial integrity; CL: Synthesize
1. The nurse on the postpartum unit should discuss with the client what her wishes are and
  mutually agree on a location. The charge nurse better understands the current and future needs of the
  client experiencing this type of loss as the client may or may not be thinking well or clearly at themoment. The postpartum unit is full of sounds of infants, and although being in a room by herself may
  support the need for separation, it is often in the best interest of the client to locate her away from the
  noise of the babies. Placing the client on another unit will remove her from the support she is seeking.
  On the other hand, she will not be hearing crying infants. This has often been the location for someone
  experiencing a loss. Discharging the mother home as soon as she is stable physically is also a
  possibility, but the nurse must also assess the client’s emotional stability and preferences for grieving.
  CN: Management of care; CL: Synthesize
1. Confidentiality and privacy are critical developmental needs for the adolescent. These
  needs are important to enable the nurse to establish a relationship of trust with the adolescent. A
  sexual history should be conducted with a teen without parents. Therefore, the nurse should not ask
  the mother to provide information or put the daughter in a position of having to make a decision about
  her mother remaining in the room. Inform the adolescent that this information is confidential, and will
  not be shared with the parent. Inform the adolescent that issues of abuse or life-threatening issues are
  required by law to be disclosed to the authorities, and all other information is private.
  CN: Management of care; CL: Synthesize
1. It is critical for medication safety to know the name, dosage, and times of administration
  of the medication taken at home. The family should bring the medication bottles to the hospital. The
  nurse should document the medication on the medical record from the bottles to ensure accuracy
  before the medication is prescribed and administered. The pharmacist is a helpful resource, but the
  safest way to identify the medication is in its original container. It is not safe to assume the client
  could correctly identify the medications from a drug book. The medication regimen may have changed
  since the record 2 years ago.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
3, 4, 5. The additional fluids should run through a separate line using a Y connector. The
nurse must contact the surgeon to clarify if the client should receive the additional 100 mL/h of IV
fluids containing potassium chloride during the bolus infusion. Rapid infusion of potassium chloride
can cause hyperkalemia with adverse cardiac outcomes such as arrhythmias. Bolus infusions of IV
fluids should be run via an infusion pump to avoid excess fluid administration. Increasing the current
IV infusion rate or adding additional fluids to the existing infusion is not safe because the current
infusion contains potassium.
CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The nurse should notify the hospital’s security staff about anyone who appears unusual.
  Typically the abductor is an older woman who wishes to have a baby. The nurse should take only one
  baby at a time to a mother to prevent the neonate being taken to the wrong mother. Infants should never
  be left in the hallway. When in the mother’s room, the infant should be placed away from the doorway
  to prevent or minimize the risk of abduction of the neonate. If an exit alarm is triggered, it is possible
  that an abductor is running away with an infant. Staff members should investigate the alarm
  immediately and stop the potential abductor. Hospital security can be alerted if someone is seen
  exiting the unit carrying a large bag or an infant.
  CN: Management of care; CL: Apply
1. The client needs specific information about the effects of the drug, specifically its effect
  on the blood. The statement about weekly blood tests to determine safe dosage and monitoring foreffects on the blood gives the client specific information to ensure follow-up with the required
  protocol for clozapine (Clozaril) therapy. Lack of accurate knowledge can lead to noncompliance
  with necessary follow-up procedures and noncompliance with medication. The supply of medication
  is not dependent on blood testing. Telling the client that the physician wants to know the progress
  does not provide specific information for this client. The blood tests are not required by the drug
  company.
  CN: Pharmacological and parenteral therapies; CL: Synthesize; flushed, dry skin; and dry mouth, nose, and throat. Orthostatic
  hypotension may also occur. Diarrhea and diaphoresis are adverse effects of cholinergic drugs.CN: Pharmacological and parenteral therapies; CL: Analyze
1. Applying a tourniquet obstructs venous blood flow and, as a result, distends the veins. A
  tourniquet does not stabilize veins or immobilize the arm, nor is it applied to occlude arterial
  circulation.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Prochlorperazine is administered postoperatively to control nausea and vomiting.
  Prochlorperazine is also used in psychotherapy because of its effects on mood and behavior. It is not
  used to treat dizziness, abdominal spasms, or abdominal distention.
  CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 16

Q

A 17-year-old client has been admitted to the hospital for a biopsy to confirm the diagnosis
of bone cancer. The nurse should assess the client for which conditions? Select all that apply.
Cough.
Dyspnea.
Pain.
Swelling.5. Fever.
Anorexia.
A nurse on the labor-and-birth unit transfers a primiparous client and her term neonate to the
mother-baby unit 2 hours after the client gave vaginal birth to the neonate. Which of the following
information is a priority for the nurse to report to the nurse receiving the client on the mother-baby
unit?
Firm fundus when gentle massage is used.
Evidence of bonding well with the neonate.
Labor that lasted 12 hours with a 1-hour second stage.
Temperature of 99°F (37.4°C) and pulse rate of 80 bpm.
A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is
assisting with his care, says, “He is doing too much. I told him to let me help, but he won’t let me.”
The nurse says to the wife, “It sounds like you need to feel you can be more helpful to him.” In order
to make the nonverbal behavior complement the words, the nurse should:
Direct the eyes at the client.
Direct the body and eyes at the wife and client.
Avoid direct eye contact with the client and wife.
Shift the eyes back and forth between the client and wife.
A nurse is having difficulty establishing a relationship with an aggressive client. What
strategy will most likely improve the relationship?
The nurse and the client agree to work to improve their involvement in the therapeutic
relationship.
The nurse establishes goals for having only positive interactions with the client.
The nurse agrees to be submissive so the client can dominate the relationship.
The nurse seeks assistance from colleagues to become more aware of the quality of the
interactions and more sensitive to the dynamics of communication.
The charge nurse on the postpartum unit has received report about a client who has just
experienced a fetal demise and will be ready for transfer out of Labor and Birth in about 2 hours. The
client has asked her primary nurse if she can stay on the obstetrical unit since she has found support
from the nursing staff there. What action should the charge nurse on the postpartum unit take?
Request a room for this client on a unit without newborns.
Ask the nurse in labor and birth to discharge the mother as soon as she is physically able to
leave.
Talk to the mother first and decide on a location that is mutually agreeable.
Admit the mother to a private room on the postpartum unit.
A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied
by her mother. What is an appropriate question for the nurse to ask this client or her mother?
“What do you think about having your mother leave the room now?”
“Mother, do you think your daughter is sexually active?”
“Mother, I am going to ask you to wait a few minutes in the waiting room now so I can
complete the health history with your daughter.”
“The two of you seem like you share everything. I am going to ask questions about sexual
history now.”157. A nurse is admitting an older female client to the gynecology surgical unit. When the nurse
asks the client what medication she is taking at home, the client responds that she is taking a little red
pill in the morning and a white capsule at night for her blood pressure. What action by the nurse is
focused on safe, effective care of this client?
Consult the pharmacist regarding identification of the medications.
Show pictures to the client from the Physician’s Desk Reference to identify the medications.
Consult the previous medical record from 2 years ago and notify the physician regarding
medications that must be prescribed.
Ask a family member to bring the medications from home in the original vials for proper
identification and administration times.
A client who had undergone an abdominal hysterectomy is in the recovery room. The
surgeon has prescribed a 250-mL bolus of normal saline over 1 hour to replace blood loss. The IV
solution infusing in the client was 1,000 mL normal saline with 40 mEq of potassium chloride at 100
mL/h. The nurse should do which of the following? Select all that apply.
Increase the IV infusion rate to 250 mL/h for 1 hour.
Add 250 mL of normal saline to the current infusion bag and continue at 100 mL/h.
Connect a 250-mL bag of normal saline to the Y-connection and calculate to infuse over 1 hour.
Contact the physician regarding continuation of the primary IV infusion during the bolus
infusion.
Administer the normal saline bolus via an IV infusion pump.
The nurse is caring for several neonates in the newborn nursery. Precautions that should be
taken to prevent an infant abduction include which of the following?
Notifying the hospital’s security staff about anyone who appears unusual.
Taking several neonates to their mothers at the same time.
Placing the infant near the doorway of the mother’s room.
Contacting the hospital’s security staff if an exit alarm is triggered.
Clozapine (Clozaril) therapy has been initiated for a client with schizophrenia who has been
unresponsive to other antipsychotics. The client states, “Why do I have to have a blood test every
week?” Which of the following responses by the nurse would be most appropriate?
“Weekly blood tests are necessary to determine safe dosage and to monitor the effect of the
medication on the blood.”
“Weekly blood tests are done so that you can receive another week’s supply of the
medication.”
“Your physician will want to know how well you are progressing with the medication
therapy.”
“Everyone taking clozapine (Clozaril) has to go through the same procedure because it is
required by the drug company.”

Answer

A

1, 2, 3, 4. Cough and dyspnea can be present at the time of diagnosis of bone cancer,
indicating that the cancer has metastasized to the lungs. About one-quarter of all adolescents with
bone cancer have lung metastasis at the time of diagnosis. Pain and swelling result from the
inflammation caused by the bone tumor and the increased vascularity of the tumor. At the time of
diagnosis, fever, anorexia, and decreased range of motion have not occurred. The tumor involves the
bone, so there is pain when pressure is exerted on the involved bone, but range of motion is not
affected. Fever and anorexia can occur if extensive metastasis has occurred.
CN: Health promotion and maintenance; CL: Analyze
1. The priority assessment is that the client has a firm fundus when gentle massage is used.
  This indicates that the client’s fundus may be soft or “boggy” when it is not massaged. The receiving
  nurse should assess the client’s fundus soon after admission and continue to monitor the client’s
  fundus, lochia, and pulse rate. Postpartum hemorrhage is associated with uterine atony. Maternal-
  infant bonding is a process that usually starts on day 2 and ends at week 1. A 12-hour labor is normal.
  The temperature and pulse are within normal limits.
  CN: Management of care; CL: Analyze
1. Assuming cultural appropriateness of eye contact with the client and his wife, this body
  language would make the nurse’s nonverbal message congruent with the nurse’s verbal message and
  demonstrate empathy. Directing the eyes only toward the client, rather than including the wife, ignores
  the wife. Avoiding eye contact with the client and wife or shifting the gaze between the client and
  wife conveys a lack of assurance about the nurse’s focus and comments.
  CN: Psychosocial integrity; CL: Apply
1. Colleagues can be a source of suggestions and validation of communication strategies.
  The nurse has identified difficulty with the relationship and should seek assistance before discussing
  improved involvement with the client because improved involvement may not be the most appropriate
  approach. Positive and negative interactions occur in relationships. The frequency of both types of
  interactions determines the quality of an interpersonal relationship. In a therapeutic relationship, both
  parties contribute to the relationship; neither one should dominate or be submissive.
  CN: Psychosocial integrity; CL: Synthesize
1. The nurse on the postpartum unit should discuss with the client what her wishes are and
  mutually agree on a location. The charge nurse better understands the current and future needs of the
  client experiencing this type of loss as the client may or may not be thinking well or clearly at themoment. The postpartum unit is full of sounds of infants, and although being in a room by herself may
  support the need for separation, it is often in the best interest of the client to locate her away from the
  noise of the babies. Placing the client on another unit will remove her from the support she is seeking.
  On the other hand, she will not be hearing crying infants. This has often been the location for someone
  experiencing a loss. Discharging the mother home as soon as she is stable physically is also a
  possibility, but the nurse must also assess the client’s emotional stability and preferences for grieving.
  CN: Management of care; CL: Synthesize
1. Confidentiality and privacy are critical developmental needs for the adolescent. These
  needs are important to enable the nurse to establish a relationship of trust with the adolescent. A
  sexual history should be conducted with a teen without parents. Therefore, the nurse should not ask
  the mother to provide information or put the daughter in a position of having to make a decision about
  her mother remaining in the room. Inform the adolescent that this information is confidential, and will
  not be shared with the parent. Inform the adolescent that issues of abuse or life-threatening issues are
  required by law to be disclosed to the authorities, and all other information is private.
  CN: Management of care; CL: Synthesize
1. It is critical for medication safety to know the name, dosage, and times of administration
  of the medication taken at home. The family should bring the medication bottles to the hospital. The
  nurse should document the medication on the medical record from the bottles to ensure accuracy
  before the medication is prescribed and administered. The pharmacist is a helpful resource, but the
  safest way to identify the medication is in its original container. It is not safe to assume the client
  could correctly identify the medications from a drug book. The medication regimen may have changed
  since the record 2 years ago.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
3, 4, 5. The additional fluids should run through a separate line using a Y connector. The
nurse must contact the surgeon to clarify if the client should receive the additional 100 mL/h of IV
fluids containing potassium chloride during the bolus infusion. Rapid infusion of potassium chloride
can cause hyperkalemia with adverse cardiac outcomes such as arrhythmias. Bolus infusions of IV
fluids should be run via an infusion pump to avoid excess fluid administration. Increasing the current
IV infusion rate or adding additional fluids to the existing infusion is not safe because the current
infusion contains potassium.
CN: Pharmacological and parenteral therapies; CL: Synthesize
1. The nurse should notify the hospital’s security staff about anyone who appears unusual.
  Typically the abductor is an older woman who wishes to have a baby. The nurse should take only one
  baby at a time to a mother to prevent the neonate being taken to the wrong mother. Infants should never
  be left in the hallway. When in the mother’s room, the infant should be placed away from the doorway
  to prevent or minimize the risk of abduction of the neonate. If an exit alarm is triggered, it is possible
  that an abductor is running away with an infant. Staff members should investigate the alarm
  immediately and stop the potential abductor. Hospital security can be alerted if someone is seen
  exiting the unit carrying a large bag or an infant.
  CN: Management of care; CL: Apply
1. The client needs specific information about the effects of the drug, specifically its effect
  on the blood. The statement about weekly blood tests to determine safe dosage and monitoring foreffects on the blood gives the client specific information to ensure follow-up with the required
  protocol for clozapine (Clozaril) therapy. Lack of accurate knowledge can lead to noncompliance
  with necessary follow-up procedures and noncompliance with medication. The supply of medication
  is not dependent on blood testing. Telling the client that the physician wants to know the progress
  does not provide specific information for this client. The blood tests are not required by the drug
  company.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 17

Q

The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?
Minimal leaking.
No swelling.
Tissue pallor.
Evidence of a bleb.

162. The sudden onset of which of the following indicates a potentially serious complication for
the client receiving an IV infusion?
1. Noisy respirations.
2. Pupillary constriction.
3. Halitosis.
4. Moist skin.

The nurse is planning to initiate a blood transfusion. Which of the following solutions
should the nurse select to prime the tubing when preparing to administer the blood?
Lactated Ringer’s solution.
Normal saline.
5% dextrose in half-normal saline.
5% dextrose in water.
When preparing to insert an IV catheter to administer fluids to a client who is going to surgery, the nurse selects the median cubital vein. Identify the location of the median cubital vein on the illustration below.
The mother of a 28-year-old client who is taking clozapine (Clozaril) states, “Something is
wrong. My son is drooling like a baby.” Which of the following responses by the nurse would be most helpful?
“I wonder if he’s having an adverse reaction to the medicine.”
“Excess saliva is common with this drug; here’s a paper cup for him to spit into.”
“Don’t worry about it; this is only a minor inconvenience compared to its benefits.”
“I’ve seen this happen to other clients who are taking Clozaril.”
The physician is calling in a prescription for ampicillin for a neonate. The nurse should do
which of the following? Select all that apply.
Write down the prescription.
Ask the physician to come to the hospital and write the prescription on the chart.
Repeat the prescription to the physician over the telephone.
Ask the physician to confirm that the prescription is correct.
Ask the nursing supervisor to cosign the telephone prescription as transcribed by the nurse.
A client taking clozapine (Clozaril) states, “I think I’m getting the flu. I have a fever and feel weak.” Which of the following should the nurse do next?
Tell the client to wait another day to see if other symptoms of the flu appear.
Advise the client to take over-the-counter medication for the flu.
Discuss the importance of maintaining an adequate fluid intake.
Report the client’s symptoms to the physician after taking the client’s temperature.
Which of the following medications should the nurse anticipate administering in the event of a heparin overdose?
Warfarin sodium (Coumadin).
Protamine sulfate.
Acetylsalicylic acid (ASA).
Atropine sulfate.
The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is:
Relief from spasms of the diaphragm.
Relaxation of smooth muscles in the bronchioles.
Efficient pulmonary circulation.
Stimulation of the medullary respiratory center.
The nurse is conducting health assessments for school-age children. A characteristic behavior of a 7-year-old girl is that she:
Likes to play only with other girls.
Prefers to play with her sister.
Prefers to play team games.
Likes to play alone.

Answer

A

1. A properly administered intradermal injection shows evidence of a bleb at the injection
  site. There should be no leaking of medication from the bleb; it needs to be absorbed into the tissue.
  Lack of swelling at the injection site means that the injection was given too deeply. The presence of
  tissue pallor does not indicate that the injection was given correctly.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
1. A serious complication of IV therapy is fluid overload. Noisy respirations can develop as
  a result of pulmonary congestion. Additional symptoms of fluid overload include dyspnea, crackles,
  hypertension, bounding pulse, and distended neck veins.
  CN: Pharmacological and parenteral therapies; CL: Analyze
1. Only isotonic (normal) saline should be used when administering a blood transfusion. The
  use of dextrose or lactated Ringer’s solution will cause the hemolysis of red blood cells.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. The median cubital vein is located in the approximate center of the antecubital space.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Telling the mother that excess saliva is a common adverse effect of the drug is most
  helpful because it gives her information about the problem, thereby helping to decrease her anxiety
  about what is occurring with her son. By offering the paper cup, the nurse also demonstrates concern
  for the client, thereby leading to increased trust. Saying “I wonder if he’s having an adverse reaction
  to the medicine” shows the nurse’s lack of knowledge about the drug, decreases confidence in the
  nurse, and indicates poor judgment. Saying, “Don’t worry about it, it’s only a minor inconveniencecompared to its benefits,” or telling the mother that the nurse has seen this happening to other clients
  is insensitive and does not assuage the mother’s anxiety.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1, 3, 4. The nurse should write down the prescription, read the prescription back to the
physician, and receive confirmation from the physician that the prescription is correct as understood
by the nurse. It is not necessary for the physician to come to the hospital to write the prescription on
the chart or to have the nursing supervisor cosign the telephone prescription.
CN: Safety and infection control; CL: Apply
1. The nurse should take the client’s temperature and report the symptoms to the physician.
  Flu-like symptoms of weakness, malaise, fever, sore throat, and lethargy may indicate leukopenia. An
  elevated temperature could also indicate an infection. Either condition requires medical intervention
  by the physician. Telling the client to wait another day or to take over-the-counter flu medication is
  inappropriate because the client is at risk for leukopenia secondary to clozapine therapy and serious
  consequences could occur. Although it would be important to encourage the client to consume
  adequate fluids, the priority is to report the symptoms and check the temperature.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. Protamine sulfate is a heparin antagonist. It is administered intravenously very slowly
  (over at least 10 minutes). Warfarin sodium and ASA have anticoagulant properties and would be
  contraindicated. Atropine sulfate is an anticholinergic drug and would not be effective in treating a
  heparin overdose.
  CN: Pharmacological and parenteral therapies; CL: Apply
1. Aminophylline, a bronchodilator that relaxes smooth muscles in the bronchioles, is used in
  the treatment of emphysema to improve ventilation by dilating the bronchioles. Aminophylline does
  not have an effect on the diaphragm or the medullary respiratory center and does not promote
  pulmonary circulation.
  CN: Pharmacological and parenteral therapies; CL: Evaluate
1. Seven-year-olds like to play with friends of the same sex. In early school-age years,
  children enjoy the company of same-sex friends. Relatives become second-choice friends to those
  from school. Team games can be competitive, and the ego of a 7-year-old may be too fragile to endure
  losing the game without losing self-confidence. Infants enjoy solitary play. The school-age child
  enjoys cooperative play with friends of the same sex and age.
  CN: Health promotion and maintenance; CL: Analyze

Question 18

Q

A nurse is planning care for a 7-year-old who is hospitalized for a hernia repair. The nurse
should assess the client for which of the following fears common in this age group?
Separation from parents.
Trying something new.
Injury and pain.
Opposite-sex relationships.
Before inserting a nasogastric (NG) tube in an adult client, the nurse estimates the length of
tubing to insert. Identify the point on the illustration where the nurse would end the measurement.
A woman who gave birth to a healthy baby 6 hours ago is having cramps in her legs. Upon
further assessment, the nurse identifies leg pain on dorsiflexion. The nurse should:
Tell the woman to massage the area.
Apply warm compresses to the area.
Instruct the woman on how to do ankle pumps.
Notify the physician.
The nurse interprets the rhythm strip below from a client’s bedside monitor as which of the following?
Normal sinus rhythm.
Sinus tachycardia.
Ventricular tachycardia.
Ventricular fibrillation.
A young adult is hospitalized with a seizure disorder. The client, who is in a bed with
padded side rails, has a tonic-clonic seizure. In what order should the nurse take the following actions?
Loosen clothing around the client’s neck.
Turn the client on his or her side.
Clear the area around the client.
Suction the airway.
The nurse interprets the rhythm strip below from a client’s bedside monitor as which of the following?
Normal sinus rhythm.
Sinus tachycardia.
Atrial fibrillation.
Ventricular tachycardia.
The nurse delegates the care of a multiparous client who gave birth to a viable term neonate vaginally 30 hours ago and is preparing to be discharged to a licensed practical nurse (LPN). The nurse should instruct the LPN to notify the nurse if the client exhibits which of the following?
Pulse rate of 100 bpm.
Oral temperature of 99°F (36.8°C).
Excessive perspiration during the assessment.
Frequent voiding in large amounts.
A woman with a history of a left radical mastectomy is being admitted for abdominal surgery. The woman has a swollen left arm. The nurse should:
Take the blood pressure only in the unaffected arm.
Start an IV line in the affected arm.
Encourage a dependent position of the affected arm.
Allow blood draws in the affected arm.
A 36-month-old child weighing 20 kg (44 lb) is to receive ceftriaxone 2 g IV every 12 hours. The recommended dose of ceftriaxone is 50 to 75 mg/kg/day in divided doses. The nurse should:
Administer the medication as prescribed.
Administer half the prescribed dose.
Call the laboratory to check the therapeutic serum level of ceftriaxone.
Withhold administering the ceftriaxone and notify the child’s primary care provider.
The nurse has provided an in-service presentation to ancillary staff about standard
precautions on the birthing unit. The nurse determines that one of the staff members needs further
instructions when the nurse observes which of the following?
Use of protective goggles during a cesarean birth.
Placement of bloody sheets in a container designated for contaminated linens.
Wearing of sterile gloves to bathe a newborn at 2 hours of age.
Disposal of used scalpel blades in a puncture-resistant container

Answer

A

1. Trying something new is usually frightening for a 7-year-old. Separation anxiety is the
  most common fear between the ages of 5 months and 5 years of age. Injury and pain are a common
  fear of the preschool child. Fear of the opposite sex is common during adolescence.
  CN: Health promotion and maintenance; CL: Analyze
When measuring for NG tube insertion, the nurse would end the measurement at the xiphoid
process.
CN: Safety and infection control; CL: Apply173. 4. The client is experiencing signs of thrombophlebitis. The nurse should notify the physician
because emboli formation is a potential risk. Massaging the area may cause the thrombus to dislocate
and become an embolus. Warm compresses will increase circulation to the area and may precipitate
embolus formation. Ankle pump exercises are helpful in preventing thrombophlebitis but will not
prevent further risk of embolus formation at this time.
CN: Reduction of risk potential; CL: Synthesize
1. This rhythm is ventricular tachycardia, which is characterized by an absent P wave and a
  heart rate of 140 to 220 bpm. Ventricular tachycardia requires immediate intervention, usually with
  lidocaine (Xylocaine).
  CN: Physiological adaptation; CL: Analyze
  175.
Clear the area around the client.
Loosen clothing around the client’s neck.
Turn the client on the side.
Suction the airway.The goal of care for a client who is having a seizure is to prevent respiratory arrest and
aspiration. The nurse should first clear the area around the client. Next, the nurse should loosen
clothing around the client’s neck and turn the client on the side. As needed, the nurse can then suction
the airway and administer oxygen.
CN: Reduction of risk potential; CL: Synthesize
1. This rhythm is atrial fibrillation. It is characterized by an irregular QRS interval, no
  definite P waves before the QRS waves, and a ventricular rate greater than 100 bpm.
  CN: Reduction of risk potential; CL: Analyze
1. During the first week postpartum, the client’s pulse rate should be slow, with an average
  of 60 to 70 bpm. A pulse of 100 bpm warrants further investigation to rule out a possible infectious
  process or postpartum hemorrhage. An oral temperature of 99°F (36.8°C) is within normal limits.
  Excessive perspiration and frequent voiding in large amounts are caused by the normal diuresis that
  occurs as the body returns to its prepregnant state.
  CN: Management of care; CL: Synthesize
1. Lymphedema occurs frequently after radical mastectomy when lymph nodes are removed.
  Aplasia, or the absence of lymph nodes, prevents proper lymph drainage. The tissue swelling is
  caused by obstructed lymph flow in the extremity. The blood pressure is taken in the unaffected arm to
  avoid further accumulation of lymphedema. An IV line should not be started in the affected arm. The
  nurse would encourage the client to elevate the extremity above the level of the heart. Blood draws in
  the affected arm should not be allowed.
  CN: Physiological adaptation; CL: Synthesize
1. The child’s primary care provider should be notified because the maximum daily
  recommended dosage for ceftriaxone for this child’s weight would be 3.3 g/day and giving this dose
  would administer 4 g/day. The nurse cannot administer a different dose than that prescribed by the
  physician. There is no therapeutic serum level of ceftriaxone.
  CN: Pharmacological and parenteral therapies; CL: Synthesize
1. One of the staff members needs further instructions when the nurse observes the staff
  member wearing sterile gloves to bathe a newborn. Clean gloves should be worn, not sterile gloves.
  Sterile gloves are more expensive than clean gloves and are not necessary when bathing a newborn.
  Goggles should be worn when there is a possibility of blood and body fluid spatter. Bloody sheets
  should be placed in labeled containers for contaminated linens. Scalpel blades are disposed of in
  specified containers.
  CN: Safety and infection control; CL: Evaluate181. 3. Three percent saline is a hypertonic solution, which will pull fluid from the interstitial and
  intracellular spaces into the bloodstream. Its use is usually reserved for severe hyponatremia (sodium
  less than 115 mEq/L). If this client were experiencing a fluid volume deficit, this IV solution could
  worsen the condition. The nurse should consult with the health care provider about this prescription.
  The nurse does not have prescribing rights and cannot change the prescription. The IV rate of 62 may
  still be dangerous for this client and the rate was prescribed at 125 mL/h.
  CN: Pharmacologic and Parenteral Therapy;CL: Analyze182. Correct answer: “X” right of the sternum at the second intercostal space is the best place for
  listening for the aortic valve sounds.
  CN: Physiological adaptation; CL: Apply
1, 2, 3, 5. When emergently managing chest pain, the nurse can use the memory mnemonic
MONA to plan care: morphine, oxygen, nitroglycerin, and aspirin. A Foley catheter is not included in
the emergent management of chest pain and can be inserted when the pain has been relieved and the
client is stable. Tylenol is not used to manage chest pain.
CN: Physiologic adaptation;CL: Synthesize
1. Minimizing urinary catheter use and duration of use in all clients, particularly those at
  higher risk for CAUTI or mortality from catheterization such as women, the elderly, and clients with
  impaired immunity, will reduce the opportunity for infection. The nurse should avoid the use of
  urinary catheters for clients who are incontinent; a bladder training program and frequent use of the
  toilet are preferred; external catheters may be used if necessary in incontinent clients. The nurse
  should not clean the periurethral area with antiseptics while the catheter is in place. Routine hygiene
  such as cleansing the meatal surface during daily bathing or showering is appropriate. Using sterile
  technique to help to reduce CAUTI is not necessary. Hand hygiene immediately before and after
  insertion or any manipulation of the catheter device or site is sufficient.
  CN: Reduction of Risk Potential; CL: Synthesize
1. Clarification is the process of confirming the appropriate medication and doses for any
  client. Verification is the process of collecting medication history. Reconciliation is the process of
  documenting medication prescription changes for a client across the continuum of care.
  Documentation is included as a step in the three steps of a formal medication reconciliation program.
  CN: Management of care; CL: Apply186. 2, 3, 5, 6, The client is hyponatremic; the nurse should notify the physician, restrict fluids,
  and prepare to insert a Foley catheter to ensure accurate intake and output. Side rails should be up in
  order to maintain client safety; it is not safe for the client to be ambulating in the hallway with family
  at this time. Encouraging fluids would not be beneficial and could be harmful.
  CN: Physiological adaptation; CL: Synthesize
1. While it is important to present options and help find solutions to the client’s concerns, the
  nurse must first listen carefully to those concerns and determine the exact nature of the concerns.
  Reminding the client to focus on getting well does not address the client’s concerns or needs.
  Arranging a meeting with the case manager is premature, because the nurse needs to first determine
  what the client’s needs are. Until the nurse understands the client’s needs, the nurse should not
  encourage the spouse to discuss the concerns with the client.
  CN: Psychosocial integrity; CL: Synthesize
1. The nurse is ultimately responsible to coordinate the client’s care while hospitalized;
  therefore, it is the nurse’s responsibility to arrange a care conference to help get the client’s questions,
  concerns, and frustrations addressed. Assuring the client that the physicians know what they are doing
  does not address the client’s concern or frustration with receiving conflicting information. While it is
  true that the client is ultimately responsible for health, asking the client to accept the consequences is
  a form of blaming the client. The physicians’ progress notes will not provide information that will
  address the client’s concern or resolve the conflicting courses of action that the two physicians are
  proposing.
  CN: Management of care; CL: Synthesize
3, 1, 4, 2. The nurse should first assess the client and then, if there is no acute injury, help the
client get back into bed. The nurse must notify the physician and the family of the fall, and finally,
document the event on the client’s health record.
CN: Safety and infection control; CL: Synthesize
1. Liver damage is a side effect of Zocor (simvastatin) and the client is demonstrating signs
  of liver damage (jaundice and concentrated urine). The nurse should report these findings to the
  physician. Although clients should not consume large amounts of alcohol while taking Zocor, the
  cause of the liver damage is likely related to the use of the Zocor and not alcohol intake unless the
  nursing assessment has revealed that alcohol intake may be a factor as well. The client should follow
  a diet low in saturated fat, but this is not the priority at this time. Increasing fluid intake will not
  reverse the liver damage.
  CN: Pharmacologic and parenteral therapies; CL: Synthesize181. 3. Three percent saline is a hypertonic solution, which will pull fluid from the interstitial and
  intracellular spaces into the bloodstream. Its use is usually reserved for severe hyponatremia (sodium
  less than 115 mEq/L). If this client were experiencing a fluid volume deficit, this IV solution could
  worsen the condition. The nurse should consult with the health care provider about this prescription.
  The nurse does not have prescribing rights and cannot change the prescription. The IV rate of 62 may
  still be dangerous for this client and the rate was prescribed at 125 mL/h.
  CN: Pharmacologic and Parenteral Therapy;CL: Analyze182. Correct answer: “X” right of the sternum at the second intercostal space is the best place for
  listening for the aortic valve sounds.
  CN: Physiological adaptation; CL: Apply
1, 2, 3, 5. When emergently managing chest pain, the nurse can use the memory mnemonic
MONA to plan care: morphine, oxygen, nitroglycerin, and aspirin. A Foley catheter is not included in
the emergent management of chest pain and can be inserted when the pain has been relieved and the
client is stable. Tylenol is not used to manage chest pain.
CN: Physiologic adaptation;CL: Synthesize
1. Minimizing urinary catheter use and duration of use in all clients, particularly those at
  higher risk for CAUTI or mortality from catheterization such as women, the elderly, and clients with
  impaired immunity, will reduce the opportunity for infection. The nurse should avoid the use of
  urinary catheters for clients who are incontinent; a bladder training program and frequent use of the
  toilet are preferred; external catheters may be used if necessary in incontinent clients. The nurse
  should not clean the periurethral area with antiseptics while the catheter is in place. Routine hygiene
  such as cleansing the meatal surface during daily bathing or showering is appropriate. Using sterile
  technique to help to reduce CAUTI is not necessary. Hand hygiene immediately before and after
  insertion or any manipulation of the catheter device or site is sufficient.
  CN: Reduction of Risk Potential; CL: Synthesize
1. Clarification is the process of confirming the appropriate medication and doses for any
  client. Verification is the process of collecting medication history. Reconciliation is the process of
  documenting medication prescription changes for a client across the continuum of care.
  Documentation is included as a step in the three steps of a formal medication reconciliation program.
  CN: Management of care; CL: Apply186. 2, 3, 5, 6, The client is hyponatremic; the nurse should notify the physician, restrict fluids,
  and prepare to insert a Foley catheter to ensure accurate intake and output. Side rails should be up in
  order to maintain client safety; it is not safe for the client to be ambulating in the hallway with family
  at this time. Encouraging fluids would not be beneficial and could be harmful.
  CN: Physiological adaptation; CL: Synthesize
1. While it is important to present options and help find solutions to the client’s concerns, the
  nurse must first listen carefully to those concerns and determine the exact nature of the concerns.
  Reminding the client to focus on getting well does not address the client’s concerns or needs.
  Arranging a meeting with the case manager is premature, because the nurse needs to first determine
  what the client’s needs are. Until the nurse understands the client’s needs, the nurse should not
  encourage the spouse to discuss the concerns with the client.
  CN: Psychosocial integrity; CL: Synthesize
1. The nurse is ultimately responsible to coordinate the client’s care while hospitalized;
  therefore, it is the nurse’s responsibility to arrange a care conference to help get the client’s questions,
  concerns, and frustrations addressed. Assuring the client that the physicians know what they are doing
  does not address the client’s concern or frustration with receiving conflicting information. While it is
  true that the client is ultimately responsible for health, asking the client to accept the consequences is
  a form of blaming the client. The physicians’ progress notes will not provide information that will
  address the client’s concern or resolve the conflicting courses of action that the two physicians are
  proposing.
  CN: Management of care; CL: Synthesize
3, 1, 4, 2. The nurse should first assess the client and then, if there is no acute injury, help the
client get back into bed. The nurse must notify the physician and the family of the fall, and finally,
document the event on the client’s health record.
CN: Safety and infection control; CL: Synthesize
1. Liver damage is a side effect of Zocor (simvastatin) and the client is demonstrating signs
  of liver damage (jaundice and concentrated urine). The nurse should report these findings to the
  physician. Although clients should not consume large amounts of alcohol while taking Zocor, the
  cause of the liver damage is likely related to the use of the Zocor and not alcohol intake unless the
  nursing assessment has revealed that alcohol intake may be a factor as well. The client should follow
  a diet low in saturated fat, but this is not the priority at this time. Increasing fluid intake will not
  reverse the liver damage.
  CN: Pharmacologic and parenteral therapies; CL: Synthesize

Question 19

Q

The health care provider’s prescription for an intravenous infusion is 3% normal saline to infuse at 125 mL/h. The client’s most recent sodium level is 132 mEq/L. The nurse should:
Hang 0.9% normal saline at 125 mL/h.
Start the IV solution as prescribed.
Consult the prescriber about the prescription.
Hang the IV solution prescribed at 62 mL/h.
The nurse is auscultating for an aortic murmur. Indicate where the nurse should place the stethoscope to best evaluate the presence of this murmur.

183. A client is admitted to the emergency department with sudden onset of chest pain. Which of
the following prescriptions should the nurse implement immediately? Select all that apply
1. Provide oxygen.
2. Administer nitroglycerin.
3. Administer aspirin.
4. Insert a Foley catheter.
5. Administer morphine.
6. Administer Tylenol.

To reduce the possibility of catheter-related urinary tract infections (CAUTIs), the nurse should:
Use sterile technique when providing catheter care.
Ensure that clients who are incontinent have indwelling urinary catheters.
Minimize urinary catheter use and duration of use in all clients.
Clean the periurethral area with antiseptics.
A client is admitted to the emergency department (ED) experiencing syncope. The nurse speaks with the family concerning the client’s condition and current medications. The client’s family states that the client takes several medications and has brought all the client’s medications with them. To determine the correct medications required for this client, the nurse performs which step of the required process to ensure safe administration of medications?
Verification.
Clarification.
Documentation.
Reconciliation.
An elderly client admitted with new-onset confusion, headache, poor skin turgor, bounding
pulse, and urinary incontinence has been drinking copious amounts of water. Upon reviewing the lab
results, the nurse discovers a sodium level of 122. What actions should the nurse take? Select all that
apply.
Encourage fluids to 2,000 mL in 24 hours.
Keep partial side rails up.
Restrict fluids to 800 mL in 24 hours.
Tell the family they may get the client up to walk in the halls.
Prepare to insert a Foley catheter.
Notify the physician.
Following the creation of an ileostomy, a client states, “I am really worried about how I’m going to manage this thing.” The first action of the nurse should be to:
Remind the client to focus energy on getting healthy.
Determine the client’s exact concerns about the ileostomy.
Arrange a meeting with the client’s case manager.
Encourage the client’s spouse to talk with the client.
A client who is being treated for nonhealing diabetic foot ulcers tells the nurse angrily, “I am so frustrated with my doctors. The wound care doctor tells me this won’t heal and I need to have my toes amputated and another doctor tells me I need to keep going with the antibiotics and dressing changes so I can save my foot. I just want to go home!” After listening to the client’s concerns, the nurse should:
Contact the client’s case manager to set up a care conference.
Assure the client that the health care providers know what they are doing.
Remind the client of the responsibilities for health habits regarding diabetes.
Review the physicians’ progress notes with the client.
While making rounds, the nurse enters a client’s room and finds the client on the floor
between the bed and the bathroom. In which order of priority from first to last should the nurse take
the following actions?
If no acute injury, get help and carefully assist the client back to bed.
Document as required by the facility.
Assess the client’s current condition and vital signs.
Notify the client’s physician and family.
The nurse is assessing a client who has been admitted to the hospital with chest pain. The
client has been taking Zocor (simvastatin) 40 mg daily for 3 years. The nurse notes that the client has
yellow sclera and a dark skin color, and the client tells the nurse the urine is getting darker. The nurse
should:
Tell the client to lower the amount of saturated fats in the diet.
Ask the client about alcohol intake.
Notify the physician.
Instruct the client to increase the fluid intake to prevent the concentration of the urine.

Answer

A

1. Three percent saline is a hypertonic solution, which will pull fluid from the interstitial and
  intracellular spaces into the bloodstream. Its use is usually reserved for severe hyponatremia (sodium
  less than 115 mEq/L). If this client were experiencing a fluid volume deficit, this IV solution could
  worsen the condition. The nurse should consult with the health care provider about this prescription.
  The nurse does not have prescribing rights and cannot change the prescription. The IV rate of 62 may
  still be dangerous for this client and the rate was prescribed at 125 mL/h.
  CN: Pharmacologic and Parenteral Therapy;CL: Analyze182. Correct answer: “X” right of the sternum at the second intercostal space is the best place for
  listening for the aortic valve sounds.
  CN: Physiological adaptation; CL: Apply
1, 2, 3, 5. When emergently managing chest pain, the nurse can use the memory mnemonic
MONA to plan care: morphine, oxygen, nitroglycerin, and aspirin. A Foley catheter is not included in
the emergent management of chest pain and can be inserted when the pain has been relieved and the
client is stable. Tylenol is not used to manage chest pain.
CN: Physiologic adaptation;CL: Synthesize
1. Minimizing urinary catheter use and duration of use in all clients, particularly those at
  higher risk for CAUTI or mortality from catheterization such as women, the elderly, and clients with
  impaired immunity, will reduce the opportunity for infection. The nurse should avoid the use of
  urinary catheters for clients who are incontinent; a bladder training program and frequent use of the
  toilet are preferred; external catheters may be used if necessary in incontinent clients. The nurse
  should not clean the periurethral area with antiseptics while the catheter is in place. Routine hygiene
  such as cleansing the meatal surface during daily bathing or showering is appropriate. Using sterile
  technique to help to reduce CAUTI is not necessary. Hand hygiene immediately before and after
  insertion or any manipulation of the catheter device or site is sufficient.
  CN: Reduction of Risk Potential; CL: Synthesize
1. Clarification is the process of confirming the appropriate medication and doses for any
  client. Verification is the process of collecting medication history. Reconciliation is the process of
  documenting medication prescription changes for a client across the continuum of care.
  Documentation is included as a step in the three steps of a formal medication reconciliation program.
  CN: Management of care; CL: Apply186. 2, 3, 5, 6, The client is hyponatremic; the nurse should notify the physician, restrict fluids,
  and prepare to insert a Foley catheter to ensure accurate intake and output. Side rails should be up in
  order to maintain client safety; it is not safe for the client to be ambulating in the hallway with family
  at this time. Encouraging fluids would not be beneficial and could be harmful.
  CN: Physiological adaptation; CL: Synthesize
1. While it is important to present options and help find solutions to the client’s concerns, the
  nurse must first listen carefully to those concerns and determine the exact nature of the concerns.
  Reminding the client to focus on getting well does not address the client’s concerns or needs.
  Arranging a meeting with the case manager is premature, because the nurse needs to first determine
  what the client’s needs are. Until the nurse understands the client’s needs, the nurse should not
  encourage the spouse to discuss the concerns with the client.
  CN: Psychosocial integrity; CL: Synthesize
1. The nurse is ultimately responsible to coordinate the client’s care while hospitalized;
  therefore, it is the nurse’s responsibility to arrange a care conference to help get the client’s questions,
  concerns, and frustrations addressed. Assuring the client that the physicians know what they are doing
  does not address the client’s concern or frustration with receiving conflicting information. While it is
  true that the client is ultimately responsible for health, asking the client to accept the consequences is
  a form of blaming the client. The physicians’ progress notes will not provide information that will
  address the client’s concern or resolve the conflicting courses of action that the two physicians are
  proposing.
  CN: Management of care; CL: Synthesize
3, 1, 4, 2. The nurse should first assess the client and then, if there is no acute injury, help the
client get back into bed. The nurse must notify the physician and the family of the fall, and finally,
document the event on the client’s health record.
CN: Safety and infection control; CL: Synthesize
1. Liver damage is a side effect of Zocor (simvastatin) and the client is demonstrating signs
  of liver damage (jaundice and concentrated urine). The nurse should report these findings to the
  physician. Although clients should not consume large amounts of alcohol while taking Zocor, the
  cause of the liver damage is likely related to the use of the Zocor and not alcohol intake unless the
  nursing assessment has revealed that alcohol intake may be a factor as well. The client should follow
  a diet low in saturated fat, but this is not the priority at this time. Increasing fluid intake will not
  reverse the liver damage.
  CN: Pharmacologic and parenteral therapies; CL: Synthesize

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