NCLEX Final ATI| 150 QUESTIONS| WITH COMPLETE SOLUTIONS LATEST UPDATE. 2023/2024 ASSURED, Exams of Nursing

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NCLEX Final ATI| 150 QUESTIONS| WITH COMPLETE

SOLUTIONS LATEST UPDATE. 2023/2024 ASSURED A+

A nurse is caring for a school age child on a children's mental health unit. What comment by the nurse would foster rapport to engage the client in conversation? "Do you like school?" "Tell me about your favorite video game." "We have another child your age on the unit." "Would you like some juice or milk to drink?" - ✔️✔️ "Tell me about your favorite video game." This open-ended statement encourages the child to respond with more than just the name of the game. This would foster rapport and encourage communication. A nurse is planning recreational activity for a young adult client with an acute exacerbation of schizophrenia. Assuming that the client is capable of all of the following, which activity should the nurse consider appropriate? Walking with a staff member around the gated grounds Playing ping-pong in the dayroom with another client Shooting baskets with several other clients in the gym Riding on the stationary bike alone in the fitness room - ✔️✔️ Walking with a staff member around the gated grounds This client should be encouraged to participate in nonthreatening, noncompetitive physical activities. This also provides an opportunity for verbal interaction with a member of the health care team. A nurse is caring for a child who is diagnosed with strabismus. The nurse explains to the parents that to prevent the development of amblyopia, it will be necessary to do which of the following?

Patch the unaffected eye. Administer mydriatic eye drops daily. Obtain prescription eyeglasses. Administer IV antibiotics. - ✔️✔️ Patch the unaffected eye Amblyopia is a disorder of the eye in which unilateral central blindness occurs as a result of another condition, such as strabismus. In strabismus, muscle weakness allows one eye to wander so that the child cannot focus on an object with both eyes at the same time. This confusion causes the brain to ignore the signals from the weak eye in favor of the strong one. This will result in central blindness if not treated by 6 years of age. To strengthen the weak eye muscles, the unaffected eye is patched. During preoperative teaching for a client scheduled for laser assisted in situ keratomileusis (LASIK) surgery, the nurse should tell the client that he may need to wear reading glasses after the surgery. can drive home after the procedure. should continue to wear his contact lenses until the day of the surgery. will not have to wear glasses after the surgery. - ✔️✔️ may need to wear reading glasses after the surgery. LASIK is a type of refractive laser eye surgery ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, many people develop presbyopia (farsightedness) with age and may need reading glasses, despite having had LASIK surgery. A nurse is reinforcing teaching with the family of a child who has Asperger's syndrome. Which comment would indicate to the nurse that adequate learning has taken place? "Aricept may slow the progression of the disorder."

"Group therapy is important for children with cognitive delays." "It will help our child if we keep a structured daily routine." "This disorder is related to our child's prematurity." - ✔️✔️ "It will help our child if we keep a structured daily routine." The child with Asperger's syndrome has a high functioning form of autism spectrum disorder; typically the child will have normal to high cognitive skills. A structured environment can help to minimize the problems these children experience with sudden schedule changes, socialization requirements, and the preference for ritualistic behavior. A nurse has been notified by the post anesthesia care unit that a client who has had a subtotal thyroidectomy is returning to the nursing unit. Which emergency equipment should the nurse have available on the unit for this client? Cardiac monitor Defibrillator Thoracotomy tray Tracheostomy tray - ✔️✔️ Tracheostomy tray In the event of laryngeal edema or tetany, respiratory distress could result in airway obstruction. Emergency intubation may be difficult due to laryngeal swelling, and endotracheal intubation may increase the risk for hemorrhage by increasing tension on the incision during insertion. A tracheostomy tray should be easily accessible. A nurse is caring for a client with a tracheostomy who is receiving mechanical ventilation. The low-pressure alarm on the ventilator sounds, indicating which of the following to the nurse? Excessive airway secretions A leak within the ventilator circuitry Decreased lung compliance Client is coughing or attempting to talk - ✔️✔️ A leak within the ventilator circuitry

The low-pressure alarm means that either the tubing has come apart or that client has become disconnected from the ventilator tubing. Almost all low-pressure alarms are the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator. A nurse has delegated an assistive personnel (AP) to provide one on one observation to a client who is recovering from a closed head injury. The nurse notes that the client is impulsive and has experienced one fall. Which of the following actions by the AP indicates to the nurse further teaching is needed? Accompanies the client to physical and occupational therapy Ambulates the client's roommate while the client sleeps Asks another AP to perform this task while at lunch Remains with the client while family members are visiting - ✔️✔️ Ambulates the client's roommate while the client sleeps One-on-one observation requires constant supervision of the client. The client might wake up while the AP is out of the room, get out of bed, and fall. A client is scheduled to have an electroencephalogram (EEG) in the morning. While preparing the client for the EEG, it is appropriate for the nurse to tell the client which of the following? "You will be given a sedative for the procedure, so you won't feel the small electrical shock." "After midnight you will not be able to eat or drink, so be sure you have enough at dinner." "You need to shampoo your hair tonight, and don't put any styling products on it afterwards." "It's common to experience temporary short-term memory loss following the procedure." - ✔️✔️ "You need to shampoo your hair tonight, and don't put any styling products on it afterwards."

An electroencephalogram (EEG) is a painless test that records the electrical activity of the brain. During the test, electrodes are attached to the scalp to record the tiny electrical charges released by the nerve cells in the brain. So that the electrodes will adhere properly to the scalp, the client's hair has to be clean and free of oil and hair-care products. A nurse is caring for a client who is receiving IV ampicillin (Unasyn). Which of the following actions should the nurse take first if the client develops urticaria and dyspnea? Administer diphenhydramine (Benadryl). Call the primary care provider. Obtain an oximetry reading. Stop the ampicillin infusion. - ✔️✔️ Stop the ampicillin infusion. The greatest risk to the client is an allergic reaction that may progress to anaphylaxis. The nurse should stop the infusion immediately so that further exposure to the client of the potential allergen is halted. TEST-TAKING STRATEGY: This question requires you to choose a priority action for a client with drug toxicity when all the actions appear plausible. Any time that a question involving medication toxicity requires you to make a choice about which action the nurse should take first, a choice that has the nurse discontinuing the client's exposure to the medication or toxic substance should always be the first choice. A community health nurse is conducting a class on body mechanics for county office workers. Which of the following should the nurse include in the teaching? (Select all that apply.) "Sit with your back supported." "Knees should be at the hip level." "Wrist and forearms should be parallel to the ground." "Keep the elbows far away from the body." "Adjust the monitor screen so that you have to tilt your head slightly to look at it." - ✔️✔️ "Sit with your back supported." "Knees should be at the hip level."

"Wrist and forearms should be parallel to the ground." "Sit with your back supported" is correct. Sitting with the back supported while at the computer helps to prevent back strain, which can lead to lower-back disc disease. "Knees should be at the hip level" is correct. Keeping the knees at the hip level while at the computer helps to prevent unnecessary strain on the hips and lower back. "Wrist and forearms should be parallel to the ground" is correct. Keeping the wrist and the forearms parallel to the ground while typing will help to prevent unnecessary strain on the wrists that could result in carpal tunnel syndrome. "Keep the elbows far away from the body" is incorrect. The arms should be kept close to the body. Keeping elbows far way from the body puts undue strain on the shoulders and the arms. "Adjust the monitor screen so that you have to tilt your head slightly to look at it" is incorrect. The head should be level when looking at the computer screen. Tilting the screen, and tilting the head to look at it, can place undue strain on the cervical spine (neck) region. A nurse is reviewing the laboratory data of a client who reports symptoms that suggest systemic lupus erythematosus (SLE). If this diagnosis is accurate, the nurse expects to note an increased platelet aggregation. red blood cell count. hemoglobin and hematocrit. erythrocyte sedimentation rate (ESR). - ✔️✔️ erythrocyte sedimentation rate (ESR). SLE is a chronic systemic autoimmune disease that causes skin, heart, lung, and kidney inflammation. Like most autoimmune diseases, a series of exacerbations and remissions is typical and, while it varies considerably in severity, clients typically die from end-stage renal

disease. Diagnosis is based on the client's history of manifestations and serologic tests. Most clients with an exacerbation of SLE will have an increased ESR. A client with an acute visual disturbance describes it as a "curtain" pulled over the visual area with occasional flashes of light. The nurse should notify the provider immediately of the possibility of cataracts. angle-closure glaucoma. a detached retina. macular degeneration - ✔️✔️ a detached retina. The retina is the thin layer of light-sensitive tissue on the back of the wall of the eye. A detached retina is a medical emergency in which the retina of the eye peels away from its underlying layer of support tissue. Without immediate treatment, the entire retina can detach, leading to permanent vision loss. Manifestations include a sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field. A client with Addison's disease comes to the emergency department reporting nausea, vomiting, diarrhea, and abdominal pain. To prevent Addisonian crisis, the nurse anticipates that the provider will prescribe IV administration of calcium. potassium. insulin. corticosteroids. - ✔️✔️ corticosteroids. Addison's disease is characterized by adrenal gland hypofunction and inadequate production of glucocorticoids. Acute adrenal insufficiency can be a life-threatening event, with severe fluid and electrolyte imbalances. Without treatment, sodium levels fall and potassium levels increase. Rapid infusion of IV fluids, such as 0.9% sodium chloride boluses, with administration

of high dose corticosteroids, such as hydrocortisone sodium succinate (Solu-Cortef), are started as soon as venous access is established. A nurse is assisting with breastfeeding immediately following the birth of a newborn. Which of the following is the most important benefit of breastfeeding during the fourth stage of labor? The nurse is available to assist the mother with breastfeeding techniques. Maternal-newborn bonding is promoted while the neonate is in an alert phase. Warmth is provided for the newborn being held against the mother's skin. Oxytocin secretion is stimulated causing uterine contractions. - ✔️✔️ Oxytocin secretion is stimulated causing uterine contractions. Production and secretion of oxytocin causes the uterus to contract, thus promoting involution and decreasing the risk for maternal hemorrhage and blood loss. A nurse is performing an assessment on a client. Which of the following in the client's history is a contraindication to use of sildenafil (Viagra)? Diabetes mellitus Current use of isosorbide (Isordil) for heart failure Eyeglasses required for presbyopia Osteoarthritis - ✔️✔️ Current use of isosorbide (Isordil) for heart failure Sildenafil (Viagra), a medication used in the treatment of erectile dysfunction, is contraindicated in clients taking any nitrates, such as isosorbide (Isordil). These medications taken concurrently may cause life-threatening hypotension. A nurse is caring for a client who has recently had a myocardial infarction (MI). The client calls the nurse to report some manifestations similar to those the client experienced the day of the MI. Which of the following should alert the nurse to the possibility of a recurrence? (Select all that apply.)

Nausea and vomiting Diaphoresis and dizziness Chest and left arm pain Anxiety and feelings of doom Leg cramps and restlessness - ✔️✔️ Nausea and vomiting Diaphoresis and dizziness Chest and left arm pain Anxiety and feelings of doom A client asks the nurse if it is common to experience vaginal yeast infections during pregnancy. Which of the following is an appropriate response? "Have you discussed this with your primary care provider yet?" "The hormonal changes in pregnancy affect the vaginal pH, making yeast infections common." "Only women who are already prone to vaginal yeast infections get them during pregnancy." "Why are you concerned about yeast infections during pregnancy?" - ✔️✔️ "The hormonal changes in pregnancy affect the vaginal pH, making yeast infections common." This is an information-seeking question, so the therapeutic response is an answer that provides the client with the information that is requested. This therapeutic answer not only tells the client that the infections are common, but also gives the client information about why this occurs. A nurse is participating in a disaster drill with the local health department. Staged victims are being used in the drill to simulate a bomb explosion at a sporting event. The nurse is one of the first responders on the scene and starts to triage the victims. Which of the following actions should the nurse take first?

Call out to people who can walk and ask them to move from the incident area to the concession stand. Perform quick head-to-toe assessments of victims. Immediately start cardiopulmonary resuscitation on victims who are not breathing. Identify those victims that need to be transported to a health care facility. - ✔️✔️ Call out to people who can walk and ask them to move from the incident area to the concession stand. All clients who can walk are asked to move away from the incident area to a specific location. This allows the nurse to quickly assess those who may need immediate assistance and reduces the chance of further injury from the disaster to these people. A client is admitted with a suspected diagnosis of tuberculosis. Which nursing action is of highest priority? Place the client on airborne isolation. Initiate the prescribed antimicrobial therapy. Ask the client about potential community exposures. Teach the client the manifestations of tuberculosis. - ✔️✔️ Place the client on airborne isolation. Clients strongly suspected of having tuberculosis (TB) should be placed on airborne isolation precautions immediately because of the highly communicable nature of the infection. Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air, including Mycobacterium tuberculosis, the agent that causes TB. A nurse is caring for a 3-year-old toddler who is undergoing insertion of pressure equalization (PE) tubes. The toddler's parent asks the nurse, "When will these tubes be removed?" Which of the following responses by the nurse is the most appropriate? "When the doctor determines it is time to remove the tubes, your toddler will be admitted to the ambulatory surgery center." "Unless they need to be replaced, the tubes are permanent."

"The tubes remain in place for approximately 1 to 2 years until they fall out on their own." "You don't need to worry about that now. The doctor will decide what to do when the time comes." - ✔️✔️ "The tubes remain in place for approximately 1 to 2 years until they fall out on their own." Children generally outgrow PE tubes, and they usually fall out on their own about 1 to 2 years after insertion. A nurse manager notes that several staff members are late in completing an annual mandatory educational session related to restraint safety. Which of the following actions should the nurse plan to take? Make a general announcement at the next staff meeting asking all employees to check their compliance with the requirement. Post a list in the employee break room naming those who are in noncompliance and the date that the requirement must be completed. Speak to each noncompliant employee individually and document the meeting in the employee's personnel file. Send an e-mail to each noncompliant employee that includes a link to future upcoming educational sessions. - ✔️✔️ Send an e-mail to each noncompliant employee that includes a link to future upcoming educational sessions. E-mail provides a simple, yet efficient way for the nurse manager to get the news out to each noncompliant employee without embarrassing anyone with a public announcement. In addition, including the appropriate link in the e-mail facilitates the employee's compliance by helping the employee to identify upcoming session(s) that coordinate with the employee's work schedule. A nurse is developing a plan of care for a client with gastroesophageal reflux disease (GERD). Because of the complications commonly associated with this disorder, the nurse plans to monitor the client for aspiration.

infection. anemia. weight loss. - ✔️✔️ aspiration. Aspiration is a common complication associated with GERD. GERD results when the esophageal sphincter malfunctions, allowing gastric acid and undigested food to back up into the esophagus placing the client at risk for aspiration. GERD is characterized by effortless, uncontrolled regurgitation whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion, but aspiration is also possible. Therefore, the client should be monitored for crackles in the lung fields, which is an indication of aspiration. A nurse is caring for a 2 year old child. The parents request a toy for their child. The nurse understands that the most appropriate toy from the playroom for this child is which of the following? Doll with clothes Cartoon DVD Video game 10-piece wood puzzle - ✔️✔️ 10-piece wood puzzle Age-appropriate toys for a 2-year-old child include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. These toys all allow for manipulation and exploration and meet the child's developmental and diversional activity needs. A clinic nurse is assessing a 66 year old client a for a routine physical. The client is new to the area and does not have old medical or immunization records available. When the nurse asks if the client has received the pneumococcal vaccine, the client replies, "I am not sure but I haven't had any immunizations in at least 5 years." The nurse should recognize that in this circumstance it is unsafe for the client to receive another vaccination. the client will need a series of three injections.

this vaccination is contraindicated for clients older than 65 years of age. the client should receive the pneumococcal vaccine. - ✔️✔️ the client should receive the pneumococcal vaccine. One dose of the pneumococcal vaccine should be given to all clients age 65 or older. If the client received the immunization more than 5 years ago and was less than 65 years of age, the CDC recommends a one-time revaccination. A nurse is caring for a child who is receiving bleomycin (Blenoxane) IV and is not voiding adequately. What is the appropriate nursing action? Assess the child's hydration status. Stop the medication immediately. Give the child a diuretic. Take no action because a decrease in urine is an expected side effect. - ✔️✔️ Assess the child's hydration status. The nurse should monitor renal function with bleomycin and other antibiotic antineoplastic medications. Monitoring includes checking laboratory values for BUN and creatinine clearance, as well as I&O. A nurse is caring for a 2 year old child who was admitted for laryngotracheobronchitis. The child is placed in a crib with a cool mist tent. Which toy would be most suitable for the child at this time? A stuffed teddy bear A cloth crib gym A plastic fire engine A cardboard picture book - ✔️✔️ A plastic fire engine

Acute laryngotracheobronchitis, or croup, is a condition of respiratory difficulty caused by infection, inflammation, and swelling of the upper airway (larynx, trachea, and bronchus). The cool mist tent is ordered to provide a high-humidity environment to ease the child's work of breathing. Consequently, the nurse selects an age-appropriate toy made of plastic that can be easily wiped clean and dry. A nurse is providing teaching to a client who is prescribed doxycycline (Vibramycin) for actinomycosis. The nurse should observe the client for which of the following? Photosensitivity Constipation Ototoxicity Discoloration of teeth - ✔️✔️ Photosensitivity Doxycycline is a tetracycline antibiotic. Photosensitivity is an adverse effect of tetracyclines in which the skin reacts abnormally to light, especially ultraviolet radiation or sunlight. The result is an intense sunburn reaction with erythema, maculas, and gray-blue patches. Prevention involves avoiding direct exposure to sunlight and ultraviolet light and using a sunscreen with a sun protection factor (SPF) of 15 or greater. A nurse observes tachycardia, dyspnea, dry cough, and distended neck veins in a client with leukemia who is receiving a blood transfusion of packed red blood cells. Which intervention should the nurse use to prevent these manifestations with the client's next transfusion? Warm the unit of blood to room temperature before administering it. Administer acetaminophen (Tylenol) prior to the blood transfusion. Give an antihistamine prior to the transfusion. Use a transfusion pump to regulate and maintain the flow rate. - ✔️✔️ Use a transfusion pump to regulate and maintain the flow rate. These are the manifestations of a hypervolemic reaction due to circulatory overload, likely if the blood is transfused too rapidly for the client's size or condition. To prevent this problem with

future transfusions, the nurse must ensure that the proper amount of blood is transfused and that a transfusion pump is used to regulate the flow rate. A client has pseudomembranous colitis caused by clostridium difficile. The priority nursing intervention for this client is performing hand hygiene before and after contact with the client. reducing the client's anxiety due to isolation procedures. assisting the client in making nutritional choices to reduce diarrhea. monitoring the client's intake and output closely for signs of fluid deficit. - ✔️✔️ performing hand hygiene before and after contact with the client. C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two virulent exotoxins that attack the lining of the intestine. The toxins destroy cells and produce pseudomembranes, patches (plaques) of inflammatory cells, and decaying cellular debris on the interior surface of the colon. The spores of C. difficile are easily transported from one client to another without hand hygiene. A nurse is planning to delegate care of a postoperative client following an appendectomy. Which of the following should the nurse delegate to an assistive personnel (AP)? Teach the client to use the patient-controlled analgesia pump. Record urinary output after emptying the indwelling urinary catheter. Get the client out of bed and to the chair for the first time after surgery. Check the client's abdominal wound dressing. - ✔️✔️ Record urinary output after emptying the indwelling urinary catheter. Emptying an indwelling urinary catheter and recording I&O is within the scope of practice for an AP.

A nurse on a mental health unit is taking care of a client diagnosed with depression. Which nursing intervention would foster a therapeutic environment for this client? Tell the client that the nurse will talk to him at her request. Allow the client to skip group activities if he chooses. Leave the client alone for frequent rest periods throughout the day. Build trust with the client by sitting quietly with him. - ✔️✔️ Build trust with the client by sitting quietly with him. Building trust with the client will give him the idea that the nurse is interested in his issues. Establishing client trust encourages him to speak more openly about issues and concerns. A pregnant client who is Hindu is being seen at the women's health center for a 12 week check up. The primary care provider tells the client that she must get more protein in her diet and suggests that the client eat more animal products. Although the client initially states that she agrees, after the primary care provider leaves the examination room, the client tells the nurse that "eating animal products will cause her to miscarry." Which of the following is an appropriate response? "Let's discuss other foods that are also high in protein that you could substitute for meat." "Eating meat during pregnancy provides necessary protein and does not cause miscarriage." "Why do you think that eating animal products will cause you to have a miscarriage?" "Your primary care provider is recommending what is best for you and your baby. - ✔️✔️ "Let's discuss other foods that are also high in protein that you could substitute for meat." Many cultures have beliefs about food that should or should not be consumed during life transitions, such as pregnancy. The nurse is also aware that many Hindu clients are vegetarian due to religious reasons. The nurse should discuss alternative protein sources with the client to help the client identify those consistent with both her religious and traditional medical beliefs.

During a client care unit meeting, the nurse manager discusses potential problems with data security related to confidential client information. The nurse manager explains that safe, effective environments where client information may be discussed include areas closed off from the public. outside the door of a client's room. lunch breaks in the cafeteria. in the hallway near the nurse's station. - ✔️✔️ areas closed off from the public. Client information may be discussed in a room on the unit with a closed door to prevent accidental disclosure of a client's personal health information. A nurse is talking with a parent of a preschooler. The parent reports that it is very difficult to get her child to go to bed at a proper time consistently. She tells the nurse that the child gets out of bed, enters her room, and cries when told to stay in bed. Which instructions should the nurse give the parent to foster a consistent bedtime for this child? "Use a stable relaxing routine, such as a bath and story time before bed." "Make sure the room is completely dark when placing the child in bed." "Let the child go to sleep in your lap and then put the child in his bed." "It's okay to let your child cry himself to sleep." - ✔️✔️ "Use a stable relaxing routine, such as a bath and story time before bed." Routines are very reassuring to preschoolers because they allow the child to be able to anticipate their environment and adapt appropriately. These actions will help the child to settle down prior to bedtime. They also provide for parental-child interaction prior to bed. A nurse is caring for a client who has had a bone marrow transplant and is on protective isolation. Which of the following statements indicates that the client understands the restrictions of this type of isolation?

"I must keep the door to my room closed at all times." "My family will be bringing me fresh flowers today." "I'm really going to miss taking my daily shower." "I should try to avoid straining during bowel movements." - ✔️✔️ "I must keep the door to my room closed at all times." Protective isolation is prescribed to protect immunocompromised clients from exposure to potentially lethal micro-organisms and includes keeping the door to the room closed at all times. A nurse at the family planning clinic is preparing to teach a class on the use of a diaphragm. Which of the following should the nurse include in the teaching session? "When using a diaphragm, it is necessary to also use spermicidal jelly." "A diaphragm will remain in place until you're ready to have children." "You can leave a diaphragm in longer than 8 hours without any complications." "A diaphragm comes in one size and does not need to be fitted." - ✔️✔️ "When using a diaphragm, it is necessary to also use spermicidal jelly." A diaphragm is a barrier device used to prevent pregnancy. It is inserted by the client prior to sexual intercourse. Use of a diaphragm alone is not 100% effective at preventing pregnancy, but the use of spermicidal jelly with it increases the effectiveness of the device. A client's provider informs the nurse that the client's abdominal aortic aneurysm (AAA) is extending. The nurse must assess the client for increases in blood pressure and respiratory rate. jugular-vein distention and peripheral edema. abdominal pain with the onset of back pain.

retrosternal chest pain radiating to the left arm. - ✔️✔️ abdominal pain with the onset of back pain. An aortic aneurysm is a weak spot in the wall of the aorta, the primary artery that carries blood from the heart to the head and extremities and allows the aorta to expand and increase in diameter. Increasing abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots. At the first prenatal visit, a nurse learns that a pregnant client is lactose intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client? Collard greens Cottage cheese Orange juice Broccoli - ✔️✔️ Collard greens Collard greens are a good source of lactose-free calcium. One cup of collard greens provides approximately the same amount of calcium as 1 cup of milk. A nurse is caring for a 3-year-old child who has persistent otitis media. When obtaining the history of the child from her parent, which of the following would be the most appropriate for the nurse to ask regarding the child's recurrent otitis media? "Is the child playing with other children with otitis media?" "Does anyone smoke around, or in the same house as, the child?" "Does the child get water in her ears during a tub bath?" "Has the child had a fever recently?" - ✔️✔️ "Does anyone smoke around, or in the same house as, the child?"

Otitis media is an infection of the middle ear (eustachian tube behind the tympanic membrane). Allergies to common irritants, such as smoke, can cause eustachian tube congestion and chronic otitis media. A nurse is caring for a toddler with acquired immune deficiency syndrome. During the assessment, the nurse understands that which of the following would indicate an opportunistic infection? Koplik spots Gingivitis Chancre Candidiasis - ✔️✔️ Candidiasis Candidiasis, or oral thrush, is caused by the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of infants, diabetics, and other clients with immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that may appear like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection noted in a human immunodeficiency virus (HIV) positive child who is developing AIDS. A nurse is caring for a hospitalized client who is dying. The family has been involved in the client's care for several days. The family is exploring the possibility of caring for the client at home. Which of the following statements indicates that the nurse has a good understanding of family-centered care? "I have contacted various community resources that will be helpful." "I will review the care plan to make changes that are necessary." "Let's set up a meeting time with the primary care provider to discuss your options for home care." "I will make a list of things that need to be done before discharge." - ✔️✔️ "Let's set up a meeting time with the primary care provider to discuss your options for home care."

In family-centered care, the client and family help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered care environment. A client who has been treated for a transient ischemic attack (TIA) is being discharged. The nurse's discharge teaching plan related to this admission should reinforce the importance of monitoring blood pressure at regular intervals. blood glucose using a glucometer. pulse rate with aerobic exercise. temperature and sensation in the feet. - ✔️✔️ blood pressure at regular intervals. Transient ischemic attacks (TIA) are caused by a temporary disturbance of blood supply to the brain, resulting in brief neurologic dysfunction. One third of clients who have had a TIA later have recurrent TIAs, and another one third have a cerebrovascular accident (CVA) that results in permanent nerve cell loss. The most common causes of TIA are atherosclerotic plaque in the carotid arteries and hypertension. Consequently, managing hypertension is important in reducing the risk of CVA. A nurse is caring for an infant with dehydration. Which of the following is the most accurate assessment for hydration status? Obtain daily weights. Check for the presence of tears. Palpate the fontanel. Assess skin turgor. - ✔️✔️ Obtain daily weights. Daily weights are the most sensitive indicator of fluid balance in clients of all ages. Daily weights are especially critical in children under 2 years of age because a greater portion of body weight is composed of fluid.

A nurse in the emergency department cares for several children who all are admitted with symptoms of influenza. After routine laboratory work is obtained from the children, which child should the nurse bring to the primary care provider's attention immediately? 6-year-old child with urine specific gravity of 1.030 2-year-old toddler with BUN level of 25 mg/dL and creatinine level of 0.5 mg/dL 6-month-old infant with WBC count of 24,000/mm3 12-year-old child with positive beta human chorionic gonadotropin - ✔️✔️ 6-month-old infant with WBC count of 24,000/mm3 This WBC count (normal is 4,000 to 10,000/mm3) is highly elevated for a 6-month-old infant who has manifestations of influenza. A septic work up (blood, urine, and spinal fluid cultures) will need to be done immediately; therefore, the provider should be notified immediately of the infant's condition. A nurse is caring for a client who is receiving hemodialysis for the first time. Which of the following indicates to the nurse that the client is at imminent risk for developing dialysis disequilibrium syndrome (DDS)? Elevated BUN Bradycardia Headache Temperature of 39.2° C (102.5° F) - ✔️✔️ Headache DDS is a central nervous system (CNS) disorder. It is a complication that may develop in clients who are new to dialysis due to the rapid removal of solutes and changes in blood pH levels. Clients beginning hemodialysis are at greatest risk, particularly if the BUN is above 175. DDS is characterized by CNS manifestations of varying severity due primarily to cerebral edema. They include headache, nausea, disorientation, restlessness, blurred vision, and asterixis. More severely affected clients progress to confusion, seizures, coma, and death.

An individual wearing a hospital-issued identification badge greets the charge nurse on the postsurgical unit and states, "I am a surgical resident assigned to this unit." The individual then asks the charge nurse for an access code to review a client's online record stating, "I'm not scheduled to attend the computer class until next week." Which of the following actions should the nurse take? Explain that it is against policy to share access codes and refer the resident to his supervisor. Access the requested client's online data and observe as the resident obtains the information needed. Access the online client data system and allow the resident to locate the client's data. Ask the client to give permission for the resident to access his medical records. - ✔️✔️ Explain that it is against policy to share access codes and refer the resident to his supervisor. Access codes and passwords should never be shared. Likewise, allowing access to the system for an individual who does not have their own access code is also not permitted. An integral part of computer training is learning about client data security, confidentiality, and signing documents that attest to your intention to follow these federal guidelines. The resident should be politely referred to his supervisor to obtain the information needed or to make arrangements to be trained sooner if necessary. A nurse is developing a teaching plan for a client diagnosed with type 2 diabetes mellitus. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following is an appropriate nursing response? "Let's discuss this with your physician; it may not be necessary." "Isn't there another favorite dish you can substitute?" "You don't have to give up pasta, just adjust the amount you eat." "You can use no-added-salt tomato products on your pasta." - ✔️✔️ "You don't have to give up pasta, just adjust the amount you eat." The American Diabetes Association (ADA) recommends that carbohydrate restriction be individualized for each client as needed. A careful assessment of the client's usual dietary

practices and modifications is an important part of teaching the client with diabetes to manage this disease and to ensure long-term success with the ADA diet. A client presents to the emergency department following a motor vehicle crash. She reports pain in her left leg, and the nurse notes that the left leg has manifestations of a fracture including bruising, swelling, and displacement of the bones. What action should the nurse take first? Ask the provider to prescribe an x-ray of the leg. Apply ice packs to the affected area. Check neurovascular status distal to the injury. Elevate the affected leg on two pillows. - ✔️✔️ Check neurovascular status distal to the injury. This action includes checking the circulation, sensation, and movement distal to (below) the level of the injury. If the nurse notes a weak or absent pulse distal to the injury, the limb's circulation is compromised, and immediate action is critical. This is the nurse's highest priority at this time. A nurse is talking with an unmarried couple who have come to the family planning clinic for advice. Which of the following is an appropriate response regarding the risks associated with an intrauterine device (IUD)? "If you experience any weight changes, you will need to be refitted for your IUD." "An IUD is more effective when it is used with a spermicidal jelly." "There is an increased risk for ectopic pregnancy when using an IUD." "An IUD should only be used by couples who have completed their family." - ✔️✔️ "There is an increased risk for ectopic pregnancy when using an IUD." An IUD is a family planning device that is inserted through the cervix into the uterus to prevent pregnancy. The IUD works by changing the lining of the uterus and fallopian tubes, making it more difficult for fertilization to occur in the uterus. Consequently, a known complication when using the IUD is an increased risk for ectopic pregnancy.

A client receiving chemotherapy has developed neutropenia. Which statement by the client indicates to the nurse that the client needs further instructions? "I make sure I always keep an antibacterial hand gel in my purse." "I guess my spouse will have to take care of the cat boxes for awhile." "I'm planning a large gathering of friends and family for the holidays." "I will eat a lot of frozen and canned fruits and vegetables." - ✔️✔️ "I'm planning a large gathering of friends and family for the holidays." A client with neutropenia must be careful to avoid exposure to infection, so this is a statement that warrants more teaching. A client experiencing neutropenia should avoid large crowds of people because a large gathering increases the client's risk for exposure to infection. TEST- TAKING STRATEGY: This question asks which statement indicates that the client needs FURTHER teaching, thus the CORRECT answer is an INCORRECT statement. A nurse is providing discharge instructions to a client who is prescribed metoprolol (Toprol-XL). Which of the following instructions should the nurse include? (Select all that apply.) Do not suddenly stop taking this medication. Take medication right before bedtime. Avoid exposure to the sunlight. Take radial pulse daily. Chew sugarless gum to relieve dry mouth. - ✔️✔️ Take radial pulse daily is correct. The client should take a radial pulse daily and report a heart rate less than 60/min. Chew sugarless gum to relieve dry mouth is correct. Chewing sugarless gum or sucking on sugarless candy can help relieve dry mouth caused by metoprolol. Do not suddenly stop taking this medication is correct. There is an increased risk of angina, hypertension, and possible myocardial infarction when metoprolol, a beta blocker, is