TEST BANK NCLEX.TEST BANK NCLEX.TEST BANK NCLEX., Exams of Nursing

Download TEST BANK NCLEX.TEST BANK NCLEX.TEST BANK NCLEX. and more Exams Nursing in PDF only on Docsity! TEST BAK NCLEX QUESTIONS 1-15 Ref # 4366 The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass graft procedure. Which of the following assessments requires immediate notification of the health care provider? * — Left foot is cool to the touch * Absent lef t pedal pulse using Doppler analysis ¢ Inability to palpate the left pedal pulse * Acute pain in the left lower leg Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left lower leg are important findings, they all require additional nursing assessment prior to contacting the health care provider. In clients without palpable pedal pulses, the next step in the assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis requires immediately notifying the health care provider. Ref # 1028 There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4h" What action should the nurse take? Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call the health care provider who prescribed the medication and clarify the order. Ref # 1440 Which individual is at greatest risk for the development of hypertension? The incidence of hypertension is greater among African-Americans than other groups in the United States. The incidence among the Hispanic population is rising. Ref # 2446 A woman, who delivered five days ago and who had been diagnosed with pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at looks wavy. nl I have taken ns " What should the nurse do next? The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to, during, or after delivery; this may occur up to 10 days after delivery. Ref # 2065 A client expresses anger when a call light is not answered within five minutes. The client demanded a blanket. How should the nurse respond? This is the best response because it gives credence to the client's feelings and then concerns. To say "let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it could have waited a few minutes is rude and non-accepting of the client's verbalized needs. Ref # 2134 The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be an to home An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer (testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with an undescended testicle.) Due to the location of the incision, pain management is the priority. Most men will be able to eat regularly when they get home; they should at least tolerate liquids before discharge. It's important that the client is able to get up and walk with assistance, but this is not the priority. Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate priority. Ref #1524 A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some point in time. Ref #1721 The clinic nurse is assisting with medical billing. The nurse uses the DRG ae Related mua manual for which purpose? DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other insurance companies often use it as a standard for determining payment. KEYWORDS DRG diagnosis related group reimbursement stimulus creates an exaggerated response of the sympathetic nervous system and can be a life- threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus. Ref # 2144 A 67 year-old client is admitted with substernal chest pressure that radiates to the jaw. The admitting diagnosis is acute myocardial infarction (MI). What should be the priority nursing diagnosis for this client during the first 24 hours? Altered tissue perfusion In the immediate post MI period, altered tissue perfusion is priority, as an area of myocardial tissue has been damaged by a lack of blood flow and oxygenation. Interventions should be directed toward promoting tissue perfusion and oxygenation. The other problems are also relevant, but tissue perfusion is the priority. Ref #1740An external disaster has occurred in the town. The triage nurse from the emergency department is transported to the site and assigned to triage the injured. Which of these clients would the nurse tag as "to be seen last" by the providers at the scene? A middle-aged person with deep abrasions that are over 90% of the body The clients that are least likely to survive are to be tagged as the "last to be seen." Deep abrasions are usually treated as second or third degree burns because the fluid loss is great. ref #1750The nurse is caring for a client who is in the advanced stage of multiple myeloma. Which action should be included in the plan of care? Careful repositioning Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones. This disease may also harm other tissues and organs, especially the kidneys. This type of cancer causes hypercalcemia, renal failure, anemia,and bone damage. Because multiple myeloma can cause erosion of bone mass and fractures, extra care should be taken when moving or positioning a client due to the risk of pathological fractures. Ref #2332 The nurse is teaching the client with chronic renal failure (CRF) about medications. The client questions the purpose of taking aluminum hydroxide. What is the best explanation for the nurse to give the client about the therapeutic effects of this medication? It decreases serum phosphate Aluminum binds phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel are commonly used to decrease serum phosphate. Ref #1771The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis (ALS). Which finding would the nurse expect? (Stephen hawkins) ALS is a chronic progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. In ALS, upper and lower motor neurons degenerate (die) and stop sending messages to muscles; all muscles under voluntary control eventually weaken and atrophy. People eventually lose their ability to speak, eat, move and breathe. However, ALS does not impair a person's mind or intelligence. ALS does not affect a person's ability to see, smell, taste, hear or recognize touch. Ref # 1625 A nurse is caring for a client two hours after a right lower lobectomy. During the assessment of the chest drainage unit (CDU), the nurse notes bubbling in the water-seal chamber. What is the first action the nurse should take? Assess the chest tube dressing, tubing and drainage system The first action the nurse should take is to thoroughly check the dressing, tubing and drainage system. Usually intermittent bubbling in the water-seal chamber right after surgery indicates an air leak from the pleural space; this is a common finding and should resolve as the lung re-expands. Continuous bubbling usually means a leak in the CDU, such as a loose connection or a leak around the insertion site. Other nursing actions will include assessing the color and amount of the drainage and assessing the lungs. After the initial post- operative period, the nurse will assist the client to change positions and cough and deep breath to help re-expand the lung and promote fluid drainage. Ref #1551Today's prothrombin time for a client receiving warfarin 20 seconds. The normal range listed by the lab is 10 to 14 seconds. What is an appropriate nursing action? Recognize that this is a therapeutic level For the client on warfarin therapy, this prothrombin level is within the therapeutic range. Therapeutic levels for warfarin are usually 11/2 to 2 times the normal levels. Ref #1599 The nurse is teaching a client with coronary artery disease about nutrition. What information should the nurse be sure to emphasize Avoid large and Eating large, heavy meals can pull blood away from the heart for the digestion process. This may result in angina for clients with coronary artery disease. Sodium for clients with cardiac disease is limited to two grams per day. Three meals a day is a correct approach. However, it does not mention the size of the meal, which is more important. Ref #1749 The client, who is receiving chemotherapy through a central venous access device (CVAD) at home, is admitted to the intensive care unity (ICU) with a diagnosis of sepsis. Which of the following nursing interventions is the priority? Prepare the client for insertion of a new CVAD Many cases of sepsis occur in immunocompromised clients and clients with chronic and debilitating diseases. Since it's likely the existing CVAD is the source of the infection, it should be cultured and removed. A new central line (usually an internal jugular or subclavian) needs to be inserted since large amounts of IV fluids are needed to restore perfusion. The new central line will also allow venous access for labs, medications and measuring central venous pressure. Together with central venous pressure monitoring, an indwelling urinary catheter will help guide fluid volume replacement. Many hospitals have restrictions on visitors with known or recent infections to help protect all clients. Ref #1525 The client is scheduled for coronary artery bypass. Based on principles of teaching and learning, what is the best initial approach by the nurse during pre-op teaching? Assess the client's learning style As with any anticipatory teaching, assessment of the client's level of knowledge and learning style should occur first. If possible, the three senses of hearing, seeing and touching should be used during any teaching to enhance recall Ref #1246 During assessment of orthostatic vital signs on a client with cardiomyopathy, the nurse finds that the systolic blood pressure (BP) decreased from 145 to 110 mm Hg between the supine and upright positions while the heart rate (HR) rose from 72 to 96 beats per minute. In addition, the client reports feeling lightheaded when standing up. The nurse should implement which of the following actions? instruct client to increase fluid intake for several hours This client is experiencing postural hypotension, a decrease in systolic blood pressure 15 mm Hg accompanied by an increase in heart rate 15 to 20 beats above the baseline with a change in position from supine to upright. This is often accompanied by lightheadedness. Fluid replacement is appropriate, but must be instituted very cautiously, as this client with cardiomyopathy will also be very sensitive to changes in fluid status and fluid overload may develop rapidly with aggressive rehydration. After the client increases fluid intake for one to two hours, the client should be reassessed for resolution of the postural hypotension. Ref #1595 The nurse is caring for a client diagnosed with acute angina. The client is receiving an intravenous infusion of nitroglycerin. What is the priority assessment during this treatment? Blood pressure the vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable, and then every 30 minutes to every hour thereafter. Clients receiving IV nitroglycerin also require continuous ECG monitoring. Ref # 2159 A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest at what period of time? Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide. The clients have the energy to carry through with the plan for suicide. Ref #1815 A mother asks about expected motor skill development for her 3 year- old child. Which activity is considered a typical motor skill for the 3 year-old? Three year-old children are developing gross motor skills that require large muscle movement. While there will always be some variation between children, movement milestones typically include pedaling a tricycle, standing on one foot for a few seconds, walking backwards and jumping with both feet. The other activities listed require more coordination and are movement milestones for older children Ref #1539 The nurse needs to accurately assess gastric placement of a nasogastric tube prior to the administration of an enteral feeding. What is the priority action the nurse should take before starting the infusion? Check the pH of the aspirate Once the initial placement of the tube has been confirmed by x-ray, the nurse will check the pH of the aspirate before administering medications or enteral feeding solutions. Current practice recommendations Antiviral medications are not usually prescribed to otherwise healthy children. Over-the-counter hydrocortisone creams can help relieve itchy skin Ref #5280 During a yearly health screening, a 54 year-old female reports having irregular menstrual cycles, mood swings and hot flashes. She requests a more natural approach to manage these symptoms of perimenopause. What education about non-pharmacological interventions will the nurse include in client Measures that have been found to be effective in helping manage symptom of hot flashes include exercise, stress reduction and getting enough sleep at night. Reducing the temperature in the room at night and taking a warm bath or shower before bedtime can help clients get a better night's sleep. Slow abdominal breathing (6-8 breaths a minute) at the onset of hot flashes can help. Other measures that can lessen the number of and severity of hot flashes include yoga, as well as avoiding alcohol, spicy foods and caffeine. Eating a more plant-based diet can also help. Ref #1776 A nurse uses the New Ballard Scale to assess gestational age of a newborn. The assessment score total is very high. What is a reasonable interpretation of this result? The baby is post-term Birth weight and gestational age are important indicators of the newborn's health and are used to identify any (potential) problems. The New Ballard Scale can help differentiate, for example, between a small for gestational age baby and one that is premature. The New Ballard Scale scoring system adds up the individual scores for 6 external physical assessments and 6 neuromuscular assessments; the total score may range from -10 to 50. Premature babies have lower scores; higher scores correlate with post-maturity. Fetal distress during labor can result in lower scores. Ref #5307 A new task force has been created at a hospital to address a recent increase in patient falls. The first meeting is scheduled with members from several departments. Which of the following statements by the nurse leader indicate intent to increase mill cha effectiveness? aa all that apply.) “Let's focus on the number of falls first and then we can talk about staffing." A leader increases meeting effectiveness by not permitting one person not to dominate the discussion, encouraging brainstorming, encouraging others to further develop ideas and helping to engage the team in future discussions. An effective team leader will periodically summarize the information and ensure that all ideas are recorded for all to see (for example, on a whiteboard) and then follow up with minutes of the meeting. Beginning and ending on time is also important to keep everyone focused on the task at hand and to demonstrate respect team members’ other commitments. Ref # 1728 A nurse is reviewing laboratory results on a client diagnosed with acute renal failure. Which lab result should be reported immediately? Serum potassium 6 Although all of these findings are abnormal, the elevated potassium level 3.5 to 5.0 is a life-threatening finding and must be reported immediately. Serious consequences of hyperkalemia include heart block, asystole and life-threatening ventricular dysrhythmias. Anemia (hemoglobin less than 13 g/dL [130 g/L] in men or less than 12 mg/dL [120 g/L] in women) is common with kidney disease. Blood urea nitrogen (BUN) will be increased in acute renal failure (7 to 30 mg/dL [2.5 to 10.7 mmol/L] is a considered normal). oP = Fro. SIUM DEEFICIT * Alkalosis * Shallow Respirations * Irritability * Confusion, Drowsiness * Weakness, Fatigue * Arrh mias - Irregular rate, fachycardia %* Letharay # Thready Pulse x | Intestinal Motility Nausea Vomiting lleus FERS 2007 reroing Eavcation Consuan Ref # 2290 A client taking isoniazid for tuberculosis (TB) asks the nurse about the side effects of this medication. The client should be instructed to report which of these findings? Extremity tingling and numbness Peripheral neuropathy is a common side effect of isoniazid and other antitubercular medications and should be reported to the health care provider. Daily doses of pyridoxine (vitamin B6) may lessen or even reverse peripheral neuropathy due to isoniazid use Isoniazide (INH) ‘Have liver function tests done. Complete the therapy or elsel Ref #1304 A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and who becomes dyspneic. The nurse should take which action? Assist the client with pursed-lip breathing Pursed-lip breathing should be encouraged during periods of dyspnea in COPD to control rate and depth of respiration, to prevent alveolar collapse and to improve respiratory muscle coordination. Clients with COPD are usually on lower doses of oxygen, titrated to maintain an oxygen saturation of 88-91%. Semi-Fowler's position is usually most comfortable for someone with COPD, because this position allows the client's diaphragm to expand KEYWORDS COPD, dyspnea, pursed-lip breathing Ref #2242 A nurse is working with one licensed practical nurse (LPN) and a mental health tech (an unlicensed assistive personnel). Which newly admitted client would be appropriate to assign to the mental health tech? A middle-aged client —E— The mental health tech (a type of unlicensed assistive personnel or UAP) can be assigned to care for a client with a chronic condition after an initial assessment by the nurse. This client has minimal risk of instability of condition and has a situation of expected outcomes. Ref #4439 The client with cancer is being treated with a biological response modifier. Which of the following side effects does the nurse anticipate with biologic therapy? Chills and fever ...uses vaccines Biological response modifier cancer therapy agents (for example, interferons and interleukins) are drugs that stimulate the body's own defense mechanisms to fight cancer cells. Flu-like findings such as chills, fever and nausea, are common side effects of this type of therapy. The other assessment findings are not what you would expect when the body is fighting pathogens. The most accurate way to deliver oxygen to the client is through a Venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client's respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 55% Ref #1864 A client has had a positive reaction to purified protein derivative (PPD). When the client asks, "What does this mean?" the nurse should respond with which statement? " the PPD skin test is used to determine the presence of tuberculosis antibodies. In an otherwise healthy person, an induration greater than or equal to 15 mm is considered a positive skin test. This indicates that the client has been exposed to the organism Mycobacterium tuberculosis. Additional tests such as a chest x-ray and sputum culture will be needed to determine if active tuberculosis is present. The sputum cytology test is the only definitive test to confirm a diagnosis of active TB. Ref # 2016 A pregnant client, at 34-weeks gestation, is diagnosed with a pulmonary embolism (PE). Which of these medications does the nurse anticipate the health care ad will initially order? Heparin infusion to maintain the aPTT at 1.5 to 2 times the intravenous unfractionated heparin (UFH). The client's activated partial thromboplastic time (aPTT) should be monitored and kept in the therapeutic range of between 1.5 to 2 times the baseline value. Alternatively, low molecular weight heparins, such as enoxaparin (Lovenox), can be used to treat PE in women who are pregnant. Warfarin should never be given during pregnancy due to its teratogenic effects Ref #2445 At the beginning of the shift, the nurse is reviewing the status of each of the assigned clients in the labor and delivery unit. Which of these clients should the nurse check first? An adolescent who is 18-weeks pregnant with a report of no fetal heart tones and is coughing up frothy sputum The 18 year-old client has an actual complication of left-sided heart failure and a possible stillborn birth. The other clients present with findings of potential, but not actual, complications. Ref #1676 the nurse is preparing to administer albuterol inhaled to a 11 year-old with asthma. Which assessment by the nurse indicates there is a need for the health care provider to adjust the medication? Apical pulse of 112 common adverse effects of beta adrenergic medications such as albuterol (AccuNeb, ProAir HFA, Proventil HFA, Ventolin HFA), is an increase in heart rate. Normal resting heart rate for children 10 years and older is the same as adults: 60-100 beats per minute Ref # 1920 A 3 year-old has just returned from surgery for application of a hip spica cast. What nursing action will be the priority? Apply waterproof plastic tape to the pet td keep it clean and dry. Shortly after returning from surgery, waterproof plastic tape will be applied around the genital area to prevent soiling. The child should be turned every two hours to help facilitate drying, from side to side and front to back, with the head elevated at all times. If a crossbar is used to stabilize the legs, it should not be used to turn the child (it may break off). After the cast has completely dried and it becomes damp, it can be either exposed to air or a hair dryer (set to cool) may be used to help dry the cast. Ref # 1530 A nurse is teaching adolescents about sexually transmitted diseases. What should the nurse emphasize is the most common infection? Chlamydia Ref #1847 The respiratory technician arrives to draw blood for arterial blood gas om aun What should the nurse understand about the ae The radial artery is preferred; the second choice is the brachial artery and then the femoral artery. If a client is receiving oxygen, it should not be turned off unless ordered. After drawing the sample, it's very important to press a gauze pad firmly over the puncture site until bleeding stops or at least five minutes. Do not ask the client to hold the pad because if insufficient pressure is used, a large painful hematoma may form. The sample of arterial blood must be kept cold, preferably on ice to minimize chemical reactions in the blood. ef #1250 A client has just received an extracorporeal shock-wave lithotripsy ESWL) procedure. What is the priority information the nurse should teach ? Drinking three to four quarts (3,000 to 4,000 mL) of fluid each day will aid passage of fragments of the broken up renal calculi and help prevent formation of new calculi. Ref # 1553 A client has received two units of whole blood today after an episode of gastrointestinal bleeding. Which laboratory report should the nurse be sure to monitor closely? Hemoglobin and hematocrit The post-transfusion hematocrit provides immediate information about red cell replacement and if there is any continued blood loss; the follow- up hematocrit should be checked around 4 to 6 hours after the infusion is completed. ef #1992 A group of nurses on a unit are discussing stoma care for clients who have had a stoma made for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown? Ileostomy which is from the small intestine, is of continuous, liquid nature. This high pH, alkaline output contains gastric and enzymatic agents that when present on skin can denude skin in a few hours. Ref #1653 The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best comment by the nurse should include which point? “Bones of children are more porous than adults’ and often have incomplete breaks.” his allows the pliable bones of growing children to bend, buckle, and break in a "greenstick" manner. A greenstick fracture occurs when a bone is angulated beyond the limits of bending. The compressed side bends and the tension side develops an incomplete fracture. Ref #1890 The nurse manager informs the nursing staff that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care, and all staff are invited to participate in the study if they wish. This affirms which ethical principle? Autonomy free to make participation in research without coercion from others. Anonymity means the person's identity is not revealed. Beneficence is the state or quality of being kind, charitable, beneficial or a charitable act. Ref #4475 An 88 year-old client is admitted to the telemetry unit following a minor surgical procedure. The client's history includes insulin dependent diabetes and a previous myocardial infarction. The nurse responds to the client's ECG alarm and finds the client's rhythm shows asystole and the client obtunded but responsive. Prioritize the actions of the nurse (with 1 being the top priority). 1. 2. 3. 4. After checking responsiveness, establishing a patent airway and then assessing breathing and circulation are the next priorities (ABCs). This assessment would provide information to decide whether the an is needed. Because the client is responsive, the monitor is not correct, as a client with asystole would be unresponsive. Asystole on a rhythm strip may simply be a loose lead; a quick way to check this is to select another lead. The client's obtunded state indicates that ion is needed, so assessment of a central pulse and blood pressure is indicated to determine whether cardiovascular compromise is responsible for this condition. If no evidence of an immediate cardiac event is present, the blood glucose should be checked. Stress and changes in food or fluid consumption secondary to surgery increase the risk of glucose imbalance in the person with diabetes. Ref #1862 The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. What is the most important instruction about exercise? Do weight- Eee Weight-bearing or resistance exercises are beneficial in the treatment of osteoporosis. Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes these exercises. In addition, other approaches are estrogen replacement and calcium supplements in a treatment protocol. Ref #4509 The nurse, who is located in a large urban area, uses telecommunications to provide health care and education to clients in remote locations. What is the best reason for using telehealth? Removes time and distance barriers from the delivery of care Telehealth is the use of technology to deliver health care, health information, or health education at a distance. People in rural areas or homebound clients can communicate with providers via telephone, email or video consultation, thereby removing the barriers of time and distance for access to care. Although increased access to information and collaboration between the client and provider can be empowering, this is not the primary reason for using telecommunications/telehealth. Ref #2233 The health care team consists of one licensed practical nurse (LPN), one unlicensed assistive person (UAP) and one LPN student. The charge nurse an RN) has made the following assignments. Which assignment should be by the nurse manager? LPNs can provide care for clients whose conditions are stable and there's a low likelihood of an emergency. Since it's a new admission, the client diagnosed with atrial fibrillation and heart failure should not be assigned to a student; the charge nurse (RN) should care for this client. A nurse can assign tasks or activities to UAP, as long as the care of the client is not too complex or variable and the client's condition is stable. Ref # 1255 During a situation of pain management, which statement is a priority to consider for the ethical guidance of a nurse Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it Is Ref #1879 Which statement describes the advantage of using a decision grid to make decisions? itis both a visual and a quantitative method of decision making A decision grid allows the group to visually examine alternatives and evaluate them quantitatively with weighting. Ref #1976 An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When a nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. What should the nurse understand about the child's situation and administration of the immunization? The measles, mumps and rubella (MM) vaccine should be given now, before the transplant MMR is a live virus vaccine, and should be given at this time. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system. Ref # 1241 A client is started on long-term corticosteroid therapy. Which comment by the client indicates a need for more teaching? "For one week every month | will stop ae To suddenly stop taking a steroid may result in a sudden drop in the blood pressure from a loss in fluid volume associated with adrenal crisis. Clients should be warned not to abruptly stop taking the medication. Corticosteroids can lower the amount of potassium in the body so the client should eat more potassium-rich foods. Weight gain is an expected effect of corticosteroid therapy; clients should regularly keep track of their weight. Normally corticosteroid medications are taken with breakfast. Ref #2254 The nurse is caring for a client diagnosed with anemia and confusion. Which task could the nurse assign to the unlicensed assistive person (UAP)? Test UAP can perform routine tasks that have known or expected outcomes because these tasks typically do not require nursing judgment or decision- making. Any nursing intervention that requires independent, specialize nursing knowledge, skill or judgment cannot be assigned to UAP. Ref #1374 The parents of a 5 month-old report that the infant has "vomited nine times in the past six hours." Based on this information, the nurse should observe for which fluid and electrolyte imbalance? Metabolic alkalosis Vomiting results in a loss of acid from the stomach. Prolonged vomiting results in excess loss of acid and leads to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse. Hemoconcentration due to fluid loss may occur, but is not the best answer because it does not answer the question about an imbalance. Ref # 1626 A client who is two days postop, has these vital signs: blood pressure of 120/70, heart rate of 110 BPM, respiratory rate of 26, and a temperature of 100.4 F (38 C). The client suddenly becomes profoundly short of breath (SOB) and the skin color becomes grayish in color. Which assessment should the a nurse do first based on the client's change in condition? Auscultate for diminished breath sounds The findings suggest pulmonary embolus as a result of a piece of a clot in the legs that has broken off. Thus, the breath sound will most likely be diminished or absent in the lung where the embolus lodged. Ref #1494 The nurse is caring for a child diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis). The nursing care plan should be based on the knowledge that this child is at risk for developing what complication? Coronary artery aneurysm Kawasaki disease affects the mucus membranes, lymph nodes, walls of the blood vessels and the heart. It can cause inflammation of the arteries, especially the coronary arteries of the heart, which can lead to aneurysms and possible heart attack in the child. Ref #1592 The nurse is caring for a client who is experiencing a hypertensive crisis. The priority assessment in the first hour of care after admission to the critical care unit should focus on which factor? Cognitive function The organ most susceptible to damage in hypertensive crisis is the brain, due to rupture of the cerebral blood vessels. Neurologic findings must be closely monitored. KEYWORDS hypertension, brain, cognitive assessment ef #2447 A community health nurse has been caring for a 16 year-old who is 22- weeks pregnant with a history of morbid obesity, asthma and hypertension. Which of these lab reports need to be communicated to the health care provider as soon as possible? Magnesium 0.8 mEq/L (0.33 mmol/L) and creatinine 3 mg/dl (265.26 umol/L) the magnesium is low (1.5-2.5) and the creatinine is high, indicating acute renal failure - this is the highest priority Ref #1914 A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point? Administration of thyroid hormone will prevent complications Early identification (ideally before 13 days-old) and continued treatment with levothyroxine (thyroid hormone replacement) corrects hypothyroidism in newborns, preventing problems. If undetected and untreated, hypothyroidism can result in poor growth and weight gain, slow heart rate, low blood pressure, and babies who are unusually quiet; the child will be at risk for permanent brain damage and intellectual disabilities. Approximately one in every 4000 babies is born with hypothyroidism. Ref #1781 The nurse assesses a full-term, 30 hour-old newborn and reviews its lab results. The nurse knows that the first-time mother is Rh negative and is breastfeeding exclusively. Which of these findings is a priority to report to the health care provider? Serum bilirubin of 11 mg/dL (188 mmol/L) But for a full-term infant who is 30 hours-old, a total serum bilirubin level of 11 mg/dL (188 mol/L) is high, which is why this is the priority finding to report to the health care provider. Ref # 1286 A nurse is caring for a postoperative client who develops evisceration of the abdominal incision. Which intervention should the nurse implement first to prevent additional complications? Cover the wound with a sterile saline-soaked dressing When evisceration occurs, the wound should first be quickly covered by sterile saline soaked dressings. This prevents tissue damage and drying of the area until a surgical repair can be done. The other interventions are also appropriate, though the call to the provider should occur immediately, as this is a medical emergency. Ref #3720 The client needs to be moved up in bed. The client is able to partially assist and weighs 135 pounds. Which action by the nursing staff best supports an awareness of ergonomics and safe client handling? (Select all that apply.) high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressure associated with diving could cause the lung to collapse again. Ref #1523 The nurse is teaching effective stress management techniques to a client one hour before surgery. Which of these actions should the nurse recommend? Deep breathing is a reliable and valid method for stress reduction and can be taught and reinforced in a short period of time preoperatively. The other approaches require more time and repetition over time Ref #1296 The nurse is assigned to a client newly diagnosed with active tuberculosis (TB) and a productive cough. Which of these interventions would be a priority for the nurse to implement? The client would be placed on airborne precautions because this bacteria can be suspended in the air for long periods of time and may be carried for long distances on air currents. Any hospital employee entering the room would need to wear a disposable micron mask or disposable particulate respirator (N-95, for example). The Centers for Disease Control and Prevention (CDC) state that visitors can wear surgical masks Ref #2338 The nursing team listens to a change-of-shift report and then the RN determines that the unlicensed assistive person (UAP) can measure vital signs for all clients except the 80-year-old female diagnosed with middle-stage Alzheimer's disease. What information mentioned in the report suggests the registered nurse should personally follow up and assess the client with Alzheimer's disease? Ref #1418 The nurse and family members, who will be providing care at home, are discussing the client's continuing care needs after discharge to home. Which of these aspects of the discharge planning evaluation should receive priority consideration? Family members must be willing and able to provide the required care at the times needed and understand the client's health care needs before the client is discharged home. Ref #2135 A client diagnosed with testicular cancer has undergone a unilateral orchiectomy. The client expresses fears about his prognosis prior to discharge. What information would the nurse want to include when helping the client better understand this type of cancer? Testicular cancer has a five-year survival rate of 95% with early With aggressive treatment and early detection/diagnosis the cure rate is 90%. The other options are incorrect information. After unilateral orchiectomy, the remaining testicle can produce adequate sperm for fertility and impotence is unlikely. In bilateral orchiectomy, fertility is lost, so sperm banking prior to surgery is recommended. Dissection of lymph nodes for surgical cancer treatment may cause nerve injury, which would increase the risk of impotence. Ref #1737 During the change-of-shift report, the assigned nurse notes a client of the Catholic religion is scheduled to be admitted for the delivery of a ninth child. Which comment made by a nurse indicates an attitude of prejudice? “All those —aE Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to have objectionable qualities. Prejudice refers to preconceived ideas, beliefs, or opinions about an individual, group or culture that limit a full and accurate understanding of the individual, culture, gender, race, event or situation. Ref #4348 The client is a new admission diagnosed with Alzheimer's disease (AD). The nurse reviews all drugs (including complementary & integrated health therapies) routinely taken at home with a family member. Which of the following treatments would be a concern for the nurse? Coconut oil no scientific evidence that coconut oil is safe and effective or prevents cognitive decline. Ref #1495 The nurse is providing discharge teaching to the parents of a 15 month- old child diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis). The child has received immunoglobulin therapy. Which instruction point would be appropriate to include during the discussion? The measles, mumps and rubella vaccine should be delayed he MMR vaccine contains three live attenuated viruses and should be delayed until the child's immune system recovers from this treatment. Ref #1266 A client has just returned to the medical-surgical unit postop for a segmental lung resection. After assessing the client, which is the first action the nurse should take? Suction excessive tracheobronchial secretions This type of surgery involves removing a bronchovascular segment of a lobe. It is typically used to remove small, peripheral lung tumors. Surgical manipulation during this procedure, along with anesthesia, can increase mucus production and lead to airway obstruction, which is why the nurse may need to suction the client if there are excessive secretions Ref # 1802 A nurse is teaching an older adult client to use a metered-dose inhaler (MDI) and is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What should the nurse recommend to improve the delivery of the medication? Add a spacer device to the MDI canister Use of a spacer is especially useful with older adults because it allows more time to inhale and requires less eye- hand coordination. If the client is not using the MDI properly, the medication can get trapped in the upper airway with an outcome of a dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth. There is an order for a 25-year-old client, who is unresponsive after suffering a traumatic brain injury, to be transferred from the hospital to a long-term care facility (LTC) today. To which staff member should the charge nurse assign this client? an The RN is responsible for facilitating continuity of care for clients and their families during the transfer from one health care setting to another. The transfer to a LTC facility often requires referrals and coordinating information from many different providers about treatments, therapies and medications. Which is the appropriate injection site to give an influenza vaccine to an adult? Ref #2225 A nurse, who is assigned for five days to a client who has exhibited manipulative behaviors, becomes aware of feeling reluctance to interact with the client. The nurse should take what action next? Discuss the feelings of reluctance with an objective peer or supervisor within the next 24 hours The nurse who experiences stress in a therapeutic relationship can gain objectivity through discussion with other professionals. The nurse may wish to have a peer observe the nurse-client interactions with this client for a shift and then have a debriefing of positive and negative actions. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship in positive and negative ways. Ref #1944 A nurse, during an assessment of a day-old newborn, notices that the breasts are enlarged bilaterally with a white, thin discharge. What action should the nurse perform next Record the findings while thinking that they are “normal” Newborn infants of both sexes may have engorged breasts and may secrete milk during the first few days to weeks after birth. Ref #1840 A client is admitted for first- and second-degree burns on the face, neck, anterior chest and hands. What should be the nurse's priority action? Due to the location of the burns, the client is at risk for the development of upper airway edema and subsequent respiratory distress. The other options are correct, but the priority is to assess breathing and manage the airway. The client with any signs of airway injury will be intubated and given 100% oxygen. Ref #1460 The nurse is caring for a child who is diagnosed with coarctation of the aorta. Which finding would the nurse expect when assessing the child? Bounding Ref #2461 A 35 year-old female client talks to the nurse in her health care provider's office about her new diagnosis of uterine fibroids. What statement by the woman is incorrect and indicates that more teaching is needed? "Even if the fibroids cause no problems, they will still need to be taken out." Fibroids that cause no findings may require only "watchful waiting.” The client may just need pelvic exams or ultrasounds every once ina while to monitor the fibroid's growth. Treatment for the symptoms of fibroids (such as painful menses and heavy periods) may include oral contraceptives, IUDs, iron supplements to prevent or treat anemia (due to heavy periods), NSAIDs for cramps or pain or even short-term hormonal therapy to help shrink the fibroids. Surgical removal using myomectomy or hysterectomy is usually reserved as a final alternative after other treatment options have failed to provide adequate relief. In addition, concerns about loss of fertility with this diagnosis and its treatment may be important to this client who is still in her childbearing years. Ref #5270 The nurse is providing care for a school-age child with cerebral palsy who has recently been admitted for repeated episodes of aspiration pneumonia and weight loss. During a discussion with the child's caregivers, which statement a the nurse best demonstrates client advocacy? "It is possible that we may need to discuss Ref #2037A woman in labor calls a nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse should act based on knowledge that fetal monitoring must now assess for what complication? Variable decelerations When the membranes rupture, there is increased risk initially of cord prolapse if the head is at a minus level. Fetal heart rate patterns may show variable decelerations, which require immediate nursing action to reposition the client, apply oxygen and notify the health care provider. Ref #1973 The nurse is caring for a toddler who is diagnosed with an infection and whose temperature is 103 F (39.4 C). Which intervention would be most effective in a the client's temperature and promoting comfort? Administer Ref # 4420 The 72 year-old client has an estimated blood loss of 600 mL during a gastric resection. The surgeon orders two units of packed cells (PC) to be administered in the post anesthesia care unit. During the administration of the second unit of PC, the nurse notes the following findings: hypertension, a bounding pulse, and increasing dyspnea. What is the probable cause of these findings? Circulatory overload Older clients are at risk for circulatory overload, especially when solutions are administered rapidly. Hypertension with a bounding pulse and dyspnea are key signs of fluid overload. The nurse should stop the infusion and contact the health care provider Ref #4416 Following a surgical procedure, a pneumatic compression device is applied to the adult client. The client reports that the device is hot and the client is sweating and itching. Which of the following steps should the nurse take? Select all that appl Ref #1825 The parents of a 6 year-old child who normally enjoys school tells a nurse that the child has not been doing well since a grandmother died two months ago. Which statement most accurately describes thoughts on death and dying at this age? Personification of death is typical of this developmental level. Recall that this age is at the end of the preschool period where magical thinking for the animation of inanimate objects is present. Ref #2450 An internal disaster has occurred at the hospital. The charge nurse is asked to review client acuity and determine which clients can and cannot be discharged. Which of these clients should not be discharged? young adult in the second —E—eOESS An overdose of acetaminophen requires close observation for several days. Also, the duration of the course of treatment for the oral antidote N-acetylcysteine (NAC) is approximately 72 hours. NAC will protect the liver if given within 8 hours after an acute ingestion, least stable Ref # 1761A nurse is preparing a client for discharge following inpatient treatment for pulmonary tuberculosis (TB). Which of these instructions should be given to the client? Continue taking medications as prescribed Early cessation of treatment may lead to development of drug resistant TB. Active TB is usually treated with a combination of four different antibiotics (isoniazid, rifampin, ethambutol and pyrazinamide) and can take anywhere from 6 to 12 months to completely kill the bacteria Ref #1812 The parents of a 7 year-old tell the nurse that their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? Ref #1812The parents of a 7 year-old tell the nurse that their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? The ethical sense and feelings of justice are developing developing a sense of justice and a desire to do what is right. At 7, children are increasingly aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment. This age group, 6 to 12 years of age, is called the school-aged group. Ref #1910 The nurse witnesses a client who is exhibiting seizure activity. Which observation is the priority and will be used to help determine _— oe ae during the seizure event, the nurse needs to observe the client's facial expression, muscle tone, movements (jerking or twitching, for example), the part(s) of the body involved, and any automatic or repeated movement (lipsmacking, chewing, swallowing, for example. Ref #2096 Two hours after receiving the first does of lithium, the client reports fine hand tremors. What is the nurse's best explanation for these findings? "These Ref #2368 At the client's request, the nurse performs a fingerstick to test the client's blood glucose and the results are 322 mg/dL (17.89 mmol/L). Following standing orders, the nurse administers 3 units of insulin lispro at 11 am. When does the nurse anticipate the insulin lispro will begin to act? 11:15 am The onset of action and peak for insulin lispro (Humalog), which is a rapid-acting insulin, is 10 to 15 minutes after administration. This type of insulin will peak in about 1.5 to 2.5 hours. It is designed to cover meals and lower high blood sugar readings. MMMM MMA AMMA AMM MATA AAA Ref #2430 A primigravida in the third trimester is hospitalized with a diagnosis of preeclampsia. The nurse determines that the client’s blood pressure has a trend of increased readings. Which action should the nurse take first? Have the client turn The priority action in this situation is to turn the client to the left side to decrease pressure on the vena cava and promote adequate circulation to the placenta and kidneys. Urine protein level and output should be checked with each voiding. Temperature should be monitored every four hours or more often if indicated, but no data in the stem supports a check of temperature. The deep tendon reflexes are checked as needed especially when magnesium drips are being infused. Ref #4347 The nurse is assessing a client who had a stroke and underwent a carotid endarterectomy. The client is now experiencing motor deficits and communication problems. Which of the following findings requires immediate follow-up? Increased pulse and decreased blood pressure Increased pulse and decreased blood pressure may indicate hemorrhage, which is a complication of the surgery. Ref #4371The client is admitted to the hospital with a diagnosis of exacerbation of right ventricular heart failure. Which of the following findings would the nurse xpect with right-sided heart failure? (Select all that apply.)