Marty’s Kaplan NCLEX Remediation – Flashcards
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The nurse in the critical care unit reviews postoperative care for a patient after a supratentorial craniotomy. It is MOST important for the nurse to instruct the aide to do which of the following? 1."Put an icepack on the patient's eye and a cool compress on his forehead" 2."Determine how much pain the patient is experiencing on a scale of 1 to 10 and report back to me." 3."Keep the head of the bed flat, with the patient lying on his back." 4."If the patient starts to have a seizure, place a padded tongue blade in his mouth right away and call for help."
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1."Put an icepack on the patient's eye and a cool compress on his forehead" Explanation: appropriate to delegate to unlicensed assistive personal (UAP) application of heat or cold to a closed inflated or painful area patient may have periorbital edema and burning after the surgery; ice will help with vasoconstriction and decrease of edema; cool compress is a comfort measure.
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The nurse supervises the staff caring for four clients receiving blood transfusions. Which client should the nurse see ?rst? 1. A client complaining of a headache. 2. A client vomiting. 3. A client complaining of itching. 4. A client with neck vein distention.
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2. A client vomiting. Explanation Strategy: Determine the least stable client. (1) febrile reaction; symptoms include fever, chills, nausea, headache; treatment is to stop blood and administer aspirin (2) CORRECT - hemolytic reaction; most dangerous type of transfusion reaction; symptoms include nausea, vomiting, pain in lower back, hematuria; treatment is to stop blood, obtain urine specimen, and maintain blood volume and kidney perfusion (3) allergic reaction; symptoms include urticaria, pruritus, fever; treatment is to stop blood, give diphenhydramine, and administer oxygen (4) circulatory overload; treatment is to stop blood, position in an upright position, and administer oxygen
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The client is brought to the emergency department by friends who state, "Our friend has been hanging with the wrong crowd. We are worried about drug use."The nurse notes that the client stares blankly and has an unsteady gait, stiff muscles, and eyes that are moving rapidly side to side and up and down. The nurse plans care. Which is most important for the nurse to anticipate? 1. Increased adventitious breath sounds. 2. Decreased blood pressure, temperature, and pulse. 3. Aggressive behaviors. 4. Nausea, vomiting, abdominal cramping.
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3. Aggressive behaviors. Explanation Strategy: The topic of the question is unstated. 1) client's symptoms indicate phencyclidine piperidine (PCP) intoxication; breath sounds important to assess with any new client but not priority; respiratory arrest can occur with PCP overdose 2) with PCP, blood pressure, temperature, and pulse are expected to increase, not decrease; overdose could even lead to a hypertensive crisis; hyperthermia can also occur 3) CORRECT - symptoms of blank stare, rigid muscles, ataxia, and nystagmus that is both vertical and horizontal indicate probable phencyclidine piperidine (PCP) intoxication; another name for PCP is angel dust; aggression in all forms is another symptom that manifests with PCP; can take the form of assault, belligerence, impulsiveness, and/or suicidality, and is very often bizarre in nature; often occurs in unpredictable outbursts; interventions should be planned to monitor for aggressive symptoms, to prevent them, and to manage them should they occur; decreasing stimuli, securing potential injurious objects in the environment, having chemical and physical restraints (along with suf?cient staff) available are all measures that can be planned in advance and utilized; PCP is used by itself, but is also frequently used as an adulterant with other drugs 4) no particular association with PCP; these are symptoms that occur with opiate withdrawal
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The home care nurse visits an elderly client diagnosed with depression. The client's daughter states that it is dif?cult for her mother to complete activities of daily living. It is MOST appropriate for the nurse to suggest which of the following? 1. Medicate the client before beginning activities. 2. Write a schedule of activities and allow extra time for the client to complete the activities. 3. Assist the client with all grooming activities. 4. Provide frequent forceful directions to keep the client focused on the activities.
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2. Write a schedule of activities and allow extra time for the client to complete the activities. Explanation Strategyz'MOST appropriateiindicates discrimination is required to answer the question. 1) will not increase client's independence 2) CORRECT - communicates to client what is expected and then gives herthe time to accomplish her tasks; depression causes decreased attention span and concentration 3) maintain client's independence by allowing her time to complete activities 4) communicating clear expectations and giving client time to complete activities are more useful
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The psychiatric home care nurse plans visits for the day. The weather report states that temperatures will be around 95 degrees. Which client should the psychiatric home health nurse see ?rst upon leaving the of?ce? 1. A client diagnosed with chronic schizophrenia who is frequently noncompliant with medications. The client lives with parents in a house without air-conditioning and is a 10-minute drive from the of?ce. 2. A client diagnosed with obsessive-compulsive disorder who is taking clomipramine. The client lives with a sibling, has a psychiatrist who is on vacation, and is a 30-minute drive from the of?ce. 3. A client diagnosed with bipolar disorder who lives with the spouse. The client was discharged from the inpatient unit 1 week ago after being started on lithium carbonate, and is a 45-minute drive from the of?ce. 4. A client diagnosed with depression who lives alone. The client likes to garden, is taking amitriptyline for depression, and is a 20-minute drive from the of?ce.
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3. A client diagnosed with bipolar disorder who lives with the spouse. The client was discharged from the inpatient unit 1 week ago after being started on lithium carbonate, and is a 45-minute drive from the of?ce. Explanation Strategy: Determine the MOST unstable patient. (1.) may need reminders about photosensitivity side effect of antipsychotics and about appropriate precautions to take (2.) may need reminders about photosensitivity side effect of clomipramine and about appropriate precautions to take; absence of psychiatrist can be especially stressful for this tightly controlled client; the nurse should strive for congruence between expected and actual arrival time (3.) CORRECT - potentially the least stable client due to recent hospitalization and taking Lithium; response to the lithium needs to be monitored, including side effects; a particular concern at this time, because of the weather, is to be certain client is maintaining adequate sodium levels as well as drinking appropriate amounts of water in orderto prevent lithiumtoxicity (4.) may need reminders about photosensitivity side effect of amitriptyline and about appropriate precautions to take
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The nurse cares for a client receiving lithium 300 mg PO TID. The nurse identi?es which symptoms as early signs of toxicity? Select all that apply. 1. Mild thirst. 2. Nausea and vomiting. 3. Coarse hand tremor. 4. Ataxia. 5. Slurred speech. 6. Muscle weakness.
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2. Nausea and vomiting 5. Slurred speech. 6. Muscle weakness. Explanation Strategy: Think about each answer. 1) lithium is an antimanic used to treat bipolar disorder; mild thirst is expected side effect; other side effects include ?ne hand tremor, polyuria 2) CORRECT—early sign of toxicity; withhold medication, obtain blood lithium level, dose will be re-evaluated 3) indicates advanced sign of toxicity; other indications include persistent GI upset, mental confusion, incoordination 4) indicates severe toxicity 5) CORRECT - also will see diarrhea, thirst, and polyuria 6) CORRECT - withhold medication and obtain blood lithium level
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During a regional outbreak of the ?u, a nursing assistant reports to work on the oncology unit. The nurse notes that the nursing assistant is coughing and has a runny nose, and the nurse assistant admits to having an elevated temperature. The nursing assistant tells the nurse that the nursing assistant has no sick leave and is the breadwinner of the family. Which of the response by the nurse is MOST appropriate? 1.'Did you take a ?u shot? 2. 'You may work at the desk and help the unit secretary with the charts.= 3. 'I will call one of the other units where clients are less vulnerable" 4. 'l'm sorry, but you will have to go home."
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4. 'l'm sorry, but you will have to go home." Explanation Strategyz'lilOST appropriateiindicates discrimination is required to answer the question. 1) should take an annual ?u shot; not relevant to this conversation 2) in?uenza is spread by droplets; even though nursing assistant will not be caring for clients, will still come in contact with other staff members; clients in oncology are immunocompromised 3) hospital is full of immunocompromised clients 4) CORRECT—during community outbreaks of the ?u, should exclude staff with febrile infections from caring for high risk clients
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A young adult is admitted to the hospital with a diagnosis of catatonic schizophrenia. When the nurse places the patient's hand over his head, it remains in that position. The nurse identi?es that this is 1. conversion hysteria. 2. waxy ?exibility. 3. dystonic reaction. 4. neurasthenia.
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2. waxy ?exibility. Explanation Strategy: Think about each answer. 1) motor or sensory neurological symptoms with no identi?able physiological cause 2) CORRECT—abnormal posturing; catatonic schizophrenia causes sudden loss of animation and a tendency to remain motionless in a stereotyped position 3) muscle spasms of any muscles ofthe body 4) unexplained chronic fatigue with nervousness, anxiety, and irritability
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The nurse cares for the client diagnosed with anorexia nervosa. Which client statement best indicates to the nurse improvement in the client's condition? 1. "I realize hit too thin and that it's not good for me, but I don't know how to eat more without getting fat." 2. The client requests a sanitary pad or tampon, saying, "I didn't think to bring anything with me; l haven't had a period for months." 3. "Either the food here is getting better or my appetite is coming back, but lately I ?nd myself looking forward to meals." 4. The client asks for a discharge date to be delayed, saying, "I don't feel ready yet to deal with the tension in my family and their demands for perfection."
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2. The client requests a sanitary pad or tampon, saying, "I didn't think to bring anything with me; l haven't had a period for months." Explanation Strategy: "BEST" indicates that discrimination is required to answer the question. 1) not best indicator, although does at least verbally manifest insight and openness to and readiness for client teaching 2) CORRECT - amenorrhea, a de?nite physiologic symptom, is resolved; menstruation is usually absent in anorexic women; its return is a measure ofsuccessful treatment; DSlil-IV-TR describes amenorrhea as a criteria measure forthe diagnosis of anorexia, and de?nes it as the absence of at least three consecutive menstrual cycles in a postmenarchal female 3) not best indicator, although does at least verbally convey interest and willingness to eat more, which will result in weigh gain; however, may be said to please nurse, to appear cooperative and motivated, when in fact that is not the case; also, anorexia nervosa has little to do with appetite and more to do with fear of obesity and of losing control over food intake 4) not best indicator, although does convey recognition of the family component to her condition and some insight
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The nurse in the emergency department (ED) cares for a client who states that her partner became angry with her and began hitting her. Which of the following actions should the nurse take FIRST? 1. Encourage the client to verbalize her feelings. 2. Assess for physical trauma. 3. Provide privacy for the client during the interview. 4. Assist the client to identify a support system.
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2. Assess for physical trauma. Explanation Strategy: Assess before implementing. 1) it is very important for the nurse to encourage the client to verbalize about the incident and relationship; assess ?rst 2) CORRECT - assess for trauma to determine physical needs 3) appropriate action; assess before implementing 4) important assessment; take care of the physical before psychosocial needs
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The nurse assists forensic investigators in the emergency department with evidence preservation and collection after a client's death. Which actions by the nurse are considered professionally negligent? Select all that apply. 1. The nurse documents time of events. 2. The nurse cuts through holes in fabric to remove client's shirt. 3. The nurse places paper bags over the client's hands. 4. The nurse gives the client's clothing to the family. 5. The nurse places evidence in a plastic bag. 6. The nurse removes intravenous lines before the medical examiner arrives.
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2. The nurse cuts through holes in fabric to remove client's shirt. 4. The nurse gives the client's clothing to the family. .5. The nurse places evidence in a plastic bag. 6. The nurse removes intravenous lines before the medical examiner arrives. Explanation Strategy: Determine the outcome of each answer choice. Is the answer choice considered negligent behavior by the nurse? 1) appropriate and necessary; nurse should document description of all wounds, mechanism of injury, time of events, and collection of evidence 2) CORRECT — nurse should not cut through or disrupt any tears, holes, blood stains, or dirt present on clothing 3) appropriate and necessary; only paper bags should be used; preserves evidence on hands and under ?ngernails 4) CORRECT — clothing should not be given to families; clothing may contain evidence 5) CORRECT — negligent action; plastic bags are not used because they retain moisture; moisture may promote mold and mildew formation, which can destroy evidence 6) CORRECT — all tubes and lines must remain in place for medical examiner
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The nurse plans staff assignments. Which clients are appropriate to assign to the LPN/LVN? Select all that apply. 1. A client who is 48 hours post surgery and requires heparin 5,000 units SQ every 8 hours. 2. A client who fell in the long-term care facility and sustained an orbital fracture yesterday. 3. A client who sustained a gunshot injury and has a chest tube to water-seal drainage. 4. A client who was admitted with a bowel obstruction and is now passing soft-formed stools. 5. A client who is 1 day post Iaminectomy and is receiving morphine sulfate via PCA pump.
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1. A client who is 48 hours post surgery and requires heparin 5,000 units SQ every 8 hours. 4. A client who was admitted with a bowel obstruction and is now passing soft-formed stools. Explanation Strategy: Assign the LPN/LVN to stable clients with expected outcomes. 1) CORRECT — post-surgical thrombosis prophylaxis, stable client, unchanging orders 2) inappropriate because of possible increased intracranial pressure, requires RN assessment 3) inappropriate because of a need for RN assessment for complications 4) CORRECT— stable client with unchanging orders, no assessment needed 5) requires frequent RN assessment, potentially changing condition
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The 7-year-old child is seen in the clinic with a diagnosis of pituitary dwar?sm. Which clinical manifestation is the nurse most likely to observe? 1. Abnormal body proportions. 2. Early sexual maturation. 3. Delicate features. 4. Coarse, dry skin.
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3. Delicate features. Explanation Strategy: Determine how each answer relates to dwar?sm. 1) see small size but normal body proportions 2) usually have delayed sexual maturity 3) CORRECT - appear younger than chronological age 4) usually see ?ne, smooth skin
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The nurse cares for a client admitted with a diagnosis of a stroke and facial paralysis. Nursing care should be planned to prevent which complication? 1. Inability to talk. 2. Loss of the gag re?ex. 3. Inability to open the affected eye. 4. Corneal abrasion.
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4. Corneal abrasion. Explanation Strategy: Think about each answer. (1) may occur, but nursing care cannot prevent it (2) may occur, but nursing care cannot prevent it (3) may occur, but nursing care cannot prevent it (4) CORRECT - client will be unable to close eye voluntarily; when facial nerve (cranial nerve Vll) is affected, the lacrimal gland will no longer supply secretions that protect eye
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The nurse on a psychiatric unit of the hospital declines the client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior? 1. Allowing the client to use abusive language will undermine the authority of the nurse. ' 2. Responding in kind to a client who uses abusive language will perpetuate the behavior. 3. Abusive language is one of the behaviors symptomatic of the client's illness. 4. The nurse should model acceptable behavior and language for all clients.
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3. Abusive language is one of the behaviors symptomatic of the client's illness. Explanation Strategy: Think about each answer. 1) inaccurate; doesn't undermine authority of staff 2) shows lack of understanding of cause for client's behavior 3) CORRECT - symptoms will respond to treatment 4) suggests that using acceptable language will change client's behavior; shows lack of understanding of client's behavior
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If the nurse cares for a client with ataxia, which action is most important? 1. Supervise ambulation. 2. Measure the intake and output accurately. 3. Consult the speech therapist 4. Elevate the foot of the bed.
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1. Supervise ambulation. Explanation Strategy: Think about each answer. (1) CORRECT — client's coordination is poor, the only relevant nursing action is to supervise ambulation (2) unnecessary (3) not relevant ( 4) not relevant
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Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness? Select all that apply. 1. Tremors. 2. Elevated temperature. 3. Depression. 4. Noctumal leg cramps. 5. Night sweats. 6. Decreased concentration.
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1. Tremors. 2. Elevated temperature. 4. Noctunal leg cramps. Explanation Strategy: Think about symptoms of withdrawal from alcohol. 1) CORRECT - symptom of withdrawal 2) CORRECT - symptom of withdrawal 3) seen in a depressed client 4) CORRECT - symptom of withdrawal 5) seen in clients with tuberculosis, leukemia, or other infections 8) seen in a depressed client
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During the client's fourth stage of labor, the nurse should palpate the client's fundus in which location?
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Explanation: uterus is normally contracted and palpable at the umbilicus
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A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors? 1. Projection and displacement. 2. Sublimation and internalization. 3. Rationalization and intellectualization- 4. Reaction formation and symbolization.
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1. Projection and displacement. Explanation Strategy: Think about each answer. Both parts of the answer must be correct 1) CORRECT - projection (attributing one's thoughts or impulses to another) and displacement (shifting of emotion concerning person or object to another neutral or less dangerous person or object) 2) sublimation (diversion of unacceptable drives into socially acceptable channels) and internalization (incorporation of someone else's opinion as one's own) 3) rationalization (attempt to make behavior appear to be the result of logical thinking) and intellectualization (excessive reasoning or logic used to avoid experiencing disturbing feelings) 4) reaction formation (development of conscious attitudes and behavior patterns into opposite of what one really wants to do) and symbolization (something represents something else); symbolization is involved in phobias; reaction formation not a defense mechanism used in phobias
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The nurse performs range-of-motion (ROM) exercises for an elderly client recently immobilized. The nurse identi?es which statement as correct about range-of-motion? 1. Passive ROM exercises increase muscle strength. 2. A full ROM must be completed for the elderly client. 3. Exercises should be completed to the point of discomfort 4. ROM assists the elderly to cany out activities of daily living (ADLs).
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4. ROM assists the elderly to carry out activities of daily living (ADLs). Explanation Strategy: Think about each answer. 1) inaccurate statement 2) full ROM may not be needed or accomplished without discomfort for an elderly client; ROM may be limited 3) should not be done to point of discomfort 4) CORRECT — emphasis should be on ROMS that support ADLs
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The nurse prepares an older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response should be based on which explanation? 1. The health care provider is able to directly observe the renal pelvis. 2. An IVP assesses glomerular ?ltration rate. 3. The health care provider is able to examine the urinary tract by x—ray. 4. Medication is injected into the urinary system.
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3. The health care provider is able to examine the urinary tract by x—ray. Explanation Strategy: Think about each answer. (1) would involve invasive procedure, such as cystoscopy (2) not primary purpose (3) CORRECT - x—rays of entire urinary tract taken, evaluates kidney function (4) not primary purpose
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Which statement should be documented by the nurse to re?ect a client's emotional adjustment to being hospitalized in the intensive care unit? 1. 'The client is unable to complete activities of daily living without assistance." 2. 'The client appears to be depressed and anxious regarding impending surgery. 3. 'The client constantly calls for nurses and cries uncontrollably." 4. 'The family is unable to visit more often than once a week because they live far away."
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3. 'The client constantly calls for nurses and cries uncontrollably." Explanation Strategy: Good documenting is the objective. (1) does not describe emotional adjustment (2) draws conclusions without supporting data (3) CORRECT - gives an objective description of the client's behavior and affect ( 4) describes the client's family, not the client
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The health care provider orders mannitol for a client with a closed head injury. Which should the nurse recognize as the desired response to this medication? 1. The blood pressure increases to 150/90. 2. Urinary output increases to 175 mL/hour. 3. There is a decrease in the level of activity. 4. There is an absence of ?ne tremors of the ?ngers.
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2. Urinary output increases to 175 mL/hour. Explanation Strategy: Think about each answer. (1) increase in blood pressure is not desired (2) CORRECT - mannitol is an osmotic diuretic; increases urinary output and decreases intracranial pressure (3) does not indicate desired effect of medication (4) does not indicate desired effect of medication
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The 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment ?ndings? Select all that apply. 1. A pincer grasp. 2. Sitting with support. 3. Tripling of the birth weight. 4. Presence of the posterior fontanelle. 5. Playing peek-a-boo. 6. Rolling from back to abdomen.
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2. Sitting with support. 5. Playing peek-a-boo. 6. Rolling from back to abdomen. Explanation Strategy: Think of behaviors of a 6-month-old child. 1) Present at 9 months of age. 2) CORRECT - Should occur at this age. 3) Should happen at 1 year. 4) Posterior fontanelle closes at 2-3 months of age. 5) CORRECT - Should be present at this time. 6) CORRECT - Should be able to do this.
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The nurse recognizes which symptoms are early signs of lithium toxicity? Select all that apply. 1. Fine motor tremors. 2. Involuntary muscle movements. 3. Seizures. 4. Nausea and vomiting. 5. Orthostatic hypotension. 6. Diarrhea.
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1. Fine motor tremors. 4. Nausea and vomiting 6. Diarrhea. Explanation Strategy: Think of lithium toxicity. 1) CORRECT - A symptom of toxicity. 2) Associated with antipsychotics. 3) Associated with severe lithium toxicity. 4) CORRECT - An early symptom. 5) Associated with antipsychotics. 6) CORRECT — An early symptom. 2. Involuntary movements. 3. Seizures. 4. Nausea and 5. Orthostatic hypotension. 6. Diarrhea.
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In preparing a teaching plan regarding colostomy irrigations, the nurse should include which information? 1. The colostomy needs to be irrigated at the same time every day. 2. irrigate the colostomy alter meals to increase peristalsis. 3. Insert the catheter about 10 inches into the stoma. 4. The solution should be very warm to increase dilation and ?ow.
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1. The colostomy needs to be irrigated at the same time every day. Explanation Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) CORRECT - colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination (2) colostomy should be irrigated only once a day (3) catheter should never be inserted more than 4 inches. (4) solution should be at body temperature; increasing the temperature does not make irrigation more ef?cient
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The nurse cares for clients in the outpatient clinic. In which order does the nurse return messages about these situations? Place the answers in order of priority. All options must be used. The umbilical cord of the 5-day-old is soft and draining exudate. The circumcision site of the 3-day-old is slightly swollen. The "soft spot" on the head of the 4-day-old feels slightly elevated when asleep. When bed is bumped, a 2-day-old rapidly extends the extremities.
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The "soft spot" on the head of the 4-day-old feels slightly elevated when asleep. The circumcision site of the 3-day-old is slightly swollen. The umbilical cord of the 5-day-old is soft and draining exudate. When bed is bumped, a 2-day-old rapidly extends the extremities. Explanation Strategy: Identify any normal behaviors. Identify the least stable infant to see ?rst. 1) ?rst: bulging fontanelle may indicate increased intracranial pressure and is most serious 2) second: circumcision should have yellowish exudate at this time, but swelling is not normal and may interfere with urination 3) third: umbilical cord should be dry and hard; draining indicates a possible infection and needs to be assessed 4) last describes the Moro Re?ex and is normal
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Which observation suggests to the nurse that the client has developed an Addisonian crisis? 1. Muscular weakness and fatigue. 2. Restlessness and rapid weak pulse. 3. Dark pigmentation of the skin. 4. Gastrointestinal disturbances and anorexia
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2. Restlessness and rapid. weak pulse. Explanation Strategy: Determine how each answer relates to Addisonian crisis (1) signs and symptoms of Addison's disease, but do not indicate a crisis (2) CORRECT - may be signs of shock related to an Addisonian crisis (3) signs and symptoms of Addison's disease, but do not indicate a crisis (4) signs and symptoms of Addison's disease, but do not indicate a crisis
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The health care provider inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker? 1. Increases the force of myocardial contraction. 2. Increases the cardiac output. 3. Prevents premature ventricular contractions (PVCs). 4. Prevents systemic overload.
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2. Increases the cardiac output. Explanation Strategy: Think about each answer. (1) action of cardiac glycosides such as digoxin (2) CORRECT - acts to regulate cardiac rhythm (3) action of antiarrhy'thmics such as quinidine (4) action of diuretics such as furosemide
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The child is in the early stages of nephrotic syndrome. The nurse discusses which dietary change with the parents? 1. Adequate protein, low sodium intake. 2. Low protein, low potassium intake. 3. Low potassium, low calorie intake. 4. Limited protein, high carbohydrate intake.
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1. Adequate protein, low sodium intake. Explanation Strategy: Think about each answer. 1) CORRECT - if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted 2) low protein contraindicated in clients with kidney disease 3) does not address protein need at all 4) may be appropriate only if the child cannot tolerate protein intake
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A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse should perform the procedure? 1. Insert the suction catheter 4 in into the tube. Apply suction for 30 seconds, using a twirling motion as the catheter is withdrawn. 2. Hyperoxygenate the client- Insert the suction catheter into the tube, and suction while removing the catheter in a back and forth motion. 3. Explain the procedure to the client. Insert the catheter gently while applying suction, and withdraw using a twisting motion. 4. Insert the suction catheter until resistance is met, and then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn.
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4. Insert the suction catheter until resistance is met, and then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn. Explanation Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) catheter is inserted until resistance is met; never suction longer than 10—15 seconds (2) use twirling motion when withdrawing catheter (3) suction is never applied when catheter is inserted ( 4) CORRECT - insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion
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The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for sugar and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason? 1. The renal threshold for glucose is elevated in the elderly. 2. Blood glucose monitoring is easier and less costly for clients to perform. 3. Urine testing for glucose provides false-positive readings. 4. Determination of the color on a reagent strip varies from person to person.
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1. The renal threshold for glucose is elevated in the elderly. Explanation Strategy: Think about each answer. 1) CORRECT - the level at which glucose starts to appear in the urine increases, leading to false-negative readings; results in elevated glucose levels 2) more expensive procedure 3) provides false-negative readings; may be negative from 0 to 180 (0-10 mmollL) mgldL 4) results are expressed as a percentage according to color change
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The toddler diagnosed with lead poisoning is admitted to the pediatric unit- The health care provider writes an order to encourage ?uids. Which ?uid is best for the nurse to offer to the toddler? 1. Milk. 2. Water. 3. Orange juice 4. Fruit punch.
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1. Milk. Explanation Strategy: Determine how each answer relates to lead poisoning. (1) CORRECT - milk contains calcium; calcium binds to lead and inhibits its absorption (2) good for ?uid replacement; does not relate to the lead poisoning (3) good for ?uid replacement; does not relate to the lead poisoning (4) good for ?uid replacement; does not relate to the lead poisoning
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The client, gravida 2 para 1, is admitted with hypertension. The client reports her wedding band is tight. The nurse assesses for which indications of mild pre-eclampsia? 1. Blurred vision and proteinuria. 2. Epigastric pain and headache. 3. Facial swelling and proteinuria. 4. Oliguria and hypertonic re?exes.
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3. Facial swelling and proteinuria. Explanation Strategy: Determine how each answer relates to pre—eclampsia. 1) only partially correct; blurred vision appears later, with severe preeclampsia 2) contains signs of eclampsia before a seizure 3) CORRECT - represents two of the three symptoms seen with pre-eclampsia; also includes hypertension 4) oliguria is seen later with severe preeclampsia
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The nurse cares for a 3-month old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action? 1. Offer the infant only clear liquids. 2. Make the infant NPO for 3 hours. 3. Feed the infant regular formula. 4. Maintain the infant NPO for 6 hours.
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2. Make the infant NPO for 3 hours. Explanation Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? 1) inappropriate 2) CORRECT - infant should be NPO 3 hours prior to the procedure 3) inappropriate 4) unnecessary for an infant to be NPO for 6 hours
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The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate? 1. The bowel preparation is incomplete. 2. The client ate something after midnight 3. This is an expected ?nding before this type of surgery. 4. The client passed the last stool left in the colon.
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1. The bowel preparation is incomplete. Explanation Strategy: Think about each answer. (1) CORRECT - colon should not have remaining soft stool (2) anything eaten after midnight would not appear as stool by the next moming (3) not expected; need to clean gastrointestinal tract for surgery ( 4) assumption; not substantiated
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The nurse cares for the postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing which physiological process? 1. Tissue injury after surgery decreases blood glucose. 2. Anesthesia acts to increase glycogen stores. 3. Being NPO inhibits normal blood glucose control. 4. Surgery often leads to insulin dependency.
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3. Being NPO inhibits normal blood glucose control. Explanation Strategy: Think about each answer. 1) inaccurate 2) inaccurate 3) CORRECT - temporary control by insulin is needed due to inability to control diabetes mellitus by diet and oral agents, surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of intravenous ?uids 4) inaccurate
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The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identi?es which type of play as characteristic of this age group? 1. Solitary play. 2. Parallel play. 3. Associative play. 4. Aggressive play.
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3. Associative play. Explanation Strategy: Picture a 4-year-old. 1) describes play for an infant 2) describes play for a toddler 3) CORRECT - this is the play that characterizes 4-year-olds 4) is not play but a behavior
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A client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for which changes? 1. The surface of the tongue. 2. Hemoglobin and hematocrit. 3. Skin surfaces in skin folds. 4. Changes in urine characteristics.
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1. The surface of the tongue. Explanation Strategy: Answer choices indicates a complication. (1) CORRECT - cephalosporin, long-tenn use of ceftriaxone sodium can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended (2) does not re?ect a problem with this medication (3) does not re?ect a problem with this medication (4) does not re?ect a problem with this medication
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The home care nurse visits a new parent and a 2-week-old infant. The client asks the nurse which solid foods to give the child ?rst. Which response does the nurse give? 1. Rice cereal is usually the ?rst solid food and is started around 4 to 5 months. 2. Strained fruits are well tolerated as the ?rst solid food, and infants like them. 3. Introduction of solid foods is not important at this time. 4. Solid foods are usually not started until the infant is around 6 months old.
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1. Rice cereal is usually the ?rst solid food and is started around 4 to 5 months. Explanation Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? 1) CORRECT - infants are less likely to be allergic to rice cereal than to any other solid food; usually started between 4 and 5 months of age; breast- fed infants may be started on solids even later 2) inaccurate 3) does not answer the parent's question 4) usually started between 4 and 5 months of age
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The nurse cares for a child diagnosed with pediculosis capitis (head lice) and is being treated with permethrin 1% cream rinse. The nurse should include which information when instructing the child's parents? 1. Apply the cream rinse every other day for 1 week. 2. Wash the child's clothing and personal belongings in soap and cool water. 3. Repeat the application of the cream rinse in 7 days if nits still present- 4. Comb the child's hair weekly with a nit comb.
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3. Repeat the application of the cream rinse in 7 days if nits still present- Explanation Strategy: Answers are implementation. Determine the outcome of each answer. ls it desired? (1) too frequent an application of the rinse (2) very hot water and dry for 20 minutes in the dryer (3) CORRECT - may be repeated 7 days after ?rst application (4) hair should be combed daily with a nit comb
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The nurse supervises nursing assistive personnel (NAP). Which tasks does the nurse delegate to the MAP? Select all that apply. 1. Apply an abdominal binder. 2. Prepare an antibiotic injection for the nurse. 3. lrrigate a client's fresh wound using sterile technique. 4. Determine the staging of a client's pressure ulcer. 5. Apply an elastic bandage. 6. Assist a client with use of a urinal.
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1. Apply an abdominal binder. 6. Assist a client with use of a urinal. Explanation Strategy: Nursing assistive personnel are assigned to clients requiring standard, unchanging procedures. 1) CORRECT — applying abdominal binder can be delegated to NAP; however, nurse is responsible for assessment of area where binder will be applied and client's comfort level after application 2) preparing injections cannot be delegated to NAP 3) wound irrigation cannot be delegated to NAP; however, in some settings, cleansing of chronic wounds using clean technique can be delegated to NAP 4) assessment and staging of pressure ulcer cannot be delegated to NAP; requires RN assessment 5) application of elastic bandage cannot be delegated to NAP; nurse's responsibility to assess circulation immediately after application 6) CORRECT — NAP can assist with toileting and basic care measures
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The nurse on the neurology unit prepares a client for discharge. The client has been treated for an exacerbation of multiple sclerosis. Which statement, if made by the client to the nurse, indicates that teaching is successful? 1. "When lam exercising, I will push a little beyond when I start to feel tired and then stop." 2. "When my muscles seem especially spastic, I will take hot baths to relieve them." 3. "I will sleep on my stomach as much as I can." 4. "I will be ?rm and steady when I pull a spastic leg open."
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3. "I will sleep on my stomach as much as I can." Explanation Strategy: "Teaching is successful" indicates correct information. (1.) overexertion must be avoided because it will cause fatigue and exacerbate symptoms; exercises for muscle strengthening done to the point of fatigue can actually cause further paresis or weakness, numbness, incoordination (2.) heat and humidity, whether environmental or a hot bath or shower, can aggravate the fatigue which is so much a part of multiple sclerosis; fatigue can precipitate and/or intensify multiple sclerosis symptoms (3.) CORRECT - may minimize spasm ofthe flexor muscles ofthe hips and knees of a person with multiple sclerosis; if these spasms are not relieved, joint contractions will occur as well as pressure ulcers on the sacrum and hips from dif?culty positioning the patient correctly (4.) spastic extremity should not be forced open; instead it should be gently rotated in the direction it is being pulled and then gradually rotated in the opposite direction, which is usually outward since spasticity usually is into an adducted position; these rotations are repeated, going a little farther each time
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The nurse prepares a patient diagnosed with cervical cancer for the insertion of an internal radiation implant. The nurse knows that it is MOST important to respond to which client statement? 1. "Unless I have a bowel movement every day, I just do not feel right." 2. "I am glad this whole process is only going to last 3 days." 3. "I will get up only when I have to urinate, and then I will go right back to bed." 4. "lf it were not for my children, I would not be going through all of this."
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3. "I will get up only when I have to urinate, and then I will go right back to bed." Explanation Strategy: Topic of question is unstated. (1.) of concern, but not priority; priorto patient receiving implant, an enema is given so rectum is empty in order to facilitate placing the implant through the vagina and into uterus; bowel movement during the implantation period (1—3 days) is avoided in order to prevent the implant from dislodging (2.) internal radiation treatment for this condition is 1—3 days (3.) CORRECT - patient will be on strict bedrest on her back with head of bed elevated no more than 20 degrees; movement is restricted; a Foley catheter is inserted into bladder in order to prevent the implant from being dislodged by a full bladder or by voiding attempts; severe radiation burns can result from a distended bladder (4.) indicates probable depression; requires further exploration but is not priority
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The home care nurse visits a client diagnosed with Parkinson's disease. The client's husband states that even though his wife eats, she is losing weight. Which of the following suggestions by the nurse is MOST appropriate? 1. Instruct the husband to offer the client thick milkshakes. 2. inform the husband that this is to be expected. 3. Observe the client feed herself. 4. Refer the client to the dietician.
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3. Observe the client feed herself. Explanation Strategy 'MOST appropriate'indicates discrimination is required to answer the question. 1) appropriate action; soft diet may be more easily tolerated; assess before implementing 2) may have dif?culty maintaining weight, but nurse should try to increase client's caloric intake 3) CORRECT—because of feeding dif?culties, client may drop more food in her lap than she eats; nurse should observe the client eat and record actual intake 4) do not pass the buck
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The nurse plans care for a neonate with tetralogy of Fallot. It is most important for the nurse to take which action? 1. Offer the infant water every four hours. 2. Enlarge the hole in the nipple of the formula bottle. 3. Position the infant on his stomach after bottle feeding. 4. Gradually increase the time between bottle feedings.
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2. Enlarge the hole in the nipple of the formula bottle. Explanation 1) should offer formula to meet nutritional needs; has increased calorie needs due to increased metabolic rate 2) CORRECT— allows the child to obtain nourishment easily; feed on a 3-hour schedule and feed soon after awakening so infant doesn't cry 3) support infant and feed in a semi-upright position 4) should offer feeding every 3 hours; stroke infant's jaw and cheek to encourage sucking; complete feeding in half an hour
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A client diagnosed with arterial insufficiency calls the nurse in the outpatient clinic to say that she is awakened at night by pain in her lower extremities. Which of the following suggestions by the nurse is BEST? 1. Elevate both legs on two pillows. 2. Sit on the side of the bed. 3. Place a bed cradle over her legs. 4. Wear cotton pants to keep her legs warm.
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2. Sit on the side of the bed. Explanation Strategy: Determine the outcome of each answer. 1) promotes venous return; does not increase circulation 2) CORRECT - enhances arterial blood supply 3) prevents pressure; does not promote arterial circulation to lower extremities 4) pain is not caused by cold, pain is caused by decreased circulation
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The home care nurse teaches the daughter of an elderly client about her father's hydration status. The nurse is MOST concerned if the daughter states which of the following? 1. 'I should check my father's mouth for dryness: 2. 'I should pinch a fold of skin on the back of my father's hand." 3. 'I should check my father's eyes for dryness." 4. 'I should make sure that my father stands up slowly.'
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2. 'I should pinch a fold of skin on the back of my father's hand." Explanation Strategy 'MOST concerned 'indicates something is wrong. 1) decreased fluid volume causes mucous membranes to dry out; tongue will reflect hydration status since it is not affected by the aging process 2) CORRECT - elasticity of skin in this area is affected by aging; gives an inaccurate assessment of hydration status 3) will be dry due to dehydration 4) decreased fluid volume causes postural hypotension; instruct to change position slowly
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The nurse cares for a 4-year-old child diagnosed with epiglottitis. It is MOST important for the nurse to take which action? 1. Instruct a nursing assistive personnel to take the child to the x-ray department. 2. Use a padded tongue blade to assess the child's gag re?ex. 3. Obtain a blood culture and arterial blood gases (ABGs) as ordered. 4. Apply a pulse oximeter and start an IV.
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4. Apply a pulse oximeter and start an IV. Explanation Strategy "MOST important" indicates priority. 1) epiglottitis is in?ammation of the epiglottis and can be life-threatening; a professional should be with the child at all times 2) never insert a tongue blade into the mouth of a child diagnosed with epiglottitis; gag re?ex can cause complete obstruction of the airway 3) crying can cause obstruction of airway 4) CORRECT - treatment includes moist air and IV antibiotics to decrease epiglottal swelling; pulse oximeter measures oxygen saturation to determine the need for supplemental oxygen
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The nursing assistive person on an acute urology unit gives the nurse the intake and output sheet for a client diagnosed with chronic kidney disease. The client's output was measured on the day shift but not recorded on the evening shift. Which action should the charge nurse take first? 1. Call the nurse assigned to the evening shift and request the information. 2. Complete an agency incident report. 3. Ask the client to give the output for last
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1. Call the nurse assigned to the evening shift and request the information. Explanation Strategy 'FIRST indicates priority. 1) CORRECT - the goal is to make every effort to retrieve the data; knowledge of output used to support decision making about most appropriate interventions; nurses often carry notes home with them or store their work sheets in their lockers; this method seeks a possible resource 2) last step; information may be available; quality client care is ?rst priority; don't have problem yet 3) some clients notice the volume and some do not; is a possible resource, but is not the best resource; is nurse's job to record output 4) focus is not maintaining system at this point; focus is on collection of prime data for management of client health needs
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The nurse receives report on the following patients upon arrival at the medicine unit. Which of the following patients should the nurse see FIRST? 1. A patient drinking contrast for an abdominal CT scan who complains of nausea. 2. A patient with a respiratory rate of 24 and an oxygen saturation of 94% on room air. 3. A patient complaining of frequent small amounts of watery diarrhea with abdominal pain and nausea. 4. A patient whose family member is threatening to sue the hospital and the nurse if the nurse doesn't talk with the family immediately.
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3. A patient complaining of frequent small amounts of watery diarrhea with abdominal pain and nausea. Explanation Strategy: Determine the MOST unstable client. (1.) symptom management is important to patient comfort and to insure the patient is able to complete the contrast for the test, but a potentially life-threatening condition takes precedence (2.) respiratory status is stable (3.) CORRECT - may indicate a possible bowel obstruction that can be life-threatening if the bowel perforates (4.) important to address the family member's concerns, but this person does not pose an immediate physical threat to the patient, staff, or other visitors, and the potentially life-threatening condition takes precedence
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An adult comes to the emergency room in acute respiratory distress. The client has a 20-year history of asthma. The nurse considers which of the following as an ominous sign in this patient? 1. Absence of wheezing on auscultation. 2. Crackles are heard on auscultation. 3. Bilateral rales are absent on auscultation. 4. Coarse rhonchi are present on auscultation.
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1. Absence of wheezing on auscultation. Explanation Strategy: Think about the causes of each sign. 1) CORRECT - indicates acute respiratory distress; small airways completely constricted; patient requires immediate intervention 2) crackles: rales; abnormal breath sounds caused by air through ?uid; not usually seen with asthma 3) not expected with asthma; symptoms of asthma include dyspnea, wheezing, nonproductlve cough, tachycardia, tachypnea 4) continuous grating sounds; indicates disease of bronchi; not expected with asthma
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The nurse instructs a client about how to collect a 24-hour urine specimen. The nurse determines that teaching is effective if the client makes which of the following statements? 1. 'I should discard my ?rst morning specimen, collect all urine for 24 hours, and place the urine in one container." 2. 'I should begin the collection at 8 am, collect all urine voided between 8 am and 8 pm, and place the urine in one container." 3. "I should not mix the urine I collect within the 24 hours." 4. "I will call the nurse to notify the lab about when to begin the test."
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1. 'I should discard my ?rst morning specimen, collect all urine for 24 hours, and place the urine in one container." Explanation Strategy: "Teaching is effective" indicates correct information. 1) CORRECT - discarding ?rst morning specimen removes residual urine from the bladder 2) collect urine for 24 hours 3) all urine should be placed in one container 4) should discard urine, note time, and collect all urine specimens during next 24 hours
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The 25-year-old client comes to the emergency department reporting cramping pelvic pain and having saturated 5 peri pads in the past 2 hours. Which priority questions does the nurse ask? *Select all that apply.* 1. "Are you feeling dizzy?" 2. "When was the ?rst day of your last period?" 3. "Are you taking ibuprofen for your pain?" 4. "When did the bleeding start?" 5. "When did you last have intercourse?" 6. 'What did you eat at your last meal?"
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1. "Are you feeling dizzy?" 2. "When was the ?rst day of your last period?" 4. "When did the bleeding start?" Explanation Strategy: Consider the ABCs when thinking about the answers. Determine why the nurse would ask each question. Is it important to this situation? 1) CORRECT — the problem is bleeding; assesses the "here and now" and worst-case scenario; helps determine true amount of blood loss 2) CORRECT — it is important to assess the last period to determine pregnancy potential and the possible loss of pregnancy 3) may be helpful to determine if the pain medication had any effect on the pain, but not priority at this time 4) CORRECT —- it is important to gather history of this event, as it will help determine amount of bleeding 5) may be a follow-up question after determining if pregnancy is a possibility, but not priority at this time 6) may be a follow-up question if pregnancy is not a possibility, but not priority at this time
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The nurse assesses the client diagnosed with seizures, migraines and type 1 diabetes. Which client statements require a follow-up by the nurse? Select all that apply. 1. "I see ?re?ies around my head." 2. "I can't seem to wake up today." 3. "My hands won't stop shaking." 4. "I usually give myself the insulin." 5. "I usually sleep after a seizure."
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1. "I see ?re?ies around my head." 2. "I can't seem to wake up today." 3. "My hands won't stop shaking." Explanation Strategy: "Requires a follow-up" indicates something is wrong. Answers are client quotes. Think about what the words indicate and how the client statements relate to the diagnoses in the stem of the question. 1) CORRECT — ?ashing lights may indicate aura before the seizure or a migraine 2) CORRECT — may indicate hyperglycemia 3) CORRECT — tremors may be associated with hypoglycemia 4) promotion of independence with self-care appropriate 5) postictal confusion and sleepiness common
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The nurse is supervising care provided by a nursing assistive personnel (NAP). Which action by the NAP requires intervention by the nurse? Select all that apply. 1. The NAP applies nonsterile gloves to empty a client's urostomy bag. 2. The NAP applies elastic compression stockings to the client after the client returns to bed after breakfast. 3. The NAP assists a 190 kg client diagnosed with lower extremity weakness to the bathroom. 4. The NAP wears a gown and gloves when assisting a client just admitted with meningitis to change into a hospital gown. 5. The NAP documents morning vital signs and blood glucose levels obtained from a group of clients.
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2. The NAP applies elastic compression stockings to the client after the client returns to bed after breakfast. 3. The NAP assists a 190 kg client diagnosed with lower extremity weakness to the bathroom. 4. The NAP wears a gown and gloves when assisting a client just admitted with meningitis to change into a hospital gown. Explanation Strategy: "Requires intervention by the nurse" indicates an incorrect action by the NAP. Determine the outcome of each nursing action. Does it require the nurse to intervene? 1) appropriate action; within scope of NAP, nonsterile procedure 2) CORRECT— compression stockings should be placed after elevation of the limbs or when there is minimal dependent edema; client who has been up for breakfast will have increased dependent edema 3) CORRECT — additional assistance in transfers is necessary for large clients; safety risk to both NAP and client 4) CORRECT— clients with meningitis require use of droplet precautions; mask should be applied 5) appropriate action; within scope of NAP
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A client newly diagnosed with Meniére's disease is counseled by the of?ce nurse about important dietary modi?cations. Which comment, if made by the client to the nurse, BEST indicates teaching is successful? 1. "l have seen a lot of dietetic foods in the store. I will focus on buying them." 2. "I will avoid Chinese restaurants and fast-food places when I go out to eat." 3. "I will buy one of those commercial salt substitutes to use when l have a craving for salt." 4. "I understand that I can have corned beef and smoked fish, but not pickles or creamed sauces."
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2. "I will avoid Chinese restaurants and fast-food places when I go out to eat." Explanation Strategy: "Teaching is successful' indicates correct information. (1.) not best; not all dietetic foods are low in sodium; labels need to be read (2.) CORRECT - clients with Meniére's disease require a low-sodium diet to decrease ?uid retention (endolymphatic ?uid, which is clear, intracellular ?uid located in the labyrinth of the inner ear); many Chinese restaurants use MSG and soy sauce, both of which are high in sodium; fast-food places and products also have a tendency to be high in sodium (3.) spices and herbs would be better substances for flavor enhancement (4.) meat and fish products that are canned, smoked, pickled, or cured should be avoided because they are high in sodium, as are pickles and, often, creamed sauces
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The nurse cares for the client diagnosed with rheumatoid arthritis (RA). The nurse expects to assess which ?ndings? Select all that apply. 1. Kyphosis of the spine. 2. Symmetrical joint swelling. 3. Crepitus with range of motion. 4. Pathological fractures. 5. Joint stiffness in the morning. 6. Joint pain relieved by resting.
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2. Symmetrical joint swelling. 5. Joint stiffness in the morning. Explanation Strategy: Think about each answer. Does it indicate rheumatoid arthritis? 1) kyphosis of the spine is seen with osteoporosis 2) CORRECT — symmetrical or mirror joint swelling occurs with RA 3) crepitus with range of motion occurs with osteoarthritis 4) pathological fractures occur with osteoporosis 5) CORRECT — RA is characterized by joint stiffness in the morning 6) osteoarthritis is characterized by joint pain that is relieved by resting
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The nurse cares for clients on the medical/surgical ?oor. Which of the following clients should the nurse assign to the LPN/LVN? 1. A client who returns after an appendectomy complicated by a pneumothorax during surgery. 2. A client with increased intracranial pressure who responds to painful stimuli. 3. A client diagnosed with cellulitis receiving antibiotics. 4. A client with a mandibular fracture immobilized by wiring the jaw who is preparing for discharge.
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3. A client diagnosed with cellulitis receiving antibiotics. Explanation Strategy: Assign stable clients with expected outcomes. 1) requires assessment and nursing judgment; assign to RM 2) requires assessment and nursing judgment; assign to RN 3) CORRECT - stable client with expected outcome 4) requires discharge teaching regarding importance of oral hygiene and nutrition
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Four children come to the office of the school nurse at the same time. After performing an assessment, the nurse determines that the parents of which of the following children should be contacted FIRST to come pick up their child? 1. A child with a red rash on the cheeks that makes the child's face look like it has been slapped. 2. A child with a fever who complains of headache, malaise, anorexia, and an earache when chewing. 3. A child with an apparent upper respiratory infection (URI) and an in?amed conjunctiva with swollen eyelids and watery drainage. 4. A child with clusters of small, erythematous, intensely pruritic papules in the antecubital space.
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2. A child with a fever who complains of headache, malaise, anorexia, and an earache when chewing. Explanation Strategy: Determine the child who is most infectious. (1.) indicates ?fth disease; most contagious before rash appears, isolation not required once rash appears; child can attend school (2.) CORRECT - indicates probable mumps; communicability greatest immediately before and after the swelling begins (3.) symptoms are of viral conjunctivitis; not priority (4.) describes eczema; not priority
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The nurse observes that a health care provider has ordered 100 mL 05W with KCI 80 mEq to infuse in 30 minutes. Which action should the nurse take ?rst? 1. Assess the client's urinary output. 2. Ensure the patency of the client's IV. 3. Request an order for IV lidocaine. 4. Contact the health care provider.
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4. Contact the health care provider. Explanation Strategy: "FIRST" indicates priority. 1) decreased kidney function can cause hyperkalemia 2) severe pain and tissue necrosis may occur because of extravasation 3) Lidocaine used for treatment of ventricular dysrhythmia 4) CORRECT — rate of IV administration should be no faster than 10 mEq/h; contact health care provider to clarify order
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The nurse provides teaching for a client diagnosed with liver cirrhosis. Which statements by the client cause the nurse to determine that teaching is effective? Select all that apply. 1. "I will use a medium- or hard-bristle toothbrush." 2. "I will limit myself to 1 serving of alcohol per day." 3. "I will eat no more than 1,200 calories per day." 4. "I will apply calamine lotion to my dry, itchy skin." 5. "I will immediately report melena to my health care provider." 6. "I will change positions in bed every 4 hours."
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4. "I will apply calamine lotion to my dry, itchy skin." 5. "I will immediately report melena to my health care provider." Explanation Strategy: "Teaching is effective" indicates correct information. Determine the outcome of each answer. Is it correct information? 1) thrombocytopenia expected with cirrhosis; client should only use soft bristle toothbrush to minimize risk of bleeding 2) client should completely abstain from alcohol use 3) malnutrition is serious clinical problem associated with cirrhosis; diet for cirrhosis client without complications should be high in calories (3,000 calories/day) 4) CORRECT - appropriate action; client may have pruritus accompanied by jaundice 5) CORRECT - melena (black, tarry stools) should be reported to health care provider immediately; can indicate bleeding esophageal varices 6) nurse will intervene; client should change positions at least every 2 hours; edema is characteristic of cirrhosis, and edematous tissues are subject to breakdown
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The nursing team consists of an RN, an LPN, and two nursing assistants. The RN should care for which of the following clients? 1. A child recovering from surgical repair of a hypospadias. 2. A client recovering from excision of a malignant melanoma. 3. A client diagnosed with a myocardial infarction requiring assistance to the bathroom. 4. A client diagnosed with urolithiasis recovering from lithotripsy.
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2. A client recovering from excision of a malignant melanoma. Explanation Strategy: RN cares for clients requiring assessment, teaching, and nursing judgment. 1) ensure patency of urinary diversion after surgery; assign to the LPN/LVN 2) CORRECT - may require a wide excision that requires nurse to anticipate the need for analgesic medications; psychological support is also necessary because of diagnosis of cancer; requires assessment, teaching, and nursing judgment 3) standard, unchanging procedure; assign to the nursing assistant 4) observe for obstruction and infection, strain urine; assign to LPN/LVN
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The nurse cares for a client admitted 2 days ago with a diagnosis of closed head injury. If the client develops diabetes insipidus, the nurse will observe which symptoms? Select all that apply. 1. Glucosuria. 2. Cracked lips. 3. Weight gain of 5 lb. 4. BP160/100, pulse 56. 5. Urinary output of 4 L/24 hours. 6. Urine specific gravity of 1.004.
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2. Cracked lips. 5. Urinary output of 4 L/24 hours. 6. Urine specific gravity of 1.004. Explanation Strategy: Think of water loss with diabetes insipidus. 1) occurs with diabetes mellitus. 2) CORRECT - due to dehydration caused by excessive water loss. 3) weight loss occurs; symptom of SlADH (syndrome of inappropriate antidiuretic hormone) opposite of diabetes insipidus. 4) late signs of increased intracranial pressure or brain damage. 5) CORRECT - excessive ?uid loss is major occurance of diabetes insipidus. 6) CORRECT - speci?c gravity very low as urine is not concentrated in the kidney.
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The client receives a blood transfusion and experiences a hemotytic reaction. The nurse anticipates which assessment ?ndings? Select all that apply. 1. Hypotension. 2. Low back pain. 3. Wet breath sounds. 4. Fever. 5. Urticaria. 6. Severe shortness of breath.
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1. Hypotension. 2. Low back pain. 4. Fever. Explanation Type: select all that apply. Did you identify the topic correctly? Signs and symptoms of hemolytic blood reaction. Note: The topic is not what you are worried about if you see it; it is very speci?c to hemolytic reaction. Use the words. is (the answer) a ?nding for hemolytic reaction? This will help keep you focused. 1) CORRECT — blood pressure drops 2) CORRECT — classic symptom related to hemolytic reaction 3) related to circulatory overload 4) CORRECT — fever is an expected symptom 5) related to an allergic reaction 6) related to circulatory overload Step 5: Do you have more than one answer? Yes. Does your answer make sense for hemolytic reactions? Yes.
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Which is the best method for the nurse to use when evaluating the effectiveness of tracheal suctioning? 1. Notes subjective data, such as "My breathing is much improved now." 2. Notes objective findings, such as decreased respiratory rate and pulse. 3. Consults with the respiratory therapist to determine effectiveness. 4. Auscultates the chest for change or clearing of adventitious breath sounds.
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4. Auscultates the chest for change or clearing of adventitious breath sounds Explanation Strategy: Determine how each answer relates to suctioning. (1) subjective data and not as conclusive (2) correct but not as effective (3) not appropriate (4) CORRECT - to assess the effectiveness of suctioning. auscultate the client's chest to determine if adventitious sounds are cleared and to ensure that the airway is clear of secretions
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Which assessment ?ndings should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome? 1. Low blood pressure and weight loss. 2. Thin extremities with easy bruising. 3. Decreased urinary output and increased serum potassium. 4. Tachycardia with reports of night sweats.
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2. Thin extremities with easy bruising. Explanation Strategy: Think about each answer. (1) BP increases and client gains weight (2) CORRECT - clients with Cushing's syndrome tend to lose weight in their legs and have petechiae and bruising (3) no correlation with urinary output; potassium decreases (4) no correlation with Cushing's syndrome
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The nurse knows which action is an important consideration in the care of a newborn with fetal alcohol syndrome? 1. Prevent iron de?ciency anemia. 2. Decrease touch to prevent overstimulation. 3. Provide feedings via gavage to decrease energy expenditure. 4. Replace vitamins depleted as a result of poor maternal diet.
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4. Replace vitamins depleted as a result of poor maternal diet. Explanation Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) not highest priority (2) infant needs to be held and cuddled due to a poorly developed CNS (3) usually unnecessary (4) CORRECT - frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function
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The nurse cares for the client during an acute manic episode. The nurse identi?es which client behaviors as most characteristic of mania? Select all that apply. 1. Paranoia. 2. Grandiose delusions. 3. Somatic difficulties. 4. Difficulty concentrating. 5. Agitation. 6. Distorted perceptions.
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2. Grandiose delusions. 4. Difficulty concentrating. 5. Agitation. Explanation Strategy: Think about mania and how it is manifested. 1) related to schizophrenia 2) CORRECT - delusions of grandeur are common during mania 3) related to personality disorders 4) CORRECT - due to excessive activity 5) CORRECT - clients are constantly in motion 6) related to depression
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The nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows which change in the urinary elimination pattern occurs normally with aging? 1. Decreased frequency. 2. Nocturia. 3. Incontinence. 4. Hematuria.
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2. Nocturia. Explanation Strategy: Think about each answer. 1) frequency increases because bladder capacity decreases 2) CORRECT - decreased ability to concentrate urine increases urine formation and increased nocturnal urine production leads to need to awaken to void 3) ureters, bladder, and urethra lose muscle tone; results in stress and urge incontinence 4) blood in the urine may be a sign of cancer, infection, or trauma of urinary tract, glomerular disease, urinary tract calculi, bleeding disorders
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The nurse assesses the client diagnosed with a spinal cord injury. Which findings suggest the complication of autonomic dysre?exia? Select all that apply. 1. Urinary bladder spasm pain. 2. Severe pounding headache. 3. Profuse sweating. 4. Tachycardia. 5. Severe hypotension. 6. Nasal congestion.
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2. Severe pounding headache. 3. Profuse sweating. 6. Nasal congestion. Explanation Strategy: Think about each answer. 1) may be the cause of autonomic dysre?exia due to over?lling of the bladder, but pain is not perceived 2) CORRECT - severe headache results from rapid onset of hypertension 3) CORRECT - especially of forehead 4) pulse will slow 5) BP will increase 6) CORRECT - also causes piloerection (goose bumps)
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An adolescent is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include which information? 1. Explain that the client will walk with a prosthesis soon after surgery. 2. Encourage the client to share feelings and fears about the surgery. 3. Take the informed consent form to the client and ask the client to sign it. 4. Evaluate how the client plans to complete schoolwork during hospitalization.
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2. Encourage the client to share feelings and fears about the surgery. Explanation Strategy: Remember therapeutic communication. (1) fails to recognize client's immediate concerns (2) CORRECT - discussing client's feelings and fears is important in dealing with anxiety due to a change in body image and functioning (3) client is underage; parents will need to sign the permit (4) is more appropriate for the postoperative period of time than for the preoperative period
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The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistive personnel (NAP). The RN should care for which client? 1. The client with a chest tube who is ambulating in the hall. 2. The client with a colostomy requiring assistance with an irrigation. 3. The client with a right-sided stroke requiring assistance with bathing. 4. The client declining medication to treat cancer of the colon.
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4. The client declining medication to treat cancer of the colon. Explanation Strategy: Determine the skill level involved with each client's care. The RN cares for clients who require assessment, teaching, and nursing judgment. (1) stable client with an expected outcome; assign to the LPN/LVN (2) stable client with an expected outcome; assign to the LPN/LVN (3) standard, unchanging procedure; assign to the NAP (4) CORRECT - requires assessment skills of the RN
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The home care nurse plans activities for the day. In which order does the nurse see the clients? Place the answers in order of priority beginning with the first Client to see. All options must be used. The elderly client diagnosed with pneumonia and discharged from the hospital 3 days ago. The client discharged yesterday after IV heparin therapy for a deep vein thrombosis. The client who is breastfeeding a 2-day-old infant born 5 days before the due date. The elderly client who used all the diuretic medication and is expectorating pink-tinged mucus
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The elderly client who used all the diuretic medication and is expectorating pink-tinged mucus The client discharged yesterday after IV heparin therapy for a deep vein thrombosis. The elderly client diagnosed with pneumonia and discharged from the hospital 3 days ago. The client who is breastfeeding a 2-day-old infant born 5 days before the due date. Explanation Strategy: identify the most unstable clients to see ?rst. 1) ?rst: the client with pink tinged mucus; symptoms of pulmonary edema; requires immediate attention 2) second: the client on heparin; still potential for problems related to heparin; assess for bleeding gums, hematuria 3) third: the client with pneumonia; potential for relapse; assess breath sounds, encourage ?uids, cough and deep breathe 4) fourth: breastfeeding client; stable client, least critical/priority
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The nurse recognizes which client symptoms as characteristic of a panic attack? Select all that apply. 1. Decreased blood pressure. 2. Palpitations. 3. Decreased perceptual field. 4. Bradycardia. 5. Diaphoresis. 6. Fear of going crazy.
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2. Palpitations. 3. Decreased perceptual field. 5. Diaphoresis. 6. Fear of going crazy. Explanation Strategy: Think about a panic attack and the neurological changes that occur. 1) blood pressure increases= 2) CORRECT - the heart rate increases and palpitations occur 3) CORRECT - the visual field narrows; part of the fight or fight reaction 4) tachycardia occurs 5) CORRECT - neurological changes cause diaphoresis 6) CORRECT clients fear they are going crazy; part of the neurological changes
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The health care provider suggests play therapy for the 7-year-old child having some difficulty adjusting to the parents' impending divorce. The nurse identifies which reason this type of therapy is effective for this age group? 1. Young children have difficulty verbalizing emotions. 2. Children hesitate to confide in anyone but their parents. 3. Play is an enjoyable form of therapy for children. 4. Play therapy is helpful in preventing regression.
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1. Young children have difficulty verbalizing emotions. Explanation Strategy: Think about each answer. (1) CORRECT - children have difficulty putting feelings into words; play is how they express themselves (2) somewhat true, but not best reason for play therapy (3) not reason play therapy is used; is used because it is the best way for children to express themselves (4) may encourage child to act out earlier developmental stage to reveal underlying conflicts
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The health care provider prescribes lithium carbonate 300 mg PO QID for an adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse should encourage the client to maintain an adequate intake of which substance? 1. Sodium. 2. Protein. 3. Potassium. 4. Iron.
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1. Sodium. Explanation Strategy: Think about each answer. (1) CORRECT - alkali metal salt acts like sodium ions in the body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity (2) doesn't interact with lithium (3) doesn't interact with lithium (4) doesn't interact with lithium
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A client receives morphine sulfate after admission to the emergency department in acute respiratory distress. The client is very anxious, edematous, and cyanotic. Which ?nding should the nurse recognize as the desired response to the medication? 1. Increase in pulse pressure. 2. Decrease in anxiety. 3. Depression of the sympathetic nervous system. 4. Enhanced ventilation and decreased cyanosis.
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2. Decrease in anxiety. Explanation Strategy: Think about each answer. (1) is not affected by morphine sulfate (2) CORRECT - morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema (3) is not the action of the medication (4) medication does not improve ventilation
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The nurse plans discharge teaching for the client after a lumbar laminectomy. Which muscle or muscles does the nurse instruct the client to exercise regularly? 1. Anal sphincter. 2. Abdominal. 3. Trapezius. 4. Rectus femoris.
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2. Abdominal. Explanation Strategy: Think about each answer. 1) does not contribute to support of the lumbar spine 2) CORRECT —- strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine 3) does not contribute to support of the lumbar spine 4) does not contribute to support of the lumbar spine
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The nurse cares for a client the ?rst day postoperative after a transurethral prostatectomy (TURP). The client has a continuous bladder irrigation (CBI). The client's spouse asks why the client has the CBI. Which response by the nurse is best? 1. "The CBI prevents urinary stasis and infection." 2. "The CBI dilutes the urine to prevent infection." 3. "The CBI enables urine to keep ?owing." 4. "The CBI delivers medication to the bladder."
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3. "The CBI enables urine to keep ?owing." Explanation Strategy: Think about each answer. 1) refers to a possible preoperative complication of infection due to the enlarged prostate 2) not the reason for the CB! 3) CORRECT - continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client 4) medication is not routinely administered via a CBl in a ?rst-day postop TURP
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The nurse recognizes which nursing intervention is most important when caring for a client just placed in physical restraints? 1. Prepare PRN dose of psychotropic medication. 2. Check that the restraints have been applied correctly. 3. Review hospital policy regarding duration of restraints. 4. Monitor the client's needs for hydration and nutrition while restrained.
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2. Check that the restraints have been applied correctly. Explanation Strategy: Answers are a mix of assessment and implementation. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation; inappropriate for the client in restraints (2) CORRECT - assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained (3) implementation; all staff members involved in a restraint event must be aware of hospital policy before using restraints (4) assessment; important to attend to client's nutrition and hydration after the client is safely restrained
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A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is for which reason? 1. Provides an avenue for nutrients to ?ow past an obstructed area. 2. Prevents ?uid and gas accumulation in the stomach. 3. Administers medications that can be absorbed directly from the intestinal mucosa. 4. Removes ?uid and gas from the small intestine.
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4. Removes fluid and gas from the small intestine. Explanation Strategy: Think about each answer. (1) tube would be placed in an area of reduced peristalsis and would slowly work past an obstruction (2) describes a tube such as a Levin or Salem Sump, which decompresses the stomach (3) tube provides for decompression instead of instillation of medications (4) CORRECT - Miller-Abbott tube provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileus
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The older client with a history of hypertension and angle-closure glaucoma visits the clinic for a routine check-up. Which medication, if ordered by the health care provider, should the nurse question? 1. Propranolol, 80 mg orally fourtimes daily. 2. Verapamil, 40 mg PO three times daily. 3. Tetrahydrozoline, 2 drops in both eyes three times daily. 4. Timolol, 1 drop in both eyes onetime daily.
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3. Tetrahydrozoline, 2 drops in both eyes three times daily. Explanation Strategy: "Medication should the nurse question" indicates a contraindication. (1) antihypertensive, beta-blocker used as an antianginal, reduces cardiac oxygen demand, no effect on glaucoma (2) calcium channel blocker used as antianginal; not contraindicated (3) CORRECT - contraindicated; ophthalmic vasoconstrictor, contraindicated with angle-closure glaucoma; use cautiously with hypertension (4) reduces aqueous formation and increases out?ow, used for glaucoma
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The client is brought to the emergency department after being raped in the home. The client asks the nurse to call the spouse to come to the emergency department. The nurse knows the most common reaction of the signi?cant other to a rape victim is re?ected in which behavior? 1. Supportive and helpful to the victim. 2. Disconnected from and apathetic toward the victim. 3. Frustrated and feeling vulnerable, but denying the need for help. 4. Emotionally distressed and needing assistance.
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4. Emotionally distressed and needing assistance. Explanation Strategy: Think about each answer. 1) signi?cant others may want to be helpful; however, they generally do not have the immediate coping strategies to do so 2) rarely feel disconnected 3) usually family members will need and respond well to psychological intervention 4) CORRECT - sexual assault by rape is a crisis situation for victim and family members and friends
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The client diagnosed with Addison's disease comes to the health clinic. When assessing the client's skin, the nurse expects to make which observation? 1. Darker skin that is more pigmented. 2. Skin that is ruddy and oily. 3. Skin that is puffy and scaly. 4. Skin that is pale and dry.
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1. Darker skin that is more pigmented. Explanation Strategy: Determine how each answer relates to Addison's disease. (1) CORRECT - increase in melanocyte-stimulating hormone results in "eternal tan" (2) not seen with Addison's disease (3) not seen with Addison's disease (4) not seen with Addison's disease
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The nurse cares for the client diagnosed with paranoid schizophrenia. The nurse knows that questioning the client about the client's false ideas will elicit which response? 1. Cause the client to defend the idea. 2. Help the client clarify thoughts. 3. Facilitate better communication. 4. Lead to a breakdown of the defense.
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1. Cause the client to defend the idea. Explanation Strategy: Think about each answer. 1) CORRECT - contraindicated; encourages client to engage in further distortion of reality 2) needs reality testing from nurse, not questioning 3) questioning is nontherapeutic; may cause client to avoid nurse physically 4) needs defense; questioning will further distort reality or elaborate on delusion
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The nurse cares for the client diagnosed with a recurrent urinary tract infection. The health care provider prescribes cipro?oxacin. The nurse instructs the client to limit intake of which ?uid? 1. Milk. 2. Cranberry juice. 3. Water. 4. Tea.
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1. Milk. Explanation Strategy: Think about each answer. 1) CORRECT — should limit intake of alkaline foods and ?uids 2) can be increased to acidify urine 3) does not need to be restricted 4) does not need to be restricted
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The nurse cares for the client diagnosed with MĂ©niere's syndrome. The nurse stands directly in front ofthe client when speaking. Which best describes the rationale for the nurse's position? 1. This enables the client to read the nurse's lips. 2. The client does not have to turn the head to see the nurse. 3. The nurse will have the client's undivided attention. 4. There is a decrease in client"s peripheral visual ?eld.
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2. The client does not have to turn the head to see the nurse. Explanation Strategy: Think about each answer. 1) client is not hard of hearing 2) CORRECT - by decreasing movement of client's head, vertigo attacks may be decreased 3) not the reason 4) there is no problem with visual ?elds
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The nurse supervisor observes the staff member entering the client's room wearing gown and gloves. The nurse knows the staff member is caring for which client? 1. The child with respiratory syncytial virus. 2. The child with Kawasaki disease. 3. The child with Lyme disease. 4. The child with infectious mononucleosis.
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1. The child with respiratory syncytial virus. Explanation Strategy: Think about each answer. 1) CORRECT - acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children 2) acute systemic vasculitis in children under 5; standard precautions 3) connective tissue disease; standard precautions 4) standard precautions
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The nurse cares for a client during a radium implant. During the removal of the implant, it is most important for the nurse to take which action? 1. Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps. 2. Handle the radium carefully using forceps and rubber latex gloves. 3. Document the date and time of removal together with the total time of implant treatment. 4. Double-bag the radium implant before the person from radiology removes it from the room.
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3. Document the date and time of removal together with the total time of implant treatment. Explanation Strategy: Answers are all implementation. Determine the outcome of each answer. is it desired? (1) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant (2) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant (3) CORRECT - important that accurate documentation be maintained on the internal radium implant (4) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant
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A client diagnosed with an adjustment disorder with depressed mood has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which time? 1. During the morning hours. 2. During the middle of the day. 3. During the afternoon hours. 4. During the evening hours.
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1. During the morning hours. Explanation Strategy: Think about each answer. (1) CORRECT - client with reactive depression has the highest level of physical and psychic energy in the morning (2) as the day progresses, energy level declines (3) as the day progresses, energy level declines (4) as the day progresses, energy level declines
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The adult client is admitted to the hospital unit diagnosed with hepatitis A. Which precautions does the nurse include in the client's overall care during hospitalization? 1. Contact precautions. 2. Airborne precautions. 3. Standard precautions. 4. Droplet precautions.
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3. Standard precautions. Explanation Strategy: Think about each answer. 1) required with patient care activities that require physical skin-to-skin contact, or occurs by contact with contaminated inanimate objects in the patient's environment 2) unnecessary; used with pathogens transmitted by airborne route 3) CORRECT— standard precautions should be used on everyone; sources for this virus are saliva, feces, and blood; use contact isolation if fecal incontinence 4) unnecessary; used when pathogens transmitted by infectious droplets
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When assessing orientation to person, place, and time for an elderly hospitalized client, which principle should be understood by the nurse? 1. Short-term memory is more efficient than long-term memory. 2. The stress of an unfamiliar environment may cause confusion. 3. A decline in mental status is a normal part of aging. 4. Learning ability is reduced during hospitalization of the elderly client.
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2. The stress of an unfamiliar environment may cause confusion. Explanation Strategy: Think about each answer. (1 ) just the opposite is true; long.term memory is more ef?cient than short-term memory (2) CORRECT - stress of an unfamiliar situation or environment may lead to confusion in elderly clients (3) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things (4) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things
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The home care nurse visits a client diagnosed with ulcerative colitis. The nurse instructs the client about an appropriate diet. The nurse determines that teaching is effective if the client selects which menu? 1. White chili, crackers, applesauce, and tea. 2. Grilled cheese sandwich on white bread, bouillon, an orange, and coffee. 3. Raisin Bran cereal, milk, white toast, and coffee. 4. Baked ?sh, cream of potato soup, cooked baby carrots, and tea.
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4. Baked ?sh, cream of potato soup, cooked baby carrots, and tea. Explanation Strategy: Recall the diet required for ulcerative colitis. 1) ulcerative colitis is in?ammation and ulceration of the colon and rectum; requires high-calorie, high-protein, *low-residue diet; chili contains beans, which are not allowed;* crackers made with white ?our and applesauce are allowed 2) raw fruit is not allowed; grilled cheese sandwich and bouillon are allowed 3) Raisin Bran not allowed 4) *CORRECT*—all of these foods are allowed on diet
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The charge nurse of a psychogeriatric unit makes rounds on the unit. Which situation requires an immediate intervention by the nurse? 1. The dietary aide removes a full breakfast tray untouched by a client with major depression who is still in bed wearing night clothing. 2. The psychiatric aide makes the bed while a client with schizophrenia is sitting in the bedside chair shaving with a disposable razor and mirror. 3. The LPN/LVN assigned to medication administration argues loudly with a bipolar client who is refusing to take prescribed medication. 4. The client care technician places personal care items in reach of a client with stage 2 dementia of the Alzheimer type and then leaves to ?ll the wash basin with water.
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4. The client care technician places personal care items in reach of a client with stage 2 dementia of the Alzheimer type and then leaves to ?ll the wash basin with water. Explanation Strategy: Determine the most unstable client. 1) these are expected signs of depression that need to be addressed but are not the priority 2) self-care with sharp items is allowed under staff supervision; this client is supervised 3) LPN's behavior needs addressing; client may have the right to refuse medication 4) CORRECT - client at risk for choking on inedible items such as soap, lotions, caps of sample bottles, etc.
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The nurse cares for clients in the skilled nursing facility. Which client requires the nurse's immediate attention? 1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin expired 2 days ago. 2. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine. 3. A client who has dysuria and foul-smelling, cloudy, dark amber urine. 4. An immunosuppressed client who has not received an in?uenza immunization.
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1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin expired 2 days ago. Explanation Strategy: Determine the least stable client (1) CORRECT - duration of warfarin is 2 to 5 days, client at risk for a repeat CVA (2) anticoagulant takes priority, client still receiving pain medication (3) painful urination, may indicate infection (4) anticoagulant takes priority
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The nurse provides care for the client diagnosed with early stage chronic kidney disease. The client states, "I do not understand why my health care provider thinks I am having trouble with my kidneys. I urinate frequently day and night." Which response by the nurse is best? 1. 'Did you tell the health care provider you are putting out lots of urine?" 2. 'If you manage your diabetes well, there should be no further damage." 3."You seem to be very upset about this diagnosis." 4. "A high volume of urine indicates your kidneys are releasing too much ?uid."
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4. "A high volume of urine indicates your kidneys are releasing too much ?uid." Explanation Strategy: "Best" indicates discrimination is required to answer the question. 1) this is a "yes/no" question, which is nontherapeutic 2) there is no information in the question that indicates the client has diabetes mellitus; in addition, the statement does not address the client's misunderstanding about the symptoms 3) the statement can be an appropriate leading statement when the nurse is exploring a subject; however, the client has enough information to a have structured discussion 4) CORRECT — in the early stage of chronic kidney disease hypertrophy of kidney tissue results in increased surface available for urinary excretion; increased or near normal urinary output may not seem abnormal to the client
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During a sudden rise in a nearby river, the nurse at a day camp evacuates the children to an area away from the river. Which action should the nurse take NEXT? 1. Place an identi?cation bracelet on each child. 2. Go back for an adequate supply of water. 3. Notify the parents of the children's location. 4. Comfort children who are anxious.
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1. Place an identi?cation bracelet on each child. Explanation Strategy: Determine the outcome of each answer. 1) CORRECT - aids in communication after rescue or recovery 2) nurse should not leave the children alone 3) identi?cation takes priority over noti?cation 4) priority is assuring that each child can be identi?ed
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The nurse on the surgical unit receives a call from the operating room to administer preoperative medication to a client scheduled for surgery. After administering the preoperative medication, the nurse discovers that the client has not signed the informed consent for the surgery. Which action should the nurse take next? 1. Notify the health care provider. 2. Ask the client to sign the consent form. 3. Transfer the client to the operating room. 4. Inform the nurse's immediate supervisor.
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4. Inform the nurse's immediate supervisor. Explanation Strategy: "next" indicates priority. 1) nurse should stay within the chain of command 2) consent not valid if client has been drinking or has been premedicated 3) surgery performed without consent considered battery 4) CORRECT— nurse should follow chain of command; risks and benefits of the procedure must be explained by the person performing the procedure
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The school nurse conducts a workshop on eating disorders for parents and teens. Which participant statements indicate correct understanding of the teaching? Select all that apply. 1. "I do not need to worry as long as my child's BMI stays between 20 and 25." 2. "I will set healthy goals for my food and ?uid intake." 3. "it is important to weigh or measure all of the food my child eats." 4. "I will keep a food journal in which I will write down what I'm eating and how I'm feeling." 5. "Our family needs to eat every meal together each day." 6. "Medical treatment of anorexia will not be effective unless my child participates willingly."
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2. "I will set healthy goals for my food and ?uid intake." 4. "I will keep a food journal in which I will write down what I'm eating and how I'm feeling." Explanation Strategy: "Correct understanding of the teaching" indicates correct information. Determine the outcome of each answer. Is it desired? 1) clients with bulimia may maintain a normal BMI, but they still need intervention 2) CORRECT —- when clients with eating disorders participate in goal setting, their chances of successful treatment increase 3) this level of involvement by family members is often counterproductive 4) CORRECT —- recognizing feelings of anxiety or powerlessness often leads to insight into maladaptive eating behaviors 5) although family involvement is a necessary part of treatment, it is not reasonable to expect families to eat all meals together 6) in cases of extreme malnutrition or dehydration emergency, medical care is required; the client may not desire this
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The nurse in the outpatient mental health clinic develops a plan of care for the client diagnosed with bulimia. The nurse determines which goal is most important? 1. The client will identify symptoms of electrolyte imbalance. 2. The client will keep dental appointments and maintain oral hygiene. 3. The client will attend appropriate community support groups. 4. The client will abstain from binge-purge behaviors.
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1. The client will identify symptoms of electrolyte imbalance. Explanation Strategy: Think Maslow. 1) CORRECT - needs to know life-threatening complications of illness, especially hypokalemia 2) important but not ?rst priority 3) ongoing, long term goal to help control illness 4) ultimate long term goal; these behaviors take time to change
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The nurse cares for clients in the outpatient surgical center. Four clients scheduled for surgery present to the surgical center at the same time. Which of the following clients should the nurse see FIRST? 1. A 19.year-old scheduled for a tonsillectomy. 2. A 25-year-old scheduled for an inguinal hernia repair. 3. A 32-year-old scheduled for a mastoidectomy. 4. A 39.year-old scheduled for removal of nasal polyps.
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3. A 32-year-old scheduled for a mastoidectomy. Explanation Strategy:"FlRST" indicates priority. 1) not the priority client 2) stable client; not the priority 3) CORRECT—chronic ear infections often cause vertigo, priority client due to safety 4) stable client
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The nurse in the pediatric clinic notes that several preschool children have received a single dose of hepatitis B vaccine during infancy. Which of the following actions by the nurse is MOST appropriate? 1. Inform the children's parents that the children must start the hepatitis B series over again. 2. Note the immunization in the child's history. 3. Contact the physician. 4. Make an appointment for the children to continue the series of hepatitis B vaccine.
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4. Make an appointment for the children to continue the series of hepatitis B vaccine. Explanation Strategy: Determine the outcome of each answer. Is it appropriate? 1) do not start series over again 2) hepatitis B immunization is a series of three injections 3) no reason to contact the physician 4) CORRECT - continue immunization series; total ofthree doses given; should schedule the third dose 3 to 4 months after the second dose; second dose usually given 1 to 2 months after ?rst dose
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The nurse cares for client with a history of heart failure. The health care provider writes orders for the client. It is most important for the nurse to question which order? 1."Digoxin 0.25 mg P0 in am." 2. "Oxygen at 4 Umin per nasal cannula." 3. "Verapamil 120 mg orally three times daily." 4. "Furosemide 40 mg N now."
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3. "Verapamil 120 mg orally three times daily." Explanation Strategy: Think about each answer. 1) appropriate order; cardiac glycoside used to treat heart failure 2) appropriate order 3) CORRECT — verapamil is contraindicated in clients diagnosed with heart failure and in clients taking digoxin 4) appropriate order; loop diuretic; monitor blood pressure, pulse rate, intake and output
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The nurse instructs a client about care of a colostomy. The client is especially concerned about controlling odor and gas. The nurse should include which instructions to the client? Select all that apply. 1. "Place an aspirin inside the colostomy pouch." 2. "Eat onions, beans, and cucumbers." 3. "Drink cranberry juice and buttermilk." 4. "Eat crackers, toast, and yogurt." 5. "Use a commercially prepared deodorizer inside the pouch." 6. "Do not skip meals or chew gum."
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3. "Drink cranberry juice and buttermilk." 4. "Eat crackers, toast, and yogurt." 5. "Use a commercially prepared deodorizer inside the pouch." 6. "Do not skip meals or chew gum." Explanation Strategy: Determine the outcome of each answer. Is it desired? 1) aspirin will not decrease odor; thoroughly clean, dry, and air pouch to eliminate odors; do not reuse disposable pouches; dispose of pouches when they no longer can be cleansed to eliminate the odor 2) avoid these foods because they contribute to gas production 3) CORRECT — helps prevent odor; eating parsley and yogurt is also helpful 4) CORRECT — helps prevent gas 5) CORRECT — helps eliminate odors 6) CORRECT— chewing gum, skipping meals, drinking beer, and smoking contribute to the production of ?atus
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The nurse plans staff assignments. Which clients are appropriate to assign to the LPN/LVN? Select all that apply. 1. A client following throat surgery for cancer with a history of diabetes. 2. A client following L-4 to L-S laminectomy with a history of breast cancer 3. A client diagnosed with multiple sclerosis with increased bilateral leg weakness. 4. A client diagnosed with hydrocephalus after a ventricular peritoneal shunt placement. 5. A client diagnosed with herpes zoster ophthalmicus and dementia.
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2. A client following L-4 to L-S laminectomy with a history of breast cancer 3. A client diagnosed with multiple sclerosis with increased bilateral leg weakness. 5. A client diagnosed with herpes zoster ophthalmicus and dementia. Explanation Strategy: Assign the LPN/LVN to stable clients with expected outcomes. 1) requires RN assessment because of the potential for an unstable airway 2) CORRECT —- stable client with predictable outcomes 3) CORRECT —- stable client with predictable outcomes 4) hydrocephalus requires assessment/evaluation; client unstable 5) CORRECT — stable client with predictable outcomes
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The nurse receives verbal patient care reports from the home health aide. Which of the following situations requires an intervention by the nurse? 1. A Mexican American female refuses to bathe because she is menstruating. 2. The family of a terminally ill Hindu man places him on the ?oor after the bed bath. 3. An African American female's hair is shampooed every third day. 4. A Pakistani male on bedrest genu?ects on the ?oor several times during the day.
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3. An African American female's hair is shampooed every third day. Explanation Strategy: "Requires and intervention" indicates an incorrect action. (1.) traditional cultural practice; females do not shower or bathe while menstruating (2.) cultural end-of-life ritual (3.) CORRECT - hair and scalp tend to be dry and need oil application rather than common shampoo, which will further dry out the scalp and make hair brittle (4.) lslamic ritual prayer done ?ve times per day; nurse should accommodate this practice to the best of the patient's ability
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Four mothers have delivered their infants vaginally within a 10-minute period. Which mother should the nurse evaluate FIRST? 1. A multipara who delivered a S-lb, 8-02 baby girl after 2.5 hours of labor and has a history of rapid labor. 2. A primipara who delivered a 7-lb, 2-oz baby boy after 16 hours of labor and is crying. 3. A multipara who delivered a 6-lb, 3-oz baby boy after 12 hours of labor and has a recent history of alcohol and marijuana use. 4. A primipara who delivered a 7-lb, 10-oz baby girl after 19 hours of labor and has a history of having been abused as a child.
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1. A multipara who delivered a S-lb, 8-02 baby girl after 2.5 hours of labor and has a history of rapid labor. Explanation Strategy: Determine the MOST unstable client. (1.) CORRECT - precipitous labor is a risk factor for early postpartum hemorrhage and also for amniotic ?uid embolism; it is de?ned as a labor pattern which progresses quickly and ends less than 3 hours from when it began; multipara status, small fetus in a favorable position, and history of previous rapid labors are contributing factors to this rapid labor (2.) birth weight and delivery time are within normal limits; need to investigate crying (3.) will need to assess mother for alcohol withdrawal symptoms (4.) birth weight and delivery time are within normal limits; careful and thorough patient teaching and follow-up will be particularly important; since there is a tendency for parents who have been abused as children themselves to then abuse their own children
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The home care nurse instructs a client diagnosed with multiple sclerosis. The client states: "I have poor concentration and have dif?culty pronouncing words". The nurse notes that the client's speech is slow and slurred. Which statement, if made by the client to the nurse, indicates further teaching is necessary? 1. "I will sit up straight when Italk and will feel con?dent." 2. "I will turn offtheTV when speaking and look at the person with whom I am talking." 3. "During a conversation, I will carefully build up to my most important points." 4. "If words fail me, lwill draw a picture."
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3. "During a conversation, I will carefully build up to my most important points." Explanation Type: Teaching/Learning question. Use TruelFalse with each answer. Topic: Incorrect method of communication with MS. 1) true statement for communicating with MS; eliminate 2) true statement for communicating with MS; eliminate 3) CORRECT — false statement for communicating with MS 4) true statement for communicating with MS; eliminate Step 5: Outcome, an incorrect practice for communication will be corrected.
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The nurse evaluates the nutritional intake of the adolescent girl attending camp. The adolescent eats all of the food provided. Each of the three meals contains foods from all areas of the "My Food Plate", averages about 900 calories, and has 3 mg of iron. The adolescent menstruates monthly and is of appropriate weight for height. Which best describes the adolescent's intake? 1. The diet is low in calories and high in iron. 2. The diet is low in calories and low in iron. 3. The diet is high in calories and low in iron. 4. The diet is high in calories and high in iron.
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3. The diet is high in calories and low in iron. Explanation STRATEGY: Think about each answer. 1) diet is high in calories (only 1,200 to 1,500 kcal/day required); iron is acceptable for a 12—13 year old female adolescent and low for an adolescent 14-18 2) diet is not low in calories but is low in iron 3) CORRECT - 900 x 3 = 2,700 calories/day and females 12—18 years old need 2000 kcal/day (males 12—13 years old need 2200 kcal/day; males at 14 years old need 2400 kcal/day; males 15 years old need 2600 kcal/day; males 16—18 years old need 2800 kcal/day); 3 mg x 3 = 9 mg/day of iron and females 12—13 years old need 8 mg/day and females 14—18 years old need 15 mg/day of iron (males 12—13 years old need 8 mg/day and males 14-18 years old need 11 mg/day of iron); with pregnancy 30 mg/day is required 4) diet is high in calories but not in iron
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A tornado has just leveled a large housing division near the hospital, and the disaster alarm has been announced at the hospital. The nurse caring for clients on the postpartumlpediatric unit considers which client most appropriate for discharge within the next hour? 1. A postpartum client who delivered over an intact perineum 12 hours ago. 2. A postpartum client diagnosed with an infection who has been receiving antibiotics for the past 24 hours. 3. A 3-year-old with newly diagnosed type 1 diabetes, diarrhea, and vomiting. 4. A 3—day—old breast-feeding infant with a total serum bilirubin of 14 mgIdL (239 umollL).
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4. A 3—day—old breast-feeding infant with a total serum bilirubin of 14 mgIdL (239 umollL). Explanation Strategy: Determine the most stable patient. 1) second most stable patient 2) do not know if antibiotics are effective or the current WBC count 3) most unstable client; requires frequent assessment of hydration status and blood glucose levels 4) CORRECT - most stable client; phototherapy considered for the infant with total serum bilirubin greater than 15 mg/dL (257 umolIL) at 72 hours of age; upper limit for breast-fed infant is 15 mgldL (257 pmoVL)
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The nurse cares for an elderly client after a left total hip replacement due to degenerative joint disease. The nurse is MOST concerned with which observation? 1. The client is positioned with a pillow between the legs. 2. The client moves slowly when getting out of bed. 3. The clients heels are on the bed with toes pointed upward. 4. The client uses an incentive spirometer every 2 hours.
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3. The clients heels are on the bed with toes pointed upward. Explanation Strategy: "MOST concerned" indicates something is wrong. 1) position prevents dislocation of prosthesis 2) prevents orthostatic hypotension 3) CORRECT - keep heels of elderly clients off the bed to prevent pressure sores 4) prevents atelectasis
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The nurse in the psychiatric day hospital program cares for a patient diagnosed with recurrent depression. The referring therapist recommends a cognitive therapy approach. The nurse doing the initial assessment knows it is MOST important to focus the assessment on which of the following? 1. The patients use of language. 2. The patient's insight into the depression. 3. The patient's socialization history and skills. 4. The patient's attitude toward medications.
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1. The patients use of language. Explanation Strategy: "MOST important" indicates that discrimination is required to answer the question. (1.) CORRECT - cognitive viewpoint on depression sees it as stemming from errors in thinking, which may be negative, illogical, and/or irrational; language is used in thought as well as in speech; speech or writing is used to express thoughts and thereby is an indicator of the patients automatic thoughts, their schemata or cognitive structure about themselves and the world, and their cognitive distortions (2.) emphasis on insight is prominent in traditional psychoanalytic and psychodynamic therapies (3.) emphasis on socialization is prominent in behavioral therapies, milieu therapies, and some interpersonal psychotherapies (4.) emphasis on medications is prominent in biochemical and psychologic therapies
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The nurse supervises care of a client who just had a short leg cast applied. The nurse determines that care is appropriate if which is observed? Select all that apply. 1. The cast is covered with a light sheet. 2. The staff handles the cast using the palms of their hands. 3. The affected limb is elevated to the level of the heart. 4. The nurse compares the toes of the casted leg with the opposite leg. 5. The staff places a fan in the client's room. 6. The staff turns the client every 4 hours.
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2. The staff handles the cast using the palms of their hands. 3. The affected limb is elevated to the level of the heart. 4. The nurse compares the toes of the casted leg with the opposite leg. 5. The staff places a fan in the client's room. Explanation Strategy: Determine the outcome of each answer. Is it desired? 1) leave cast uncovered and exposed to the air 2) CORRECT —- prevents development of pressure area 3) CORRECT — decreased edema 4) CORRECT — assess for neurovascular functioning; also assess circulation, motion, and sensation in the casted extremity 5) CORRECT — increases circulation of air in room to facilitate drying the cast 6) turn the client every 2 hours to facilitate drying the cast, support major joints when turning
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The nurse at the daycare center observes children playing on the playground. The nurse is MOST concerned if which of the following is observed? 1. Two children are ?ghting over a ball. 2. One child tries to pull another child off the swing. 3. A 2-year-old is crying, tugging at his ear, and hugging a stuffed animal. 4. A 3—year—old is leaning forward with mouth open, tongue protruding, and drooling.
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4. A 3—year—old is leaning forward with mouth open, tongue protruding, and drooling Explanation Strategy:"MOST concerned" indicates something is wrong. 1) potential injury could occur 2) potential injury could occur 3) actual problem; may indicate otitis media 4) CORRECT - indication of acute epiglottitis; sitting upright to breathe better, tongue protrusion increases pharyngeal movement; drooling caused by difficulty swallowing because of pain and excessive secretions
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The nurse cares for a client diagnosed with myasthenia gravis. Which of the following clinical manifestations would the nurse expect to see? Select all that apply. 1. Rigidity. 2. Muscle weakness that improves with rest. 3. Paresthesia of the lower extremities. 4. Propulsive gait. 5. Ptosis. 6. Diplopia.
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2. Muscle weakness that improves with rest. 5. Ptosis. 6. Diplopia. Explanation Strategy: Determine how each answer relates to myasthenia. 1) resistance to passive movement of the extremities; seen with Parkinson's disease 2) CORRECT - caused by acetylcholine de?ciency, transmission of nerve impulses is limited, resulting in difficulty stimulating or initiating muscular movement; muscle weakness increases with exertion; administer medication on time and plan activities to follow medication 3) seen with injury to spinal canal 4) seen with Parkinson's disease; short, hesitant steps 5) CORRECT - drooping eyelids, may also have impaired speech, dysphagia 6) CORRECT - double vision
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A severe storm has blown out the windows on a 30-bed medical/surgical unit. The nurse determines that clients have to be evacuated to other rooms throughout the hospital. Which client should the nurse transfer FIRST? 1. A 40-year-old client admitted with exacerbation of asthma who is receiving nebulizer treatments. 2. A 56-year-old client with unstable type 1 diabetes and a recent blood glucose of 124 mg/dL. 3. A 58-year-old client transferred from cardiac intensive care earlier in the day post-myocardial infarction. 4. A 60-year-old client with a peptic ulcer who is receiving a blood transfusion.
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1. A 40-year-old client admitted with exacerbation of asthma who is receiving nebulizer treatments. Explanation Strategy: Determine the most unstable client. 1) CORRECT - client is at risk of ineffective airway clearance due to particles in the air from storm debris and damage to the windows 2) blood sugar slightly elevated above normal limits but not the priority over the client with asthma nor the one receiving blood transfusions; should transfer third 3) may be anxious; does not take priority over other clients; transfer fourth 4) second most unstable client; requires frequent monitoring due to blood transfusion
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An adolescent girl comes to the outpatient clinic when she discovers that the person she had intercourse with 3 weeks ago has syphilis. Which of the following does the nurse expect to see if the client has contracted syphilis? 1. A papule-like lesion in the vaginal area. 2. AbnormaIPap smear. 3. Non-reactive blood serology test. 4. Cluster of painful blisters on the genital area.
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1. A papule-like lesion in the vaginal area. Explanation Strategy: Think about how each answer relates to syphilis. 1) CORRECT - primary syphilis; chancre develops within 2—6 weeks; appears at point of entry; starts as small papule, develops into painless ulcer 2) screening test for cancer of the cervix 3) VDRL becomes reactive 2—6 weeks after the primary infection; syphilis is treated with penicillin G [M or erythromycin for 10—15 days if allergic to PCN 4) genital herpes; may have difficulty voiding; recurrence during times of stress, infection, menses
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The nurse plans discharge care for the client diagnosed with recurrent cancer and who has lymphedema. Which client statements alert the nurse to a need for home health services? Select all that apply. 1. "I use this magnifying glass when I need to read small print." 2. "Sometimes I don't get to the bathroom in time." 3. "My hands always shake when Itry to pick things up." 4. "My dentures don't ?t so I don't wear them, but I eat just ?ne." 5. "I can't feel a thing in my feet. it's been that way for a while." 6. "I'm not able to get in the bathtub anymore."
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2. "Sometimes I don't get to the bathroom in time." 3. "My hands always shake when Itry to pick things up." 4. "My dentures don't ?t so I don't wear them, but I eat just ?ne." 5. "I can't feel a thing in my feet. it's been that way for a while." Explanation Strategy: "Need for home health services" indicates there may be a potential problem. Determine if the client statements indicate a potential problem. 1) this client is using an appropriate way to manage the presbyopia; the client may need a referral to an ophthalmologist, but home health is not necessary 2) CORRECT— a home health referral could bene?t this client by assessing for durable medical equipment that might assist the client in using the bathroom; if incontinence is a problem, the client may need assistance with personal care 3) CORRECT— this client may need assistance preparing meals, and managing medication administration 4) CORRECT— although the client says helshe "eats just ?ne", a dietary referral will ensure the client has the home resources and ability to eat a balanced diet; the fact that the dentures don't ?t may indicate the client has lost signi?cant weight 5) CORRECT — a home health referral will determine if this client has safety needs in the home because of numbness in the feet; slippery or uneven surfaces could be dangerous for this client 6) a home health referral is not necessary as long as the client is able to meet his/her hygiene needs in other ways besides tub baths, such as showering or sponge baths
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The home care nurse visits a 52-year.old man with an above-knee amputation (AKA). The nurse reviews with him how to care for the residual limb. Which of the following instructions by the nurse is BEST? 1. Apply cream to the residiual limb every day. 2. Cover the residual limb with a nylon sock while awake. 3. Keep the residual limb elevated on a pillow at night. 4. Expose the residual limb to air daily.
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4. Expose the residual limb to air daily. Explanation Strategy: Determine the outcome of each answer. is it desired? 1) may predispose to infection of residual limb; skin needs to be ?rm; wash and dry gently twice each day 2) precipitates moisture and warmth that may predispose to infection; use only cotton or wool residual limb socks; change daily and ensure the sock ?ts smoothly 3) do not elevate after the ?rst 24 h, may result in flexion contracture 4) CORRECT - facilitates healing of residual limb; inspect daily for pressure areas, dermatitis, and blisters
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The nurse cares for the client in balanced suspension traction. The client reports pain in the affected extremity, and the nurse administers the prescribed pain medication. One hour later, the client tells the nurse that the pain is unrelieved. Which action does the nurse take ?rst? 1. Contact the physician. 2. Turn on the client's radio. 3. Ask the client to rate his pain using a numeric rating scale. 4. Perform a neurovascular assessment.
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4. Perform a neurovascular assessment. Explanation Strategy: 'First' indicates priority. 1) nurse should ?rst complete assessment 2) distraction is used to help the client cope with pain; nurse should ?rst determine cause of pain 3) client says pain is unrelieved; nurse should determine cause of pain 4) CORRECT— pain unrelieved by medication is a sign of acute compartment syndrome
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The nurse in the outpatient clinic receives a call from the parent of a teenager diagnosed with infectious mononucleosis. The mother complains that her child seems angry and depressed since developing mononucleosis. Which of the following responses by the nurse is MOST appropriate? 1. 'Why do you think your child is angry? 2. 'Teens become frustrated because of feeling weak and fatigued." 3. 'Would you like the physician to talk with your child? 4. "My child had mono and was crabby all the time."
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2. 'Teens become frustrated because of feeling weak and fatigued." Explanation Strategy: Remember therapeutic communication. 1) nontherapeutic; do not ask 'why' questions 2) CORRECT - because of teen's active life style, may react with anger and depression to the weakness and fatigue; allow teen to vent and reassure teen that activities can be resumed after the acute phase 3) passing the buck; nurse should respond to the situation 4) nontherapeutic; focus is on nurse and not the client
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The nurse notices that a client who practices Judaism has a lunch tray containing beef, green beans, salad, vanilla pudding, and milk. Which of the following actions by the nurse is MOST appropriate? 1. Ask the client if she would like a chicken entre. 2. Inform the client that an alternate meal will be requested. 3. Ask the client if the beef is cooked appropriately. 4. Offer the client more vegetables.
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2. Inform the client that an alternate meal will be requested. Explanation Strategy: Determine the outcome of each answer. ls it appropriate? 1) dairy/meat combination is prohibited 2) CORRECT - dietary laws based on biblical and rabbinical regulations; milk/milk products not eaten at same meal with meat 3) dairy/meat combination is prohibited 4) dairy/meat combination is prohibited
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The nurse overhears the supervisor reprimand the head nurse for not discussing feelings with a patient. Shortly after, a patient asks the head nurse for an extra blanket. The head nurse angrily responds, "Get it yourself" The nurse recognizes the head nurse is displaying which defense mechanism? 1. Compensation. 2. Displacement. 3. Conversion. 4. Projection.
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2. Displacement. Explanation Strategy: Think about the answers. 1) an attempt to overcome real or imagined shortcomings 2) CORRECT—head nurse is displacing feelings of anger at the supervisor onto the patient who is less threatening 3) anxiety is repressed and converted into physical symptoms 4) attributing to others one's feelings, impulses, thoughts, or wishes
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The nurse performs dietary teaching for a client diagnosed with acute in?ammatory bowel disease. The nurse determines further teaching is required if the client makes which statement? 1. "I like to make my sandwiches with white bread." 2. "My favorite dessert is tapioca pudding." 3. "My family likes to eat roasted chicken." 4. "I drink red wine with dinner."
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4. "I drink red wine with dinner." Explanation Strategy: "Further teaching is required" indicates incorrect information. (1.) appropriate action; should avoid whole-grain breads; during acute phase, diet should be low-residue, high-protein, and high-calorie (2.) acceptable food on a low-residue diet (3.) acceptable food on a low-residue diet (4.) CORRECT - may exacerbate the in?ammatory condition
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The nurse receives report from the previous shift. Which client does the nurse see first? 1. The client post coronary artery bypass graft (CABG) having the atrioventricular (AV) wires removed later in the day. 2. The client with type 1 diabetes scheduled for a cardiac catheterization later today. 3. The client1 day postoperative with an epidural catheter in place. 4. The client diagnosed with cardiomyopathy being evaluated for a heart transplant.
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3. The client1 day postoperative with an epidural catheter in place. Explanation Strategy: Determine which client is the least stable. 1) although the client requires a high level of nursing care, no indication that the client is unstable 2) client requires preoperative assessment and teaching, no indication the client is unstable 3) CORRECT - epidural used for pain relief, monitor for urinary incontinence, hypotension, respiratory depression, and nausea and vomiting 4) requires monitoring but client with epidural takes priority
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The nurse cares for clients on the medical/surgical ?oor. Because of a staffing shortage, an RN has been reassigned from postpartum. Which of the following clients should the nurse give to the reassigned nurse? 1. A client admitted with facial trauma after an auto accident. 2. A client diagnosed with a heat stroke. 3. A client having a systemic reaction to latex. 4. A client with progressive systemic sclerosis experiencing Raynaud's phenomenon.
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4. A client with progressive systemic sclerosis experiencing Raynaud's phenomenon. Explanation Strategy: Assign stable clients with expected outcomes. 1) requires close monitoring to assess for a patent airway; assess eye functioning, observe for neurological changes; not a stable client 2) dehydration and hyperthermia, place in air-conditioned room, lie ?at with legs elevated, administer oxygen; not a stable client 3) potential anaphylactic reaction; not a stable client 4) CORRECT - chronic connective tissue disease that caused in?ammation, ?brosis, and sclerosis of the skin and vital organs; stable client who can be assigned to the reassigned RN
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The nurse plans a diet for the child diagnosed with cystic ?brosis (CF). Which dietary requirements are considered by the nurse? Select all that apply. 1. High-protein. 2. Low-sodium. 3. High-calorie. 4. Low-protein. 5. Low-carbohydrate. 6. High-sodium.
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1. High-protein. 3. High-calorie Explanation Strategy: think of physiology of cystic ?brosis. 1) CORRECT - impaired intestinal absorption due to cystic ?brosis necessitates a diet high in protein and calories 2) no need to reduce sodium 3) CORRECT - impaired intestinal absorption due to cystic ?brosis necessitates a diet high in protein and calories 4) need high protein for growth and because of loss of nutrients 5) the level of carbohydrate is not as important as increased calories 6) sodium should not be elevated
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A client with newly diagnosed type 1 diabetes says to the nurse, "I know that I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which response by the nurse is best? 1. "It is best to buy new shoes in the morning." 2. "Have each foot measured every time you buy new shoes." 3. "Buy shoes a half-size larger than your foot size so the ?t is roomy." 4. "Buy vinyl shoes because they won't lose their shape easily."
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2. "Have each foot measured every time you buy new shoes." Explanation Strategy: All answers are implementations. Determine the outcome of each answer choice. ls it desired? (1) should buy shoes in the afternoon when feet are larger than in the morning (2) CORRECT - feet enlarge with age, break in shoes gradually rather than all at one time, have measurements for shoes taken while standing (feet are larger) (3) buy correct shoe size (4) leather shoes recommended because they "breathe," vinyl could cause foot to perspire and aggravate fungal infections
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The nurse cares for a client one day after a thoracotomy. Nursing actions listed on the care plan include turn, cough, and deep breathe q 2 h. What does the nurse understand the purpose of this nursing action to be? 1. Promote ventilation and prevent respiratory acidosis. 2. Increase oxygenation and removal of secretions. 3. Increase pH and facilitate balance of bicarbonate. 4. Prevent respiratory alkalosis by increasing oxygenation.
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1. Promote ventilation and prevent respiratory acidosis. Explanation Strategy: Think about each answer choice. (1) CORRECT - primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis (2) answer choice #1 is better in that it refers to ventilation rather than oxygenation (3) increasing the pH is not desirable (4) respiratory alkalosis is not prevented by this nursing measure
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The nurse in the pediatric of?ce observes a child in the waiting room. The nurse notes the child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. Which does the nurse identify as the child's chronological age? 1. 1 year old. 2. 2 years old. 3. 3 years old. 4. 5 years old.
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3. 3 years old. Explanation Strategy: Picture the child at each age. (1) unable to walk up and down stairs with hand held until 18 months (2) unable to jump until 30 months (3) CORRECT - able to jump with both feet and stand on one foot momentarily at 30 months (4) behaviors are seen in younger child
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The nurse cares for the client after an electroconvulsive therapy (ECT) treatment. The nurse reports which observation to the health care provider? 1. Headache. 2. Disruption in short- and long-term memory. 3. Transient confusional state. 4. Backache.
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4. Backache. Explanation Strategy: Look for an unexpected observation. 1) expected effect 2) expected effect 3) expected effect 4) CORRECT - client undergoing ECT needs to be instructed about what could be experienced during and after ECT; expected effects include headache, disrupted memory (short— and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the health care provider
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Which statement, if made by the nurse to the client experiencing in?ammation due to rheumatoid arthritis, is correct? 1. "If you are having a 'bad' day, postpone your exercises until the next day." 2. "Passive exercises are better for you than active exercises." 3. "When inflammation is severe, decrease the number of repetitions of the exercise." 4. "You can substitute your normal household tasks for your exercises to provide variety."
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3. "When inflammation is severe, decrease the number of repetitions of the exercise." Explanation Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) consistency is important to maintain joint mobility (2) active exercises are better than passive or active-assistive exercises (3) CORRECT - should reduce repetitions when client experiences more pain (4) should do exercises that have been prescribed for client
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The client is admitted for regulation of insulin dosage. The client takes 15 units of isophane insulin at 08:00 every day. At 16:00, which nursing observations indicate a complication from the insulin? *Select all that apply.* 1. Acetone odor to the breath. 2. irritability. 3. Polyuria. 4. Tachycardia. 5. Headache. 6. Diaphoresis.
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2. irritability. 4. Tachycardia. 6. Diaphoresis. Explanation Strategy: Think about difference between hypoglycemia and hyperglycemia; think about type of insulin and length of action. 1) related to hyperglycemia 2) CORRECT - isophane insulin is an intermediate-acting insulin that peaks from 8 to 12 hours after administration; this is when signs and symptoms of hypoglycemia will occur 3) related to hyperglycemia 4) CORRECT - isophane insulin is an intermediate-acting insulin that peaks from 8 to 12 hours after administration; this is when signs and symptoms of hypoglycemia will occur 5) related to hyperglycemia 6) CORRECT - isophane insulin is an intermediate-acting insulin that peaks from 8 to 12 hours after administration; this is when signs and symptoms of hypoglycemia will occur
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Which observation indicates to the nurse that the client needs further teaching before self-administering insulin? 1. The client draws up the short-acting insulin ?rst, then the intermediate-acting insulin. 2. The client gently rotates the insulin bottle before withdrawing the dose. 3. The client rotates injection sites following the guide on the printed diagram. 4. The client administers the insulin while it is still cold from the refrigerator.
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4. The client administers the insulin while it is still cold from the refrigerator. Explanation Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) when mixing short-acting insulin with other types of insulin, the client should draw up the clear (short-acting [regular]) before the cloudy (intermediate-actin g) 2) bottle of insulin should never be vigorously shaken, but rather gently mixed 3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper absorption 4) CORRECT - insulin should be administered at room temperature; temperature extremes should be avoided
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The parent brings 10-year-old and 3-year-old children to the pediatric of?ce. The younger child reports dysuria. The health care provider orders a catheterized urine specimen. The nurse takes which action? 1. Describes the procedure to the child in short, concrete terms while talking calmly. 2. Allows the child to play with the equipment during the procedure. 3. Involves the older sibling in explaining the procedure. 4. Shows the child a diagram ofthe urinary system.
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1. Describes the procedure to the child in short, concrete terms while talking calmly. Explanation Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) CORRECT - children this age need simple explanations 2) might contaminate the equipment; must be a sterile procedure 3) not likely to listen to sibling 4) not appropriate for this age
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The client is treated in the telemetry unit for cardiac disease. The client receives propranolol hydrochloride 20 mg PO at 09:00. When the nurse enters the room to give the medication to the client, the nurse ?nds the client wheezing with a nonproductive cough and shortness of breath. Initially, the nurse should take which action? 1. Hold the medication and count the respirations. 2. Hold the medication and call the health care provider. 3. Take an apical pulse and then give the medication. 4. Give the mediation as ordered.
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1. Hold the medication and count the respirations. Explanation Strategy: Determine the outcome of each answer choice. (1) CORRECT - side effects include increased airway resistance; client is experiencing bronchospasm; should assess and then call the health care provider (2) should assess the client's condition ?rst (3) client is experiencing a side effect; medication should not be given (4) medication should be held; client is experiencing a side effect
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The older client diagnosed with pneumonia is admitted to the medical/surgical unit. Which other client does the nurse place with the older client? 1. The 20-year-old in traction for multiple fractures of the left lower leg. 2. The 35—year-old with recurrent fever of unknown origin. 3. The 50-year-old recovering alcoholic with cellulitis of the right foot. 4. The 89-year-old with Alzheimer's disease awaiting long term care facility placement.
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3. The 50-year-old recovering alcoholic with cellulitis of the right foot. Explanation Strategy: Determine the transmission of organisms. 1) clients with fractures are considered "clean"; don't place with an infectious client 2) don't know the cause ofthe fever 3) CORRECT - generalized nonfollicular infection that involves deeper connective tissue, both clients have infections 4) elderly are high risk for developing pneumonia
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The nurse in the outpatient clinic assists with the application of a cast to the left arm of a pre-school-aged child. After the cast is applied, the nurse should take which action? 1. Petal the edges of the cast to prevent irritation. 2. Elevate the client's left arm on two pillows. 3. Apply cool, humidi?ed air to dry the cast. 4. Ask the client to move the ?ngers to maintain mobility.
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2. Elevate the client's left arm on two pillows. Explanation Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) done when cast is completely dry, prevents crumbling of plaster into cast (2) CORRECT - minimizes swelling, elevated for ?rst 24 to 48 hours, protects from pressure and ?attening of cast (3) would delay drying of cast (4) maintaining mobility of ?ngers not most important after application of cast
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The nurse cares for clients on a psychiatric unit and is suddenly faced with multiple issues. In which order does the nurse address these situations? *Place the answers in order of priority starting with the ?rst client to be seen. All options must be used.* The client with substance abuse reports harassment another client. The client diagnosed with schizophrenia tells the nurse the TV should be destroyed. The client diagnosed with bipolar disorder walks into the day room wearing only underwear. The client diagnosed with depression says to the nurse, 'My plan is complete, and I'm ready to go.'
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The client diagnosed with depression says to the nurse, 'My plan is complete, and I'm ready to go.' The client with substance abuse reports harassment another client. The client diagnosed with schizophrenia tells the nurse the TV should be destroyed The client diagnosed with bipolar disorder walks into the day room wearing only underwear. Explanation Strategy: Think about physical danger ?rst. 1) ?rst, the client diagnosed with depression could indicate impending suicide; requires immediate follow-up 2) second, the client with substance abuse should be removed to quiet area, decrease environmental stimuli; may cause distraction for other clients 3) third, the client diagnosed with schizophrenia is experiencing command hallucination; protect from injury and destroying the TV 4) fourth, the client wearing only underwear is not a harm to self or others initially
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The nurse cares for the client who has had an above-knee amputation (AKA) with an immediate prosthetic ?tting. It is most important for the nurse to take which action? 1. Assess drainage from Penrose drains. 2. Observe dressings for signs of excessive bleeding. 3. Elevate the stump for no less than 40 hours. 4. Provide cast care on the affected extremity.
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4. Provide cast care on the affected extremity. Explanation Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of each implementation. 1) drains not usually used with amputations 2) rigid cast dressing frequently used to create a socket for prosthesis 3) elevation of extremity forthis length of time is unnecessary; rigid cast dressing helps prevents swelling 4) CORRECT — cast applied to provide uniform compression, prevent pain and contractures
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The nurse cares for the client on suicide precautions. The nurse makes these observations: the client is verbalizing other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members. Based on this data, which nursing action is most appropriate? 1. Recommend the health care provider decrease the client's medication dosage. 2. Recommend the treatment team reevaluate the client's treatment plan. 3. Give the client privileges to walk around the hospital alone. 4. Ask the family to begin planning for the client's discharge.
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2. Recommend the treatment team reevaluate the client's treatment plan. Explanation Strategy: All answers are implementations. Determine the outcome of each answer choice. is it desired? (1) may reverse the client's progress (2) CORRECT - data suggest that client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually on the basis of a full—data picture (3) may be the team's decision, but not until a thorough review of the case is completed (4) premature
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The nurse reviews client assignments on a medical/surgical unit. The nurse determines that the assignment is appropriate if the nursing assistive personnel is caring for which client? 1. The client with AIDS dementia complex who requires a urine specimen. 2. The client reporting postoperative pain after repair of a torn rotator cuff. 3. The client with GI bleeding due to a duodenal ulcer who is receiving packed cells. 4. The client with type 1 diabetes receiving prednisone for a herniated disk.
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1. The client with AIDS dementia complex who requires a urine specimen. Explanation Strategy: Assign clients with standard, unchanging procedures. (1) CORRECT - standard, unchanging procedure (2) assign to the RN (3) assign to the RN (4) assign to the RN
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The nurse cares for clients on the pediatric unit. The parent of the 2-year-old who is one day postoperative tells the nurse, "My child is so restless and overactive." The nurse takes which action? 1. Directs the LPN/LVN to obtain the child's vital signs. 2. Asks the parent if the child's sutures are still intact. 3. Tells the nursing assistive personnel to take the child for a walk. 4. Checks to see when the child last received pain medication.
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4. Checks to see when the child last received pain medication. Explanation Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment. 1) no indication there are any problems 2) passing the buck 3) implementation; should ?rst assess 4) CORRECT - young children typically become restless and overactive if in pain; grimacing, clenching teeth, rocking, and aggressive behavior may also be observed
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Which client statement indicates to the nurse the client is using the defense mechanism of conversion? 1. "I love my family with all my heart, even though they don't love me." 2. "I was unable to take my ?nal exams because I was unable to write." 3. "I don't believe I have diabetes. | feel perfectly ?ne." 4. "If my spouse was a better housekeeper I wouldn't have such a problem."
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2. "I was unable to take my ?nal exams because I was unable to write." Explanation Strategy: Think about each answer choice. 1) indicates reaction formation 2) CORRECT - client has converted the anxiety over school performance into a physical symptom that interferes with the ability to perform 3) indicates denial 4) indicates projection
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The nurse cares for an elderly client who has just had a prosthetic hip implant. The nurse should position the client in which position? 1. With the affected hip internally rotated and ?exed. 2. With the affected hip adducted when turned. 3. In the supine position with the knees elevated 90 degrees. 4. Side-lying with the affected hip in a position of abduction.
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4. Side-lying with the affected hip in a position of abduction. Explanation Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) ?exion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period (2) ?exion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period (3) ?exion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period (4) CORRECT - position of abduction should be maintained
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A client has been taking propranolol 40 mg BID and furosemide 40 mg daily for several months. Two weeks ago, the health care provider added verapamil 80 mg TlD to the client's medication regimen. The client returns to the outpatient clinic for evaluation. It is most important for the nurse to assess for which symptom? 1. Tachycardia. 2. Diarrhea. 3. Peripheral edema. 4. Impotence.
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3. Peripheral edema. Explanation Strategy: Determine how each answer choice relates to the medication. (1) will cause bradycardia (2) usually causes constipation (3) CORRECT - verapamil is a calcium channel blocker, depresses myocardial contractility, decreases work of ventricles and Oz demand, dilates coronary arteries; when used with other antihypertensives can cause hypotension and heart failure (4) not most important or frequent side effect
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The nurse cares for a client several days after an above-knee amputation (AKA). Which symptom is characteristic of an infected residual limb wound? 1. The client is anxious and restless. 2. There is a small amount of dark drainage on the dressing. 3. The client reports persistent pain at the operative site. 4. The skin is cool above the operative site.
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3. The client reports persistent pain at the operative site. Explanation Strategy: Determine how each answer choice relates to an infected wound. (1) may be due to changes in body image or pain (2) expected, not indicative of an infection (3) CORRECT - pain is characteristic of in?ammation and infection (4) warm skin above operative site would indicate infection
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The nurse receives report from the previous shift. In which order does the nurse see these clients? *Place the clients in order of priority starting with the first client to see. All options must be used.* The client post coronary artery bypass graft having the atrioventricular wires removed at 1500. The client 1 day postoperative with an epidural catheter in place The client diagnosed with cardiomyopathy being evaluated for a heart transplant. The client diagnosed with type 1 diabetes scheduled for a cardiac catheterization at 1400.
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The client 1 day postoperative with an epidural catheter in place The client diagnosed with cardiomyopathy being evaluated for a heart transplant. The client diagnosed with type 1 diabetes scheduled for a cardiac catheterization at 1400. The client post coronary artery bypass graft having the atrioventricular wires removed at 1500. Explanation Strategy: Look for most unstable client and work towards most stable client. 1) ?rst: most unstable client with epidural needs assessment for adverse effects of epidural and is fresh postop with respiratory considerations 2) second: client needing heart transplant will be unstable, requires monitoring and early assessment; circulation consideration. 3) third: needs assessment of blood glucose and preoperative needs but falls behind respiratory and unstable circulation 4) fourth: stable client having atrioventricular wires removed
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A client is receiving imipramine. It is most important for the nurse to instruct the client to immediately report which symptoms? Select all that apply. 1. Fever. 2. Dry mouth. 3. Increased fatigue. 4. Vomiting and diarrhea. 5. Staggering gait. 6. Sore throat.
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1. Fever. 2. Dry mouth. 3. Increased fatigue. 4. Vomiting and diarrhea. 6. Sore throat. Explanation Strategy: Think about side effects of imipramine. 1) CORRECT - side effect of imipramine. 2) CORRECT - side effect of imipramine. 3) CORRECT - side effect of imipramine. 4) CORRECT - side effect of imipramine. 5) not a side effect of imipramine. 6) CORRECT - side effect of imipramine.
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The nurse prepares a dopamine infusion for the client. Which action does the nurse take first? 1. Evaluates the urine output. 2. Obtains the client's weight. 3. Determines the patency of the IV line. 4. Measures pulmonary artery pressures.
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3. Determines the patency of the IV line. Explanation Strategy: Determine how each answer choice relates to dopamine. 1) not a critical assessment at this time 2) contains correct information but is not a priority 3) CORRECT — if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious adverse effects 4) not a critical assessment at this time
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A client is diagnosed with obsessive-compulsive disorder manifested by the compulsion of hand-washing. The nurse knows which behavior best describes the clients need for repetitive acts of hand-washing? 1. Hand-washing represents an attempt to manipulate the environment to make it more comfortable. 2. Hand-washing externalizes the anxiety from a source within the body to an acceptable substitute outside the body. 3. Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety. 4. Hand-washing helps maintain the client in an active state to resist the effects of depression.
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3. Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety. Explanation Strategy: Think about each answer choice. 1) not a manipulation on the client's part 2) not an accurate statement regarding the compulsive behavior of this client 3) CORRECT - compulsive behavior is an unconscious attempt to control and/or relieve the tension and anxiety the client is experiencing 4) client is not subject to depression but to high levels of anxiety
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A client is admitted with irritable bowel syndrome. The nurse anticipates that the client's history will re?ect which information? 1. Pattern of alternating diarrhea and constipation. 2. Chronic diarrhea stools occurring 10 to 12 times per day. 3. Diarrhea and vomiting with severe abdominal distention. 4. Bloody stools with increased cramping after eating.
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1. Pattern of alternating diarrhea and constipation. Explanation Strategy: Think about each answer choice. (1) CORRECT - condition is often called spastic bowel disease; no in?ammation is present (2) refers to in?ammatory bowel disease such as ulcerative colitis or Crohn's disease (3) refers to in?ammatory bowel disease such as ulcerative colitis or Crohn's disease (4) bloody stools do not occur with irritable bowel syndrome
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Nursing management prior to an intravenous pyelogram (IVP) would include which action? 1. A fat-free meal the evening before the examination and radiopaque tablets at bedtime. 2. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter. 3. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract. 4. Explaining the importance of following directions regarding voiding during the test.
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3. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract. Explanation Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) fat-free meal is associated with a gallbladder series (2) a retention Foley catheter may be in place, but not forthe purpose ofdilating the bladder sphincter (3) CORRECT - because ofthe need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered (4) there are few directions the client needs to follow during the test
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The nurse cares for the client admitted with a diagnosis of acute hypoparathyroidism. It is most important for the nurse to have which item available? 1. Tracheostomy set. 2. Cardiac monitor. 3. IV monitor. 4. Heating pad.
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1. Tracheostomy set. Explanation Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) CORRECT - tracheostomy set is the most important for the client's safety due to risk for laryngospasm 2) nice to have, but not the most important 3) nice to have, but not the most important 4) unnecessary
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The nurse cares for a client receiving a continuous tube feeding. Which nursing action is most appropriate? 1. Rinse the bag and change the formula every 4 hours. 2. Rinse the bag and change the formula every shift. 3. Change the bag and formula every shift. 4. Rinse the bag and change the formula every 2 hours.
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1. Rinse the bag and change the formula every 4 hours. Explanation Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) CORRECT - there is an increased growth of organisms after 4 hours (2) inappropriate due to increased organism growth (3) inappropriate due to increased organism growth (4) not a necessary action to maintain asepsis
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The 6-month-old infant has had all of the required immunizations for this age. The nurse knows that this would include which immunizations? 1. Three doses of diphtheria, tetanus, and pertussis vaccine. 2. Measles, mumps, and rubella vaccine. 3. One dose of rotavirus. 4. Varicella vaccine.
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1. Three doses of diphtheria, tetanus, and pertussis vaccine. Explanation Strategy: Think about each answer choice. 1) CORRECT - ?rst dose ofthe DPT may be given at2 months of age, the second is given around 4 months,the third at 6 months 2) MMR is given at 12 to 15 months 3) rotavirus is given at 2, 4 and 6 months 4) varicella given at 12 to 15 months
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The extremely angry client with bipolar illness tells the nurse, "I just found out that my spouse has ?led for divorce. I need to use the phone to call right now!" Which action by the nurse is most appropriate? 1. Allow the client to use the phone. 2. Confront the client about the anger and inappropriate plan of action. 3. Do not allow the client to use the phone because this is an involuntary admission. 4. Set limits on the client's phone use because of the inability to control behavior.
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1. Allow the client to use the phone. Explanation Strategy: All answers are implementations. Determine the outcome of each answer choice. is it desired? 1) CORRECT - client is able to use phone unless otherwise indicated by court order or health care provider's order 2) has not lost civil right to use phone 3) denies the client's civil rights (4) inappropriate
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The teenage client diagnosed with anorexia nervosa is admitted to the hospital. Which behavior does the nurse expect the client to present? 1. View appearance as "skinny." 2. Be hypoactive and withdrawn. 3. Want to discuss and plan meals. 4. Have a close relationship with a parent.
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3. Want to discuss and plan meals. Explanation Strategy: Determine how each answer choice relates to anorexia. 1) usually view the appearance as fat 2) inaccurate for client with anorexia nervosa 3) CORRECT - display a marked preoccupation with food 4) inaccurate for client with anorexia nervosa
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The infant is admitted with vomiting and diarrhea. The infants anterior fontanelle is depressed and the temperature is 103.2= F (39.5' C). Which nursing action is most appropriate? 1. Obtain daily weights and evaluate weight loss. 2. Observe the infant's ability to take in ?uids. 3. Place a full bottle of pediatric electrolyte solution at the bedside. 4. Start an intravenous infusion.
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2. Observe the infant's ability to take in ?uids. Explanation Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. is there an appropriate assessment? Yes. 1) assessment; correct information, but is not what the question asks for 2) CORRECT - assessment; will assist in determining if hydration can be done through oral ?uids alone 3) implementation; does not do anything to improve the situation; placing a full bottle at the bedside doesn't guarantee the infant is taking ?uids 4) implementation; would be implemented later
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A client with clear lung sounds and unlabored breathing receives aminophylline IV. Which is the most appropriate nursing action if the client's IV in?ltrates? 1. Apply warm soaks to the in?ltration site, start a new IV, and continue IV medications. 2. Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing. 3. Restart the IV and continue the previous medication schedule. 4. Call the health care provider and recommend the IV medications be changed to PD.
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4. Call the health care provider and recommend the IV medications be changed to PD. Explanation Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) continued IV medication may not be necessary based on the current assessment (2) health care provider should be noti?ed if IV medications are not infusing as scheduled (3) client has improved breathing, so IV medications may not be indicated (4) CORRECT - before a new IV is started on this client, the health care provider should be called and PO medications recommended
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A client is admitted for a series of tests to verify the diagnosis of Cushing's syndrome. Which assessment ?nding, if observed by the nurse, supports this diagnosis? Select all that apply. 1. Buffalo hump. 2. Intolerance to heat. 3. Hyperglycemia. 4. Hypernatremia. 5. Intolerance to cold. 6. lrritability.
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1. Buffalo hump. 3. Hyperglycemia. 4. Hypernatremia. Explanation (1) CORRECT - hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (2) indication of hyperthyroidism (3) CORRECT - hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (4) CORRECT - hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (5) indication of hypothyroidism (6) indication of hypoparathyroidism
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The nurse cares for the elderly client receiving IV ?uids of 0.9% NaCI at 125 mL/h into the left arm. During a routine assessment, the nurse ?nds the client has distended neck veins, shortness of breath, and crackles in both lung bases. Which action does the nurse take ?rst? 1. Decreases the IV rate to 20 mL/h and noti?es the health care provider. 2. Decreases the IV rate to 100 mL/h and continues to monitor the client. 3. Discontinues the IV and starts oxygen at 6 L/min. 4. Assesses for in?ltration of the IV solution.
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1. Decreases the IV rate to 20 mL/h and noti?es the health care provider. Explanation Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. 1) CORRECT — 20 mUh (KVO - keep vein open) will keep access open 2) need to notify health care provider; rate still too much since client is in ?uid overload 3) IV line may be necessary; diuretics may be ordered 4) description indicates circulatory overload, not in?ltration
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The of?ce nurse reinforces the health care provider's explanation for a myelogram. Which statement correctly describes a myelogram for the client? 1. "The test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown." 2. "The test involves injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk." 3. "The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal." 4. "The test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space."
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3. "The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal." Explanation Strategy: Determine how each answer choice relates to a myelogram. 1)x-ray examination cannot determine the extent of myelin breakdown 2) no such procedure; injecting contrast medium into a ruptured disk would not allow visualization of the spinal column 3) CORRECT — contrast medium is injected into spinal subarachnoid space through a spinal puncture; identi?es tumors, cysts, herniated vertebral disks 4) no such procedure; air is not injected into the subarachnoid space
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The nurse supervises care given to clients on a medical surgical unit. The nurse intervenes if which activity is observed? 1. The nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition. 2. The nurse injects insulin through a single-lumen percutaneous central catheter for the client receiving total parenteral nutrition. 3. The nurse applies lip balm to the lips immediately after performing a blood draw to obtain a specimen. 4. The nurse wears a disposable particulate respirator when administering rifampin to the client with tuberculosis.
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3. The nurse applies lip balm to the lips immediately after performing a blood draw to obtain a specimen. Explanation Strategy: "Nurse intervenes" indicates an incorrect action is expected. 1) appropriate procedure, prevents airborne contamination 2) insulin is the only medication that can be given, compatible with TPN 3) CORRECT — applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur 4) use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hour
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The client is diagnosed with right-sided weakness. The nurse instructs the client how to walk down stairs using a cane. Which client behavior indicates the teaching is successful? 1. The client puts the right leg on the step, then the cane, followed by the left leg. 2. The client leads with the cane, followed by the right leg and then the left leg. 3. The client advances the right leg, followed by the left leg and the cane. 4. The client puts the cane on the step and advances the left leg, followed by the right leg.
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2. The client leads with the cane, followed by the right leg and then the left leg. Explanation Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) to go down stairs, advance weak leg and cane ?rst; to go up stairs, advance strong leg, then weak leg and cane 2) CORRECT - to go down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down 3) should advance cane and weak leg ?rst 4) weaker leg and cane advance ?rst
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A client is returned to the unit after surgery with a cuffed tracheostomy tube in place. The nurse knows the purpose of the cuff on the tracheostomy tube includes which reason? 1. Guarantees secure placement of the tracheostomy tube in the airway. 2. Prevents ischemia of the tracheal wall by distributing the pressure applied to it. 3. Decreases the chance of aspiration into the trachea. 4. Protects the trachea from ischemia and edema.
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3. Decreases the chance of aspiration into the trachea. Explanation Strategy: Think about each answer choice. 1) inaccurate, not the purpose ofthe cuff on a tracheostomy tube 2) complication of using a cuffed tracheostomy tube 3) CORRECT - seals trachea, helps to prevent aspiration 4) trauma from overin?ated tube may cause edema
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An 11-year-old child falls off a bicycle and sustains a minor head injury that is treated at the outpatient clinic. The nurse instructs the child's parent about care at home. The nurse determines further teaching is needed if the parent makes which statement? 1. "My child may have dizziness for 24 hours." 2. "My child can drink carbonated beverages if vomiting occurs." 3. "My child may report feeling nauseated." 4. "My child will probably have a headache."
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2. "My child can drink carbonated beverages if vomiting occurs." Explanation Strategy: Determine how each answer choice relates to a minor head injury. (1) expected for at least 24 hours (2) CORRECT - vomiting is unexpected; should be reported to health care provider immediately; also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache (3) expected for at least 24 hours (4) expected for at least 24 hours; should not get more intense
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The adult client has missed her menstrual period. The clients last menstrual period began May 8 and ended May 12. The nurse determines the client's estimated date of birth (EDB) is which date? 1. February 1. 2. February 15. 3. February 19. 4. March 14.
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2. February 15. Explanation Strategy: Remember Naegele's rule. 1) should add 7 days 2) CORRECT — when using the Naegele's rule, add 7 days to ?rst day of last menstrual period and subtract 3 months 3) incorrectly started with the last day of the menstrual cycle 4) incorrect
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The nurse conducts a physical examination of the client suspected to have bulimia. Which nursing observation most likely indicates bulimia? 1. Edema of the lower extremities. 2. The presence of lanugo. 3. Ulcerated oral mucous membranes. 4. Dry, yellowish colored skin.
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3. Ulcerated oral mucous membranes. Explanation Strategy: Determine the cause of each symptom. Does it relate to bulimia? 1) common with anorexia 2) seen with anorexia 3) CORRECT - due to frequent vomiting 4) bulimics are normal in appearance
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The nurse observes a client who is taking phenelzine eat another client's lunch. After a few minutes, the client reports headache, nausea, and rapid heartbeat, and begins to vomit. The nurse anticipates administering which medication? 1. Buspirone. 2. Fluoxetine. 3. Prochlorperazine. 4. Nifedipine.
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4. Nifedipine. Explanation Strategy: Think about the action of each medication. (1) antianxiety; side effects include light-headedness, confusion, hypotension, palpitations (2) SSRI antidepressant; side effects include palpitation, bradycardia, nausea and vomiting (3) antiemetic; side effect include drowsiness, orthostatic hypotension (4) CORRECT - antihypertensive; client experiencing hypertensive crisis due to ingesting tyramine; side effects include dizziness, headache, nervousness
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The nurse receives report on clients from the previous shift. In which order does the nurse see the clients? *Place the answers in order of priority beginning with the first client to be seen. All options must be used.* The client receiving IV potassium, who reports burning at the IV site. The client receiving cipro?oxacin IV who reports a fine macular rash on the chest. The client scheduled to receive heparin and the aPTT is 70 seconds. The client receiving a blood transfusion who reports a dry mouth.
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The client receiving cipro?oxacin IV who reports a fine macular rash on the chest. The client receiving IV potassium, who reports burning at the IV site. The client scheduled to receive heparin and the aPTT is 70 seconds. The client receiving a blood transfusion who reports a dry mouth. Explanation Strategy: identify most critical client and stability of each client. 1) ?rst: the client receiving ciprofloxacin indicates a hypersensitivity reaction; should stop medication and notify the health care provider 2) second: the client receiving potassium; should decrease rate to prevent irritation of the vein, but hypersensitivity reaction requires ?rst attention 3) third: the client to receive heparin; lower limit of normal is 20 - 25 sec; upper limit of normal is 32 - 39 sec; aPTT is within therapeutic range; therapeutic levels increase aPTT 1.5 to 2 times control value; should give medication 4) fourth: the client receiving a blood transfusion; not an immediate concern; routine transfusion evaluation
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The school nurse observes a group of preschool children in the playroom. The nurse recognizes which activity as appropriate behavior forthe 5-year-old child? 1. The child plays with a large truck with another child. 2. The child talks on a toy telephone and imitates the same-sex parent. 3. The child works on a puzzle with several other children. 4. The child holds and cuddles a large stuffed animal.
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2. The child talks on a toy telephone and imitates the same-sex parent. Explanation Strategy: Picture the child. 1) cooperative play occurs in school-aged children 2) CORRECT - imitative behavior seen at this age 3) too advanced for this age 4) too regressed for this age
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The nurse cares for a multipara client who delivered an infant 1 hour ago. The nurse observes that the client's breasts are soft; the uterus is boggy to the right of the midline and 2 cm below the umbilicus; moderate lochia rubra. It is most important for the nurse to take which action? 1. Perform a straight catheterization. 2. Offer the client the bedpan. 3. Put the baby to breast. 4. Massage the uterine fundus.
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2. Offer the client the bedpan. Explanation Strategy: All answers are implementations. Determine the outcome of each answer choice. ls it desired? (1) encourage the client to void before catheterizing (2) CORRECT - boggy uterus deviated to right indicates full bladder, encourage client to void (3) will increase uterine tone, but the problem is a full bladder (4) ?ndings indicate a full bladder
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A client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which is the initial priority nursing action? 1. Provide adequate hygiene and nutrition. 2. Decrease environmental stimuli. 3. Slowly involve the client in unit activities. 4. Administer and monitor sedative and mood-stabilizing medications.
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4. Administer and monitor sedative and mood-stabilizing medications. Explanation Strategy: Answers are implementations. Determine the outcome of each answer choice. is it desired? (1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority (2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression (3) this action is inappropriate at this time (4) CORRECT - is most important to gain control with a physically aggressive client in manic phase; client has signi?cant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents
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During the change-of-shift report, the charge nurse overhears two nurses exchanging loud, rude remarks about one nurse's excessive use of overtime. Which of the following statements by the charge nurse is MOST appropriate? 1. "I want to see both of you in my of?ce right away." 2. "Would you please lower your voices and ?nish the report." 3. "I want the two of you to stop yelling and work this problem out." 4. "Both of you are good nurses and are under a lot ofstress right now."
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2. "Would you please lower your voices and ?nish the report." Explanation Strategy: Determine the outcome of each response. Is it appropriate? 1) confrontation is not the appropriate con?ict management approach when emotions are high 2) CORRECT — forcing is the most appropriate con?ict management technique; enables nurses to exchange information; client care takes priority over interpersonal con?ict 3). need cooling-off period before issues can be discussed; communicating about patient care takes priority 4)"don't worry"response; may make the nurses feel better but does not address the immediate task of completing the report
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The nurse has just received change-of-shift report. Which client should the nurse see FIRST? 1. A client diagnosed with COPD with an Pa02 of 70 mm Hg. 2. A client diagnosed with type 1 diabetes who was just informed her husband is seriousiy injured. 3. A client scheduled to leave for the operating room in 30 minutes for a heart valve replacement. 4. A client 10 hours postop after a right mastectomy complaining of wet sheets under her back.
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4. A client 10 hours postop after a right mastectomy complaining of wet sheets under her back. Explanation Strategy: "FIRST" indicates priority. 1) oxygenation considered "normal to good" for client with COPD; stable client 2) physical needs take priority 3) requires preop injection; all other preparation should be completed; stable client 4) CORRECT - may indicate hemorrhage from operative site; unstable client
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After being admitted for management of a cervical spine injury, a client in a rehabilitation center reports a severe headache. Which of the following actions should the nurse take FIRST? 1. Administer an analgesic medication. 2. Ask the client to rank the pain from 1 to 10. 3. Obtain the client's blood pressure. 4. Place the client in a sitting position.
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4. Place the client in a sitting position. Explanation Strategy:"FlRST"indicates priority. 1)priority is to decrease blood pressure 2) cervical spine injury and severe headache should clue nurse that client that client has autonomic dysre?exia 3) priority is to decrease blood pressure; assess for cause after initial action taken 4) CORRECT—pounding headache and profuse sweating are indications of autonomic hyperre?exia; place in a sitting position immediately to decrease blood pressure and reduce risk of cerebral hemorrhage
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The client returns from surgery for a right total hip arthrpolasty with a large surgical dressing and a Jackson-Pratt drain. Which, if observed by the nurse 2 hours after surgery, necessitates calling the health care provider? 1. There is a small amount of bloody drainage on the surgical dressing. 2. The patient complains of increased hip pain. 3. A harsh, hollow sound is auscultated over the trachea. 4. The patient's blood pressure is 136.86.
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2. The patient complains of increased hip pain. Explanation Strategy: "necessitates calling the health care provider";indicates a complication. 1) expected outcome, complications of total hip replacement include dislocation of prosthesis, excessive wound drainage, thromboembolism, and infection 2) CORRECT - indicates dislocation of prosthesis; other indications include shortening of affected leg, leg externally rotated, soft popping sound heard when affected leg is moved; maintain abduction, use wedge or abduction or regular pillow, avoid stooping, do not sleep on operated side until directed to do so, ?ex hip no more than 60 degree or as prescribed by health care provider, never cross legs, avoid position of ?exion during sexual activity, walking is excellent exercise, avoid overexertion; in 3 months will be able to resume ADLs, except strenuous sports 3) describes normal breathing sounds 4) within normal limits
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The nurse in a small town is called to a neighbor's house in the middle of a blizzard. The neighbor woman states she is in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second stage of labor. it is MOST important for the nurse to take which action? 1. Time the frequency of the contractions. 2. Assess the type of vaginal discharge. 3. Monitor the strength of the contractions. 4. Observe the perineum.
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4. Observe the perineum. Explanation Strategy: Assess before implementing. 1) priority is assessing if baby is crowning 2) priority is assessing if baby is crowning 3) labor is not the priority; nurse should determine if the birth is imminent 4) CORRECT - baby will descend into birth canal and may crown, major responsibility in second state of labor; support infant's head; apply slight pressure to control delivery
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An elderly client is brought to the emergency department reporting acute back pain. The client denies any chronic illness, allergies, or previous hospitalizations. Which is the best initial response for the nurse to make to this client? 1. "We'll get this pain under control in no time." 2. "Are you sure you've never been in the hospital?" 3. "Did you fall, lift something heavy, or turn the wrong way?" 4. "On a scale of 1 to 10, with 10 being the worst, rate the pain you are experiencing."
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4. "On a scale of 1 to 10, with 10 being the worst, rate the pain you are experiencing." Explanation Strategy:"BEST"indicates priority. 1) false reassurance; nurse should complete assessment 2) confrontational response; pain assessment is priority 3) should ?rst assess intensity of pain as well as location 4) CORRECT—assessment, is objective and clear, and responds directly to client's report; gives information for further intervention
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The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST? 1. A client newly diagnosed with type 1 diabetes who had a myocardial infarction 2 days ago. 2. A client diagnosed with right.sided heart failure and glaucoma. 3. A client diagnosed with chronic obstructive pulmonary disease and psoriasis. 4. A client diagnosed with rheumatoid arthritis and malnutrition.
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1. A client newly diagnosed with type 1 diabetes who had a myocardial infarction 2 days ago. Explanation Strategy: Determine the most unstable client. 1) CORRECT—both diseases are in the dynamic phase and require close monitoring; most unstable client 2) client should be seen second 3) two chronic illnesses 4) client more stable than #1
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A tornado has just leveled a large housing division near the hospital, and a disaster alarm has been declared at the hospital. The nurse caring for clients on the maternal-child unit considers which client appropriate for discharge within the next hour? Select all that apply. 1. A multipara client who delivered over an intact perineum 12 hours ago. 2. A postpartum client with an infection who has been on antibiotics forthe past 24 hours. 3. A 3—year—old with newly diagnosed type 1 diabetes, diarrhea, and vomiting. 4. A 3-day-old breast-feeding infant with a total serum bilirubin of 14 mg/dL. 5. A client at 34 weeks'gestation diagnosed with generalized edema and complaints of epigastric pain. 6. A 2-day—old infant delivered of a mother receiving intrapartum antibiotic therapy for vaginal group B-streptococcus (GBS).
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1. A multipara client who delivered over an intact perineum 12 hours ago. 4. A 3-day-old breast-feeding infant with a total serum bilirubin of 14 mg/dL. 6. A 2-day—old infant delivered of a mother receiving intrapartum antibiotic therapy for vaginal group B-streptococcus (GBS). Explanation Strategy: Determine the most stable clients. 1)CORRECT - stable patient 2) do not know if antibiotics are effective or the current WBC count 3) requires frequent assessment of hydration status and blood glucose levels 4) CORRECT - phototherapy considered for the infant with total serum bilirubin greater than 15 mg/dL at 72 hours of age 5) epigastric pain indicates pending eclampsia 6) CORRECT - group B streptococcal (GBS) disease causes sepsis; because mother received intrapartum prophylaxis, infant has 1-in.4,000 chance of developing sepsis due to GBS
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The nurse plans care for a patient in hemorrhagic shock from injuries sustained in a fall. it is MOST important for the nurse to take which of the following actions? 1. Obtain vital signs. 2 Identify the source of the bleeding. 3. Elevate the head of the bed 30". 4. Administer 0.9% NaCl 1v.
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2 Identify the source of the bleeding. Explanation Strategy: Assess before implementing. 1) assessment; more important to determine the source of bleeding 2) CORRECT - assessment ?rst step; initial priority to identify and then apply direct pressure and elevate affected area if possible 3) intervention; elevate the extremities 4) intervention; 1—2 liter bolus Of isotonic ?uids (Iactated Ringer or 0.9% NaCl) will be given
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The nurse instructs a mother of a child diagnosed with a myelomeningocele and who developed an allergy to latex. The nurse determines that teaching is effective if the mother selects which menu for her child? 1. Guacamole with pita bread, lettuce, tomato juice. 2. Poached halibut, brown rice, carrots, peach cobbler. 3. Scrambled eggs, whole wheat toast, nectarine, skim milk. 4. Baked chicken leg, macaroni and cheese, spinach, milkshake.
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4. Baked chicken leg, macaroni and cheese, spinach, milkshake. Explanation Strategy: "Teaching is effective" indicates correct information. 1) if a person has a latex allergy, there is cross-reaction to tomatoes and avocados 2) peach is a cross-reactive food with latex 3) nectarines are cross-reactive with latex 4) CORRECT —this meal does not have any cross-reactive foods with latex; foods to avoid include apple, apricot, avocado, banana, carrot, celery, cherry, chestnut, ?g, grape, kiwi, melon, nectarine, passion fruit, papaya, peach, pear, pineapple, plum, potato, and tomato
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The nurse prepares an elderly client newly diagnosed with type 1 diabetes for discharge. The client is alert and oriented and lives alone in her home. It is MOST important for the nurse to assess for which of the following? 1. Clients vision and manual dexterity. 2. Clients understanding of diabetes. 3. Clients need for visits from the home care nurse. 4. Client's ability to perform blood glucose monitoring.
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1. Clients vision and manual dexterity. Explanation Strategy:"MOST important indicates discrimination is required to answer the question. 1) CORRECT - client must have the visual acuity and manual dexterity to draw up and administer insulin 2) it is important that the client understands diabetes, but priority is assessing client's ability to manage insulin administration 3) may be necessary 4) important, but ?rst assess the client's vision and manual dexterity
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The nurse in the outpatient clinic receives a call from a client who has been receiving continuous ambulatory peritoneal dialysis (CAPD) for one year. The client states that after infusing 2 L of dialysate, 1200 ml returned. Which statement by the nurse is BEST? 1. "Record the difference as intake." 2. "When was your last bowel movement?" 3. "Are you having shoulder pain?" 4. "increase your ?uid intake."
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2. "When was your last bowel movement?" Explanation Strategy: Determine if it is appropriate to assess or implement. 1) the difference between in?ow and out?ow is counted as intake; ensure that all ?uid has drained from the peritoneal cavity; change positions or ask client to walk around 2) CORRECT - full colon can create out?ow problems; ensure that bowel evacuation has occurred 3) referred shoulder pain may be caused by rapid infusion of dialysate; instruct to decrease infusion rate; this client is having an out?ow problem 4) will not affect out?ow
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The nurse cares for a client in labor. The clients examination reveals that the cervix is 5 cm dilated and 100% effaced and the fetal head is at—1. The membranes rupture and the nurse notes clear ?uid. Which of the following actions should the nurse take FIRST? 1. Ambulate the client for 15 minutes and evaluate the fetal heart rate every 30 minutes. 2. Prepare for delivery and notify the care provider. 3. Apply an electronic fetal monitor and start an IV. 4. Encourage the client to void every 1—2 hours and take her temperature every hour.
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4. Encourage the client to void every 1—2 hours and take her temperature every hour. Explanation Strategy:"FlRST"indicates priority. 1) do not ambulate the client; head is too high, may cause cord to prolapse 2) too early to set up for delivery, has approximately 2—3 remaining hours of labor; sterile equipment should be opened for no more than 1 hour 3) no indication that the client is in trouble 4) CORRECT - facilitates descent of the fetal head; temperature evaluation is necessary because Of ruptured membranes
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The nurse cares for a 27-year-old female diagnosed with type 1 diabetes. Two days after admission, the client begins complaining of severe nausea. Which of the following actions should the nurse take FIRST? 1. Determine the client's most recent fasting serum glucose level. 2. Perform a comprehensive client assessment. 3. Ask the client if she is pregnant. 4. Administer an antiemetic.
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2. Perform a comprehensive client assessment. Explanation Strategy:"FlRST"indicates priority. 1) no relationship between diabetes and nausea; last glucose reading does not give the nurse information about client's current condition 2) CORRECT—nausea not usually associated with diabetes; assess before implementing 3) nurse is making assumptions based on clients age; should perform a comprehensive assessment 4) assess before implementing
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The nurse counsels the mother of a child diagnosed with impetigo. The nurse notes that the infection has not improved and learns the mother has not been caring for the child's skin because it "takes too much time." it is MOST important for the nurse to assess for which symptom? 1. White patches on buccal mucosa. 2. Hearing loss. 3. Respiratory wheezing. 4. Periorbital edema.
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4. Periorbital edema. Explanation Strategy: What indicates a complication? 1) describes Candida, a fungal infection 2) not caused by impetigo 3) not caused by impetigo 4) CORRECT - impetigo is caused by Staphylococcus and Streptococcus; untreated, can cause acute glomerulonephritis; periorbital edema indicates poststreptococcal glomerulonephritis
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The nurse cares for a client receiving a heparin drip via an infusion pump. The health care provider orders warfarin 5 mg PO. Which action should the nurse take next? 1. Administer medication as ordered. 2. Notify the health care provider. 3. Check the most recent serum partial prothrombin levels. 4. Assess client for signslsymptoms of bleeding.
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1. Administer medication as ordered. Explanation Strategy: "NEXT" indicates priority 1) CORRECT - warfarin interferes with the hepatic synthesis of vitamin K-dependent clotting factors; oral anticoagulant therapy should be instituted 4 to 5 days before discontinuing the heparin therapy 2) no reason to notify the health care provider 3) partial thromboplastin time used to monitor effectiveness of heparin; therapeutic level is 1.5 to 2.5 times the control 4) warfarin takes 3 to 5 days to reach peak levels
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The nurse administers promethazine 25 mg IM to a client complaining of nausea and vomiting. After receiving the medication, the client complains of dizziness when standing up. Which action should the nurse take ?rst? 1. Notify health care provider. 2. Monitor severity ofsymptoms. 3. Instruct client to ask for assistance before ambulating. 4. Assess client's hydration status.
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4. Assess client's hydration status. Explanation Strategy: Complete assessment before implementing 1) complete assessment before contacting health care provider 2) is complaining of orthostatic hypotension; determine if ?uid volume de?cit contributing to dizziness 3) appropriate action, but nurse should ?rst complete assessment 4) CORRECT—side effects include anorexia, dry mouth and eyes, constipation, orthostatic hypotension; client is at risk for ?uid volume de?cit due to vomiting, which exacerbates the orthostatic hypotension
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The nurse plans care for a 14-year-old hospitalized with a diagnosis of anorexia nervosa. The nurse identi?es that which activity is most appropriate for this client? 1. Making jewelry with the occupational therapist. 2. Exercising in the physical therapy department. 3. Assisting the dietician to plan the week's menus. 4. Reading teen magazines with other clients her age.
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1. Making jewelry with the occupational therapist. Explanation Strategy: Determine the outcome of each answer. 1) CORRECT - one of the goals for a client with anorexia is to achieve a sense of self—worth and self-acceptance that is not based on appearance; this activity will promote socialization and increase self-esteem 2) goal is for client to achieve 85-95% of ideal body weight; may be able to exercise after short term goals are met 3) meal planning is a part of self-care activities, but more important for client to achieve a sense of self-worth 4) can read magazines in the presence Of others without interacting
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A 25-year-old woman is receiving aminophylline 0.7 mg/kg/h by continuous lV infusion into her left arm. It is MOST important for the nurse to observe her for which of the following? 1. Slowed pulse and reduced blood pressure. 2. Constipation and decreased bowel sounds. 3. Palpitations and nervousness. 4. Dif?culty voiding and oliguria.
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3. Palpitations and nervousness. Explanation Strategy:"MOST important indicates discrimination is required to answer the question. 1) causes rapid pulse and dysrhythmias; decrease intake of colas, coffee, and chocolate because they contain xanthine 2) causes diarrhea, nausea, and vomiting; administer with food or full glass of water 3) CORRECT - effects of aminophylline include nervousness, nausea, dizziness, tachycardia, seizures 4) medication has no effect on the kidneys; encourage intake of 2,000 cc per day to decrease viscosity of airway secretions
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The nurse cares for the client following a scleral buckling. Which nursing action is most important? 1. Remove all reading material. 2. Assess for nausea. 3. Assess drainage from affected eye. 4. irrigate affected eye every 3 hours.
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2. Assess for nausea. Explanation Strategy:"MOST important indicates priority. 1) scleral buckling compresses the sclera to repair a detached retina; should take precautions to prevent moving eyes rapidly 2) CORRECT - nausea and vomiting increase intraocular pressure and could cause damage to the area repaired 3) wear eye shield; avoid sneezing, coughing, straining at stool 4) do not irrigate
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The health care provider prescribes an increase in the parenteral nutrition infusion rate from 50 mLIhourto 100 mL/hour. The parenteral nutrition is infusing through a peripherally inserted central catheter (PICC) device. Which is the priority action for the nurse? 1. Assess hourly urine output. 2. Evaluate a serum total protein level. 3. Assess vital signs every 4 hours. 4. Obtain aspartate aminotransferase (AST) test.
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1. Assess hourly urine output. Explanation all answers are assessment and physical 1) CORRECT— circulation, parenteral nutrition is hyperosmolar and will pull ?uid into the intravascular space; client may have osmotic diuresis 2) notA, B, or C; eliminate; parenteral nutrition is high in protein, but most important is response to rate change 3) too broad to specify A, B, or C; eliminate; may see change in vital signs, but urine output would be better indicator of increased intravascular volume 4) not A B, or C; eliminate
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The nurse cares for a client diagnosed with diastolic heart failure. The nurse observes the recent onset of the above rhythm. Which is the most appropriate action for the nurse to take? Rhythm is A-Fib 1. Administer digoxin 0.25 mg intravenous. 2. Instruct client to take a deep breath and hold it. 3. Assess level of consciousness and orientation. 4. Auscultate posterior chest.
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3. Assess level of consciousness and orientation. Explanation consider each step and the assessment data needed in this situation 1) implementation, should assess ?rst; eliminate; digoxin is not a ?rst-line drug used to treat atrial ?brillation due to risk oftoxicity 2) implementation, need more information; eliminate; Valsalva maneuver not indicated in this situation; used for supraventricular tachydysrhythmias 3) CORRECT— assessment, physical, circulation; is best indicator of effect of atrial ?brillation on cardiac output; change in LOC and alertness is earliest indication 4) assessment, physical, airway, but not priority; eliminate; atrial ?brillation may contribute to left heart failure
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The nurse receives a phone call from the adult child who reports, 'Ijust got here to see my elderly parent, and I think heat stroke has occurred. 1 think the air conditioning is not working and the house is very hot" The adult child reports the parent is confused, very thirsty, nauseated, and in pain. Which is the most appropriate statement for the nurse to make? 1. 'If perspiration is present, heat stroke has not occurred." 2. "Give your parent cool ?uids to drink immediately." 3. "What medications does your parent take daily?" 4. "Remove any excess clothing immediately."
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4. "Remove any excess clothing immediately." Explanation consider each step ofthe decision tree, and considerwhich action is safe forthis client 1) implementation, psychosocial; eliminate; this is education ofthe family member 2) implementation, physical, not desired; eliminate; risk of aspiration due to altered mental status 3) assessment, not needed; eliminate 4) CORRECT— implementation, physical, circulation; remove clothing to begin cooling process; othertemperature reducing measures can be completed, but this is ?rst step
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The terminally ill client reports to the nurse that a do-not—resuscitate order has been initiated. The client is concerned family members do not accept this wish. Which action by the nurse is best? 1. Reassure the client things will work themselves out. 2. Allow the next of kin to make ?nal health care decisions. 3. Schedule a meeting with the client and family. 4. Contact the hospital social worker.
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3. Schedule a meeting with the client and family. Explanation all the answers are implementation and psychosocial; considerthe outcome of each action; eliminating answers using therapeutic communication will work as well 1) nurse needs to proactively address client's concerns 2) nurse needs to advocate for the client; client wants to be a DNR 3) CORRECT— client's family members need to acknowledge and understand the client's wishes; a meeting with the client and family will open the lines of communication and allow time for questions/explanations 4) ?rst action is to open lines of communication with client and family
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The nurse cares for the client who suffers from depression and anxiety. The client states, 'I feel overwhelmed because I'm the only caregiver for my 2 children." Which response by the nurse is best? 1. 'Do you participate in any religious or spiritual activities?" 2. "What can we do to help take your mind off things?" 3. "You do not plan to have any more children, do you?" 4. "Why do you not work outside the home?"
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1. 'Do you participate in any religious or spiritual activities?" Explanation "best response" is a therapeutic communication question; follow tools to answer this type of question 1) CORRECT— spirituality and religious beliefs have potential to exert in?uence on how people understand meaning/purpose in their lives and how they use critical judgement and solve problems 2) distraction not always best technique; nurse should assess client's coping mechanisms 3)judgmental question; nurse should assess client's coping mechanisms 4) asking 'Why" is confrontational and should be avoided on the NCLEX-RN® exam
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During a urinary bladder catheter insertion with a size 16 catheter on the 68-year-old male, the nurse feels increased resistance. Which is the most appropriate action for the nurse to take? 1. Withdraw the catheter and apply more lubricant. 2. lnstruct the client to take a deep breath and bear down. 3. Stop catheter insertion and instruct client to take deep breaths. 4. Withdraw the catheter and notify the health care provider.
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3. Stop catheter insertion and instruct client to take deep breaths. Explanation the answers are all implementations and all are physical; A B, or C does not apply to these answers; move to step 5: outcome evaluation; determine what would happen if the nurse performs each action 1) catheter should not be withdrawn and reinserted; increases risk of infection 2) Valsalva maneuver will not facilitate passage through urethra 3) CORRECT—will relax urethral muscles and facilitate passage through prostate gland 4) determine if there is something the nurse can do before contacting HCP
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The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment?ndings? Select all that apply. 1. Hypotension. 2. Low back pain. 3. Wet breath sounds. 4. Fever. 5. Urticaria. 6. Severe shortness of breath.
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1. Hypotension. 2. Low back pain. 4. Fever. Explanation Type: select all that apply. Did you identify the topic correctly? Signs and symptoms ofhemolytic blood reaction. Note: The topic is not what you are worried about ifyou see it; it is very speci?cto hemolytic reaction. Use the words. Is (the answer) a ?nding for hemolytic reaction? This will help keep you focused. 1) CORRECT— blood pressure drops 2) CORRECT— classic symptom related to hemolytic reaction 3) related to circulatory overload 4) CORRECT—fever is an expected symptom 5) related to an allergic reaction 6) related to circulatory overload Step 5: Do you have more than one answer? Yes. Does your answer make sense for hemolytic reactions? Yes.
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The nurse observes the new graduate nurse obtain blood through a peripherally inserted central catheter (PICC). Which observation requires an intervention by the nurse? 1. The nurse discards 1 mL blood prior to obtaining the blood sample. 2. The nurse uses a 10 mL syringe to ?ush through the port of the catheter. 3. The nurse applies clean gloves prior to beginning the procedure. 4. The nurse uses the push-pause technique to ?ush the catheter.
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1. The nurse discards 1 mL blood prior to obtaining the blood sample. Explanation the nurse is looking for an incorrect action; step 5: read each answer and ask is this a correct action or not 1) CORRECT—should discard 3 to 5 mL blood to prevent contamination of blood sample with intravenous ?uids or medications 2) 10 mL size syringe recommended to reduce pressure on lumen of catheter during ?ushing 3) clean gloves are used; sterile not necessary for obtaining blood sample 4) push-pause technique reduces the risk of clot formation and damage to catheter
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The nurse speaks with the client and spouse who have been undergoing family counseling. The client's spouse states, "You never take any responsibility for the messes you always cause!" Which response by the nurse is best? 1. 'Why do you say that?" 2. "Blaming is not effective." 3. "Let's focus only on the positives." 4. "When is the last time you two had a vacation?"
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2. "Blaming is not effective." Explanation therapeutic communication question; use the rules to help eliminate answers 1) asking "why" is confrontational and should be avoided on the NCLEX—RN® exam 2) CORRECT—family members often blame others forfailures, errors, or negative consequences of an action to keep focus away from themselves; response to fear of being blamed by others 3) nurse needs to correct unhealthy communication patterns 4) nurse needs to correct unhealthy communication patterns
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The nurse meets with the parent of a 13-year-old boy in the pediatric health care provider's of?ce. The parent voices concern that the child has recently become clumsy and uncoordinated. Which response by the nurse is correct? 1. "Your son might have attention de?cit hyperactivity disorder." 2. "I'll talk with the health care provider about assessing for subtle motor dysfunction." 3. "Your son's clumsiness is expected at this age." 4. "This may be an early sign of depression."
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3. "Your son's clumsiness is expected at this age." Explanation Type: Correct response. Use True/False with each answer. Topic: Uncoordination in 13-year—old males. 1) false statement about uncoordination in 13—year—old males; eliminate 2) false statement about uncoordination in 13—year—old males; eliminate 3) CORRECT—true statement about uncoordination in 13-year-old males 4) false statement about uncoordination in 13-year—old males; eliminate Step 5; outcome of answer#3 is a true statement
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The health care provider orders metoclopramide 2 mglkg IV to be given to a client 30 minutes before the client receives cisplatin. The client asks the nurse why the metoclopramide is being given. Which response will the nurse provide the client?? 1. 'Metoclopramide prevents or reduces the side effects caused by cisplatin." 2. 'Metoclopramide increases the effectiveness ofthe cisplatin." 3. 'Cisplatin prevents or reduces the side effects ofthe metoclopramide." 4. "Cisplatin increases the effectiveness of metoclopramide."
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1. 'Metoclopramide prevents or reduces the side effects caused by cisplatin." Explanation Type: This is a teaching/learning question. Use True/false on each answer. Topic: True statement about the use ofmetoclopramide with cisplatin. 1) CORRECT—true statement about the use ofmetoclopramide and cisplatin 2) false statement about the use ofmetoclopramide and cisplatin 3) false statement about the use of metoclopramide and cisplatin 4) false statement about the use ofmetoclopramide and cisplatin Step 5: What is the outcome of#1? The client is given correct information. Look both medications up ifyou did not get this question correct.
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The nurse instructs a student nurse about the correct way to set up a sterile ?eld. The nurse determines that teaching is effective if which action is observed? 1. The student nurse places the supplies at the edge of the sterile ?eld. 2. The student nurse wears a gown and gloves at all times. 3. The student nurse sets up the sterile ?eld above waist level. 4. The student nurse opens supplies with sterile gloves.
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3. The student nurse sets up the sterile ?eld above waist level. Explanation Type of question is teaching/learning evaluation. Use True/False. Topic of the question is correct sterile ?eld. Strategy: Determine if the outcome of each answer is correct for a sterile ?eld. 1) false action for a sterile ?eld 2) false action fora sterile ?eld 3) CORRECT—true action for a sterile ?eld 4) false action for a sterile ?eld Step 5: The outcome of answer#3 is the student nurse used correct sterile ?eld technique.
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The client diagnosed with end-stage renal disease (ESRD) is prescribed hemodialysis treatments 3 times a week After 2 weeks of treatment, the client reports, 'I have a headache when the dialysis ?nishes. Is this normal?" Which is the most appropriate response by the nurse? 1. 'l have seen this a lot in clients. Don't worry too much about it." 2. "Headaches may occur at the beginning of treatment and should improve overtime." 3. "Have you experienced any headaches similar to these in the past?" 4. "Why are you so worried about this? It is a common side effect"
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2. "Headaches may occur at the beginning of treatment and should improve overtime." Explanation think about how to therapeutically communicate with the client 1) this answer is about the nurse, not the client; this answer also negates the client's concern 2) CORRECT— providing correct information is therapeutic; headache, nausea, fatigue may occur a?er hemodialysis due to disequilibrium syndrome; rapid removal of electrolytes and solutes from blood contributes; reduction of blood ?ow during dialysis decreases risk of disequilibrium syndrome 3) more important to deal with the here and now 4) 'Why' questions are not therapeutic; blood pressure is assessed prior to and after hemodialysis, but is not related to headache
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The client diagnosed with malnutrition is prescribed continuous enteral feedings through a gastrostomy tube. Which actions will the nurse include in the plan of care? Select all that apply. 1. Cover the insertion site with an adhesive bandage. 2. Add 8 hours of feeding to the bag at a time. 3. Rotate the gastrostomy tube 360 degrees once daily. 4. Auscultate forwhoosh of air through the gastrostomy tube. 5. Check for slight in-and-out movement ofthe gastrostomy tube.
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3. Rotate the gastrostomy tube 360 degrees once daily. 5. Check for slight in-and-out movement of the gastrostomy tube. Explanation the topic is plan of care for a gastrostomy tube; ask if the answer would be in the plan of care 1) gastrostomy insertion site should be covered with sterile bandage to reduce the risk ofinfection 2) only 4 hours of enteral feeding should be added to bag to reduce the risk of bacterial contamination 3) CORRECT— should be rotated 360 degrees daily to reduce the risk ofskin irritation and breakdown 4) insertion of air is not recommended for gastrostomy tube placement assessment; this action would not be placed in the plan of care 5) CORRECT— slight in-and-out movement indicates that the gastrostomy tube is not embedded in the wall of stomach
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The client diagnosed with rheumatoid arthritis is prescribed 50 mg etanercept subcutaneous weekly. The client reports joint swelling, symmetrical joint pain, and deformities of both hands. Which ?nding should the nurse report to the health care provider? 1. White cell count 14,000/mm3 (14 x 10%). 2. C—reactive protein 1.2 mg/dL. 3. Serum hemoglobin 9 mg/dL (90 g/L). 4. Sedimentation rate 22 mm/hr.
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1. White cell count 14,000/mm3 (14 x 10%). Explanation all the answers are ?ndings; step 5: ask which is not expected in a client with RA 1) CORRECT—WBC of 14,000 (14x 10") may indicate active infection and is contraindicated; requires further investigation 2) expected with moderate to severe RA 3) expected with moderate to severe RA 4) expected with moderate to severe RA
