NCLEX STUDY Kaplan Trainer 2 – Flashcards
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The nurse supervises care given to a group of clients on the unit. The nurse observes a staff member entering a client's room wearing gown and gloves. The nurse knows the staff member is caring for which client? 1. An 18-month-old with respiratory syncytial virus. 2. A 4-year-old with Kawasaki disease. 3. A 10-year-old with Lyme disease. 4. A 16-year-old with infectious mononucleosis.
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(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 assesses the client diagnosed with a spinal cord injury. Which findings suggests the complication of autonomic dysreflexia? 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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1) may be the cause of autonomic dysreflexia due to overfilling 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 flesh)
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The adolescent is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse includes which information in the preoperative teaching session? 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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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 client at 16 weeks gestation has an amniocentesis. The client asks what will be learned from this procedure. The nurse responds that which condition can be detected? 1. Tetralogy of Fallot. 2. Talipes equinovarus. 3. Hemolytic disease of the newborn. 4. Cleft lip and palate.
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1) cardiac abnormality detected at birth; pulmonary stenosis, ventricular septal defect, overriding aorta, hypertrophy of right ventricle 2) congenital deformity detected at birth; foot twisted out of normal position, clubfoot 3) CORRECT — maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis 4) congenital deformity detected at birth, midline fissure or opening into lip and/or palate
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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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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 × 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 × 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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The client returns from surgery. There is a fine, reddened rash around the area where providone iodine prep was applied prior to surgery. The nursing notation in the client's record includes which observation? 1. Time and circumstances under which the rash was noted. 2. Explanation given to the client and family of the reason for the rash. 3. Notation on an allergy list and notification of the health care provider. 4. The need for application of corticosteroid cream to decrease inflammation.
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1) would be noted, but is not as high a priority 2) inappropriate 3) CORRECT — suspected reaction to substances should be reported to the health care provider and noted on list of possible allergies 4) inappropriate
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The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings? 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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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 specific to hemolytic reaction. Use the words. Is (the answer) a finding 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
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The nurse develops a comprehensive care plan for the young client diagnosed with anorexia nervosa. The client is referred to assertiveness skills classes. This is an appropriate intervention because the client may exhibit which problem? 1. Aggressive behaviors and angry feelings. 2. Self-identity and self-esteem issues. 3. An intense focus on reality. 4. Family boundary intrusions.
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1) these clients do have problems with feelings of anger; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries 2) CORRECT — clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do 3) do not have problems with reality 4) these clients do have problems with family boundary intrusion; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries
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Correct steps of a dressing change
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1) First Use clean gloves to remove old dressing to protect nurse. 2) Second Prepare the cotton swabs with providone-iodine. 3) Third Use circular motion going from center to outside area; clean to dirty. 4) Fourth Apply dressing to area. 5) Last Tape dressing in place.
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The client is diagnosed with pneumonia secondary to chronic pulmonary disease. Which nursing goal is most appropriate? 1. Maintain and improve the quality of oxygenation. 2. Improve the status of ventilation. 3. Increase oxygenation of peripheral circulation. 4. Correct the bicarbonate deficit.
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1) primary problem is not level of oxygenation, but the level of carbon dioxide contributing to an acidotic state 2) CORRECT — to improve the quality of ventilation refers to levels of carbon dioxide and oxygen 3) not appropriate for the situation 4) not appropriate for the situation
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The client comes to the clinic to have a hemoglobin A1c performed. Which client statement indicates to the nurse an understanding of the procedure? 1. "This test is performed by using a first voided urine specimen." 2. "This test needs to be performed in the morning before I eat breakfast." 3. "This test indicates how well my blood sugar has been controlled the past 2-3 months." 4. "I must follow my diet carefully for several days before the test."
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1) blood sample is needed; can be obtained from a finger stick or a venapuncture 2) timing of test is not important 3) CORRECT — when RBCs are being formed, glucose is attached (glycosylated) and remains attached throughout the life of the RBC; normal 2.5 to 6% 4) current blood glucose doesn't affect test
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The nurse recognizes which 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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1) blood pressure increases. 2) CORRECT - the heart rate increases and palpitations occur. 3) CORRECT - the visual field narrows; part of the fight or flight 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 diagnoses Graves' disease for the client. The nurse expects the client to exhibit which symptom? 1. Lethargy in the early morning. 2. Sensitivity to cold. 3. Weight loss of 10 lb in 3 weeks. 4. Reduced deep tendon reflexes.
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1) will be restless 2) will have heat intolerance due to increased metabolic rate 3) CORRECT — increased metabolic rate causes weight loss even with increased appetite 4) reflexes will be hyperactive
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The parent tells the nurse about having had difficulty forming relationships. The parent is worried the 7-year-old child will have the same problem. Which statement by the nurse is best? 1. "Children develop trust from birth to 18 months of age." 2. "Children develop trust from 18 months to three years of age." 3. "Children develop trust from three to six years of age." 4. "Children develop trust from six to twelve years of age."
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1) CORRECT — Erikson states that trust results from interaction with dependable, predictable primary caretaker 2) toddler stage concerns autonomy verses shame and doubt 3) preschool stage concerns initiative versus guilt 4) latency or school age stage concerns industry versus inferiority
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The client was just placed in physical restraints. Which nursing intervention is most important for the client's care? 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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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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The geriatric residents of a long-term care facility participate in a reminiscing group. The nurse identifies which goal as the primary goal of this type of group activity? 1. Provides psychosocial educational opportunities for stress and coping. 2. Provides an avenue for physical exercise. 3. Provides an environment for social interaction and companionship. 4. Reorients and provides a reality test for confused clients.
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1) is not primary goal of a reminiscing group 2) is not primary goal of a reminiscing group 3) CORRECT — primary goal of a reminiscing group for geriatric clients is to review and share their life experiences with the group members (4) groups that facilitate orientation to time, person, place, and current events are called reality orientation groups
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Which assessment information indicates to the nurse the client has hypocalcemia? 1. Constipation. 2. Depressed reflexes. 3. Decreased muscle strength. 4. Positive Trousseau's sign.
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1) symptom associated with hypercalcemia 2) symptom associated with hypercalcemia 3) symptom associated with hypercalcemia 4) CORRECT — positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia
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The nurse obtains a specimen from the client for sputum culture and sensitivity (C and S). Which instruction is best? 1. After pursed lip breathing, cough into a container. 2. Upon awakening, cough deeply and expectorate into a container. 3. Save all sputum for three days in a covered container. 4. After respiratory treatment, expectorate into a container.
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1) coughing into a container is indicated, but not pursed-lip breathing 2) CORRECT — specimens should be obtained in the early morning because secretions develop during the night 3) appropriate for acid-fast stain for TB 4) earliest specimen is most desirable
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The client has a nasogastric tube connected to intermittent low suction. At 07:00, the nurse documents 235 mL of greenish drainage in the suction container. At 15:00, there is 445 mL of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the tube with 30 mL of normal saline. Which is the actual amount of drainage from the nasogastric tube for 07:00 to 15:00? 1. 150 mL. 2. 210 mL. 3. 295 mL. 4. 385 mL.
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1) CORRECT - 445 − 235 = 210 − 60 = 150 2) does not subtract 60 mL of fluid used to irrigate tube 3) does not take into account solution added to container during day shift; does not subtract for fluids used to irrigate tube 4) does not subtract 235 mL that was in container from previous shift
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The nurse cares for the client with 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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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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The health care provider prescribes lithium carbonate 300 mg PO QID for the adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse encourages the client to maintain an adequate intake of which substance? 1. Sodium. 2. Protein. 3. Potassium. 4. Iron.
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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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The client reports a severe headache, nausea, and photophobia. The health care provider orders a complete blood count (CBC) and a lumbar puncture (LP). A diagnosis of bacterial meningitis is made. Which laboratory result does the nurse expect? 1. Cerebrospinal fluid (CSF) cloudy, hemoglobin (Hgb) 13 g/dL (130 g/L), hematocrit (HCT) 38%, white blood cell count (WBC) 18,000/mm3. 2. CSF with red blood cells (RBCs) present, Hgb 10 g/dL (100 g/L), HCT 37%, WBC 8,000/mm3. 3. CSF cloudy, Hgb 12 g/dL (120 g/L), HCT 37%, WBC 7,000/mm3. 4. CSF clear, Hgb 15 g/dL (150 g/L), HCT 40%, WBC 11,000/mm3.
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1) CORRECT — cerebrospinal fluid (CSF) normally clear, colorless; normal white blood cell count (WBC) 5,000 to 10,000 per mm3, normal hemoglobin (Hgb) (male 13 to 18 g/dL (130-180 g/L), female 12 to 16 g/dL)(120-160 g/L), normal hematocrit (HCT) (male 42 to 52%, female 35 to 47%); CSF is cloudy indicating inflammation/infection; Hgb and HCT are within the normal ranges; WBC is elevated indicating infection 2) indicates trauma or hemorrhage 3) WBC too low, not typical of bacterial meningitis 4) indicates viral meningitis; clear CSF, increase in WBC not as significant as bacterial meningitis
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A Miller-Abbott tube is ordered for the client. The nurse knows this tube is inserted for which main reason? 1. Provides an avenue for nutrients to flow past an obstructed area. 2. Prevents fluid and gas accumulation in the stomach. 3. Administers medications that can be absorbed directly from the intestinal mucosa. 4. Removes fluid and gas from the small intestine.
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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 nurse prepares discharge teaching for the parents of the newborn. Which information does the nurse provide regarding the accuracy of a PKU (phenylketonuria) test? 1. The initial specimen should be collected as close to discharge as possible but not later than 7 days. 2. The infant can have water but should not have formula for 6 hours before the test. 3. The test will need to be repeated at 6 weeks and at the 3-month check-up. 4. Blood will be drawn at three 1-hour intervals; there is no specific preparation.
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1) CORRECT — if initial specimen is collected before newborn is 24 hours old, a repeat test should be performed by 2 weeks of age 2) no restriction on formula intake 3) test may be repeated within 2 weeks to ensure accuracy 4) only one blood sample is needed
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Promethazine hydrochloride 25 mg IV push is ordered for the client. Prior to administering this medication, the nurse makes which assessment? 1. The color of the medication solution. 2. The client's pulse and temperature. 3. The time of the last analgesic dose the client received. 4. The patency of the client's vein.
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1) is true, but not as high a priority as the IV patency 2) no relevance to the question asked 3) promethazine hydrochloride is used as an adjunct to analgesics but has no analgesic activity itself 4) CORRECT — is very important to determine absolute patency of the vein; extravasation will cause necrosis
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The nurse reviews procedures with the health care team. The nurse intervenes if the RN staff member makes which statement? 1. "It is my responsibility to ensure the consent form has been signed and is attached to the client's record." 2. "It is my responsibility to witness the signature of the client before surgery is performed." 3. "It is my responsibility to explain the surgery and ask the client to sign the consent form." 4. "It is my responsibility to answer questions the client may have before surgery."
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Strategy: "Nurse intervenes" indicates an incorrect statement is required. Question is unstated. Read answer choices for clues. 1) describes the nurse's responsibility in obtaining consent 2) signature indicates the nurse saw the client sign the form 3) CORRECT — health care provider should provide explanation and obtain client's signature 4) the nurse should answer questions after the health care provider has obtained consent
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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 significant other to a rape victim is reflected 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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1) significant 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 is newly diagnosed with Buerger's disease. The clinic nurse obtains a health history. The nurse expects the client's history to include which symptom? 1. Heart palpitations. 2. Dizziness when walking. 3. Blurred vision. 4. Digital sensitivity to cold.
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1) no cardiac involvement 2) dizziness not seen; intermittent claudication (pain with exercise) seen 3) optic nerve not affected 4) CORRECT — vasculitis of blood vessels in upper and lower extremities
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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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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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The newborn is diagnosed with fetal alcohol syndrome. The nurse knows which action is an important consideration for this newborn? 1. Prevent iron deficiency anemia. 2. Decrease touch to prevent over stimulation. 3. Provide feedings via gavage to decrease energy expenditure. 4. Replace vitamins depleted as a result of poor maternal diet.
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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 client returns from surgery after a right mastectomy. There is an IV of 0.9% NaCl infusing at 100 mL/h into the left forearm. The IV infiltrates several hours later. The nurse supervises the student nurse preparing to insert a new peripheral intravenous catheter. The nurse intervenes in which situation? 1. The student nurse selects a site where the veins are soft and elastic. 2. The student nurse selects a site on the distal portion of the left arm. 3. The student nurse selects a site close to the wrist joint. 4. The student nurse holds the skin taut prior to insertion of the catheter.
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1) acceptable site selection 2) acceptable site selection; insertion site proximal to the infiltrated area may be used if same extremity must be used; right extremity avoided with mastectomy 3) CORRECT - inappropriate; movement in area could cause displacement 4) acceptable procedure
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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) 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 client has a modified radical mastectomy and axillary dissection. Which nursing diagnosis is a correctly stated, priority nursing diagnosis for the client immediately after the procedure? 1. Anxiety related to the mastectomy. 2. Impaired Skin Integrity related to the mastectomy. 3. Pain related to surgical incision. 4. Deficient Self-care related to dressing changes.
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Strategy: Think about each answer. 1) is stated incorrectly with "related to the mastectomy" 2) is stated incorrectly with "related to the mastectomy" 3) CORRECT — immediately after surgery the priority is optimizing the client's comfort 4) is not an immediate priority
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The client has a history of hypertension and angle-closure glaucoma. Which medication order does the nurse question? 1. Propranolol 80 mg PO QID. 2. Verapamil 40 mg PO TID. 3. Tetrahydrozoline 2 drops in each eye TID. 4. Timolol 1 drop in each eye once daily.
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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 outflow, used for glaucoma
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The nurse cares for the client diagnosed with a recurrent urinary tract infection. The health care provider prescribes ciprofloxacin. The nurse instructs the client to limit intake of which fluid? 1. Milk. 2. Cranberry juice. 3. Water. 4. Tea.
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1) CORRECT — should limit intake of alkaline foods and fluids 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 health care provider prescribes estrogen 0.625 mg daily for the 43-year-old woman. The nurse identifies which symptom as a common initial adverse effect of this medication? 1. Nausea. 2. Visual disturbances. 3. Tinnitus. 4. Ataxia.
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1) CORRECT — common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence 2) seen with long-term use 3) ringing in the ears is seen with long-term use 4) unsteady gait rarely seen
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The nurse assesses the client immediately after an exploratory laparotomy. Which nursing observation indicates the complication of intestinal obstruction? 1. Protruding soft abdomen with frequent diarrhea. 2. Distended abdomen with ascites. 3. Minimal bowel sounds in all four quadrants. 4. Distended abdomen with reports of pain.
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1) does not support intestinal obstruction 2) does not support intestinal obstruction 3) immediately after postoperative abdominal surgery, bowel sounds are absent or decreased; would be no passage of stool; ascites not often seen 4) CORRECT — if an obstruction is present, the abdomen will become distended and painful
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The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which is the best response by the nurse? 1. 11 months of age. 2. 14 months of age. 3. 17 months of age. 4. 20 months of age.
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1) not able to physiologically control sphincters until 18 months of age 2) not able to physiologically control sphincters until 18 months of age 3) not able to physiologically control sphincters until 18 months of age 4) CORRECT — average of training begins at 20 months; by 24 months may be able to achieve daytime bladder control
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The nurse cares for the client diagnosed with hypoparathyroidism. Which nursing action has the highest priority for this client? 1. Develop a teaching plan. 2. Plan measures to deal with cardiac dysrhythmias. 3. Take measures to prevent a respiratory infection. 4. Assess laboratory results.
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1) not highest priority action related to the diagnosis 2) CORRECT — cardiac dysrhythmias related to low serum calcium would be the highest priority 3) potential for respiratory infection is not a major threat 4) not highest priority action related to the diagnosis
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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 pattern of urinary elimination occurs normally with aging? 1. Decreased frequency. 2. Nocturia. 3. Incontinence. 4. Hematuria.
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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 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 cares for the client the first 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 flowing." 4. "The CBI delivers medication to the bladder."
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1) refers to a possible preoperative complication of infection due to the enlarged prostate 2) not the reason for the CBI 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 CBI in a first-day postop TURP
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The client is diagnosed with an adjustment disorder with depressed mood. The client 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) 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 nurse plans care for the 20-year-old client. Which psychosocial stage does the nurse identify as the priority to consider? 1. Identity versus identity diffusion. 2. Intimacy versus isolation. 3. Integrity versus despair and disgust. 4. Industry versus inferiority
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1) appropriate for adolescents 2) CORRECT — this is the stage for 19- to 35-year-olds 3) for 65 years and older 4) for 6 to 12 years of age
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The nurse cares for the homebound client with a urinary catheter. The client's spouse states the catheter is obstructed. Which observation by the nurse confirms this suspicion? 1. The nurse notes that the bladder is distended. 2. The client reports a constant urge to void. 3. The nurse notes that the urine is concentrated. 4. The client reports a burning sensation.
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1) CORRECT — bladder distention is one of the earliest signs of obstructed drainage tubing 2) seen with a urinary tract infection 3) seen with dehydration 4) seen with a urinary tract infection
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The client receives parenteral nutrition (PN) for several weeks. If the PN is abruptly discontinued, the nurse expects the client to exhibit which signs and symptoms? 1. Tinnitus, vertigo, blurred vision. 2. Fever, malaise, anorexia. 3. Diaphoresis, confusion, tachycardia. 4. Hyperpnea, flushed face, diarrhea.
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1) not seen 2) suggestive of infection 3) CORRECT — insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination 4) not seen
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The client is diagnosed with a gastric ulcer. The nurse anticipates the client will experience pain at which time? 1. Two to three hours after a meal. 2. During the night. 3. Prior to the ingestion of food. 4. One-half to 1 hour after a meal.
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1) feature of a duodenal ulcer 2) feature of a duodenal ulcer 3) feature of a duodenal ulcer 4) CORRECT — pain related to a gastric ulcer occurs about 0.5 to 1 hour after a meal and rarely at night; is not helped by ingestion of food
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During a prenatal visit, the client states, "I have been very nauseated during my first trimester, and I don't understand the reason." Which response by the nurse is best? 1. "You are nauseated because of the fatigue you are feeling." 2. "The nausea is due to an increase in the basal metabolic rate." 3. "The nausea is caused by an elevation in the hormones." 4. "If you eat different kinds of foods, you won't be nauseated."
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1) describes an erroneous rationale for the nausea 2) describes an erroneous rationale for the nausea 3) CORRECT — during the first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and hCG from the endocrine system 4) describes an erroneous rationale for the nausea
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The nursing assistive personnel (NAP) reports to the RN that the client with anemia reports weakness. Which nursing response is best? 1. "Listen to the client's breath sounds and report back to me." 2. "Set up the client's lunch tray." 3. "Obtain a diet history from the client ." 4. "Instruct the client to balance rest and activity."
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1) requires assessment; should be performed by the RN 2) CORRECT — standard, unchanging procedure; decreases cardiac workload 3) involves assessment; should be performed by the RN 4) assessment and teaching required; performed by the RN
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The 4-year-old child is admitted with drooling and an inflamed epiglottis. The nurse identifies which symptom as indicative of an increase in respiratory distress? 1. Bradycardia. 2. Tachypnea. 3. General pallor. 4. Irritability.
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1) tachycardia occurs early in hypoxia 2) CORRECT — increase in the respiratory rate is an early sign of hypoxia, also for tachycardia 3) pallor is not specific for hypoxia 4) client may be anxious and restless, but is generally not described as irritable
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The nurse observes the student nurse auscultate the right middle lobe (RML) lung of the client. The nurse knows the student nurse is auscultating correctly if the stethoscope is placed in which position? 1. Posterior and anterior base of right side. 2. Right anterior chest between the fourth and sixth intercostal spaces. 3. Left of the sternum, midclavicular, at right fifth intercostal space. 4. Posterior chest wall, midaxillary, right side.
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1) cannot auscultate the RML from the posterior 2) CORRECT — RML is found in the right anterior chest between the fourth and sixth intercostal spaces 3) point of maximum impulse or apical pulse 4) cannot auscultate the RML from the posterior
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The client is diagnosed with myasthenia gravis. It is most important for the nurse to consider which action? 1. Prevent accidents from falls as a result of vertigo. 2. Maintain fluid and electrolyte balance. 3. Control situations that could increase intracranial pressure and cerebral edema. 4. Assess muscle groups toward the end of the day.
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Strategy: Answers are a mix of assessment and implementation. Is there an appropriate assessment? Yes. 1) does not experience vertigo 2) fluid and electrolytes usually not a problem for this client 3) increased intracranial pressure is not associated with myasthenia gravis 4) CORRECT — client has increased muscle fatigue, needs more assistance toward end of day
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The nurse cares for a client during an acute manic episode. The nurse identifies 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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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 client is admitted to the outpatient oncology unit for routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm3, RBC 5.1 million/mm3, total serum calcium 9.3 mg/dL (2.3 mmol/L). Based on the lab values, the nurse determines which is the priority nursing diagnosis? 1. Risk for Activity Intolerance related to decrease in red cells. 2. Risk for Infection related to low white cell count. 3. Risk for Anxiety secondary to hypoparathyroid disease. 4. Risk for Fluid Volume Deficit due to decreased fluid intake.
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1) not a priority 2) CORRECT — clients with a low WBC count are susceptible to infection 3) not correctly stated as a nursing diagnosis and is not appropriate 4) not a priority for this client
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The nurse cares for the client diagnosed with Ménière's syndrome. The nurse stands directly in front of the 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 field.
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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 fields
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The client is admitted to the emergency department in acute respiratory distress. The client is very anxious, edematous, and cyanotic. The client receives morphine sulfate. Which finding does 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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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 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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1) required with client care activities that require physical skin-to-skin contact, or occurs by contact with contaminated inanimate objects in the client'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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The nurse evaluates the desired client response to diuretic therapy. Which action is the most reliable client measure for the nurse to use? 1. Obtain daily weights. 2. Obtain urinalysis. 3. Monitor Na+ and K+ levels. 4. Measure intake.
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1) CORRECT — effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights 2) does not relate to the effects of diuretic therapy 3) important to consider, but is not a priority 4) important to consider, but is not a priority
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The 7-year-old child is having some difficulty adjusting to the parents' impending divorce. The health care provider suggests play therapy. The nurse identifies which reason this 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) 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 adult client receives dexamethasone for chronic lymphocytic leukemia. It is most important for the nurse to report which finding to the health care provider? 1. Prothrombin time (PT) 12 seconds and hemoglobin (Hgb) 15 g/dL (150 g/L). 2. Blood urea nitrogen(BUN) 18 mg/dL (6.4 mmol/L) and creatinine 1.0 mg/dL (88 µmol/L). 3. Serum potassium (K) 3.4 mEq/L (3.4 mmol/L) and serum calcium (Ca) 7.8 mg/dL (2 mmol/L) . 4. Aspartate aminotransferase (AST) 18 U/L and alanine aminotransferase (ALT) 12 U/L.
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Strategy: "most important to report to the health care provider" indicates a complication. 1) normal PT 9.5 to 12 sec, normal Hgb male: 13 to 18 g/dL (130-180 g/L), female: 12 to 16 g/dL (120-160 g/L) 2) normal BUN 10 to 20 mg/dL (3.6-7.2 mmol/L) 60 years or younger, normal creatinine 0.7 to 1.4 mg/dL (62-124 µmol/L) 3) CORRECT — normal K 3.5 to 5.0 mEq/L, normal Ca 8.5 to 10.5 mg/dL (2.2-2.6 mmol/L), indicates hypokalemia and hypocalcemia 4) normal AST 8 to 40 units, normal ALT 8 to 40 units
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The nurse prepares the client for a magnetic resonance imaging (MRI). Which client statement indicates the teaching is successful? 1. "The dye used in the test will turn my urine green for about 24 hours." 2. "I will be put to sleep for this procedure. I will return to my room in two hours." 3. "This procedure will take about 90 minutes to complete. There will be no discomfort." 4. "The wires that will be attached to my head and chest will not cause me any pain."
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Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? 1) if contrast is used, it does not change the color of the urine 2) client is not anesthetized for this procedure 3) CORRECT — procedure takes approximately 90 minutes, not painful 4) indicates misunderstanding of MRI because no wires are used
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The nurse prepares the client for an IV pyelogram (IVP) scheduled in 2 hours. The nurse contacts the health care provider if the client makes which statement? 1. "I take metformin for type 2 diabetes." 2. "I completed the bowel prep last evening." 3. "I ate a light meal last evening." 4. "I had an IVP 3 years ago."
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1) CORRECT — should discontinue 48 hours prior to procedure, contrast media can cause life-threatening lactic acidosis 2) appropriate action; removes feces, fluid, and air from bowel so kidneys, ureters, and bladder will not be obscured 3) appropriate action 4) no reason to contact the health care provider
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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. BP 160/100, pulse 56. 5. Urinary output of 4 L/24 hours. 6. Urine specific gravity of 1.004.
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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 SIADH (syndrome of inappropriate antidiuretic hormone) opposite of diabetes insipidus. 4) late signs of increased intracranial pressure or brain damage. 5) CORRECT - excessive fluid loss is major occurrence of diabetes insipidus. 6) CORRECT - specific gravity very low as urine is not concentrated in the kidney.
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The health care provider orders chlorpromazine to control the alcoholic client's restlessness, agitation, and irritability following surgery. The nurse checks the order with the health care provider because of which rationale? 1. The nurse believes the client's symptoms reflect alcohol withdrawal. 2. The nurse does not know if the client is allergic to this medication. 3. The nurse knows the client is not psychotic. 4. The nurse routinely checks on the health care provider's orders.
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1) CORRECT — medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences 2) not best rationale for checking with health care provider about this order 3) not best rationale for checking with health care provider about this order 4) not best rationale for checking with health care provider about this order
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The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistive personnel (NAP). The RN cares 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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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 nurse develops care plans for these four clients. The nurse plans to use a restraint for which client? 1. The infant with septicemia. 2. The child after a tonsillectomy. 3. The infant after a cleft lip repair. 4. The child with meningitis.
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1) not in need of restraints 2) not in need of restraints 3) CORRECT — arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line 4) not in need of restraints
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The client develops a low intestinal obstruction. The nurse anticipates which findings? Select all that apply. 1. Nausea. 2. Vomiting. 3. Explosive diarrhea. 4. Tarry stool 5. Abdominal distention. 6. Rectal bleeding.
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Strategy: Think of intestinal anatomy. 1) CORRECT - nothing moving in the intestine causes nausea. 2) CORRECT - nothing moving in the intestine causes vomiting. 3) blockage causes no stool. 4) blockage results in no stool. 5) CORRECT - as stool backs up, abdominal distention occurs. 6) blockage results in no stool and no bleeding is associated.
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The client diagnosed with metastatic lung cancer is admitted to the hospital. The client's orders include do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. The client's BP is 86/50, respirations are 8, and the client is nonresponsive. Naloxone hydrochloride 0.4 mg IV is ordered stat. It is important for the nurse to consider which action? 1. The BP and respirations will need to increase before a second dose of naloxone can be given. 2. Naloxone should not be given to the client because of the DNR status. 3. A dose of naloxone may need to be repeated in 2 to 3 minutes. 4. Naloxone is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives.
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1) will not change without naloxone, respirations increase within 2 min 2) DNR indicates no resuscitation should be done if heart stops; does not preclude administration of medications to correct iatrogenic problems 3) CORRECT — half-life of naloxone is short; may go back into respiratory depression; may need to be repeated 4) used for respiratory depression of opiates, not used with barbiturates or sedatives
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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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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 plans care 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) 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 assesses orientation to person, place, and time for the elderly hospitalized client. Which principle does the nurse understand? 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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1) just the opposite is true; long-term memory is more efficient 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 clients may be slower at doing things 4) mental status and learning ability are not affected by aging, although elderly clients may be slower at doing things
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The client is diagnosed with Cushing syndrome. Which assessment finding does the nurse recognize as pertinent to this diagnosis? 1. Low blood pressure and weight loss. 2. Thin extremities with easy bruising. 3. Decreased urinary output and decreased serum potassium. 4. Tachycardia with reports of night sweats..
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1) BP increases and client gains weight 2) CORRECT — clients with Cushing 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 syndrome
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The client with type 1 diabetes asks the nurse why the health care provider prescribed short-acting insulin instead of intermediate-acting insulin. Which response by the nurse is best? 1. "More injections are required with intermediate-acting insulin than with short-acting insulin." 2. "Hypoglycemia and hyperglycemia are more common with intermediate-acting insulin." 3. "Development of eye and kidney damage is less likely with short-acting insulin." 4. "Blood glucose levels can be controlled more accurately with short-acting insulin."
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1) fewer injections are required with intermediate-acting insulin 2) no change in incidence of hypoglycemia or hyperglycemia 3) complications are caused by blood vessel damage from sugar and fat deposits, not type of insulin used 4) CORRECT — tighter blood glucose control occurs with short-acting insulin, especially initially
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The client is admitted with a tentative diagnosis of late stage AIDS dementia complex. The nursing assessment is most likely to reveal which finding? 1. Hyperactive deep tendon reflexes. 2. Peripheral neuropathy affecting the hands. 3. Disorientation to person, place, and time. 4. Impaired concentration and memory loss.
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Strategy: Think about each answer and how it relates to AIDS-related dementia. 1) not relevant to this condition 2) not relevant to this condition 3) CORRECT — approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation 4) is a sign of early-onset dementia
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The nurse cares for the client receiving haloperidol. The nurse anticipates which adverse effects? 1. Blood dyscrasia and extrapyramidal symptoms. 2. Hearing loss and unsteady gait. 3. Nystagmus and vertical gaze palsy. 4. Alteration in level of consciousness and increased confusion.
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1) CORRECT — major adverse effects of haloperidol include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS) 2) not seen with haloperidol 3) not seen with haloperidol 4) not seen with haloperidol
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Identify the most unstable clients to see first.
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1) first: 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 fluids, cough and deep breathe 4) fourth: breastfeeding client; stable client, least critical/priority
