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A client with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome confides that he is homosexual and his employer does not know his HIV status. Which response by the nurse is best?


 
RATIONALE: The nurse is responsible for maintaining confidentiality of this disclosure by the client.

CLIENT NEED: Psychosocial adaptation;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: B

 
The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets is most appropriate?


 
RATIONALE: Pets are discouraged when parents are trying to allergy proof a home for a child with bronchial asthma, unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish is a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold.

CLIENT NEED: Health promotion and maintenance;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: B

 
An elderly client is being admitted to same day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that:


 
RATIONALE: Under the policy for valuables, the nurse documents the description on an envelope with the client, the client and nurse sign the envelope, and the valuables envelope is locked in the safe. The other options increase the risk of loss or damage to the client’s valuables.

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: B

 
When an infant resumes taking oral feedings after surgery to correct intussusception, the parents comment that the child seems to suck on the pacifier more since the surgery. The nurse explains that sucking on a pacifier:


 
RATIONALE: Sucking provides the infant with a sense of security and comfort. It also is an outlet for releasing tension. The infant should not be discouraged from sucking on the pacifier. Fussiness after feeding may indicate that the infant’s appetite is not satisfied. Sucking is not manipulative in the sense of seeking parental attention.

CLIENT NEED: Health promotion and maintenance;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: A

 
Under which circumstance may a nurse communicate medical information without the client’s consent?


 
RATIONALE: Sexually transmitted diseases are communicable diseases that must be reported. The nurse is responsible for reporting these diseases to the appropriate public health agency, and to otherwise maintain the client’s confidentiality. The client’s family cannot request release of medical information without the client’s consent. A physician’s order is not a substitute for a client’s consent to release medical information in the absence of a communicable disease.

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
A 22-year-old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7 and he demonstrates evidence of decorticate posturing. Which of the following is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring?


 
RATIONALE: In a life-threatening emergency where time is of the essence in saving life or limb, consent is not required. This client has a Glasgow Coma Scale score of 7, which means he is comatose. The client has deteriorated to a level where he cannot be aroused, withdraws in a purposeless manner from painful stimuli, exhibits decorticate posturing, and may or may not have brain stem reflexes intact. The placement of the ICP monitor is crucial to determine cerebral blood flow and prevent herniation. The client’s fiancée cannot sign his consent because, until she is his wife or has designated power of attorney, she is not considered his next of kin. The physician should insert the catheter in this emergency. He does not need to get a consultation from another physician. When consent is needed for a situation that is not a true emergency, two nurses can receive a verbal consent by telephone from the client’s next of kin.

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: D

 
A 68-year-old client’s daughter is asking about the follow-up evaluation for her father after his pneumonectomy for primary lung cancer. The nurse’s best response is which of the following?


 
RATIONALE: Follow-up generally involves semiannual chest radio graphs. Recurrence usually occurs locally in the lungs and may be identified on chest radio graphs. Follow up after cancer treatment is an important component of the treatment plan. Serum markers (liver function tests) have not been shown to detect recurrence of lung cancer. There are no data to support the need for an abdominal computed tomography scan.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: D

 
The nurse is preparing to administer blood to a client who requires postoperative blood replacement. The nurse should use a blood administration set that has a:


 
RATIONALE: All blood products should be administered through a micron mesh filter. Blood is never administered without a filter. Leukocytes can be removed by using leukocyte poor filters, and this is recommended to decrease reactions in clients, such as hemophiliacs, who require frequent transfusions. Blood is too concentrated to administer through a micro drip set.

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: A

 
During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients feel that they have an active role in their health care?


 
RATIONALE: One of the best strategies to help clients feel in control is to ask them their view of situations, and to respond to what they say. This technique acknowledges that clients’ opinions have value and relevance to the interview. It also promotes an active role for clients in the process. Use of a questionnaire or written instructions is a means of obtaining information but promotes a passive client role. Asking whether clients have questions encourages participation, but alone it does not acknowledge their views.

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply.


 
RATIONALE: Socialization and communication, in addition to increased activity, are all means to aid in prevention of self-injury. Education of family members may foster development of strategies to prevent self-injury; hence, mitten restraints could be avoided. Applying lotion after bathing may not be appropriate when the skin is broken and not intact.

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWERS: B,C,D,E

 
A client with severe major depression states, “My heart has stopped and my blood is black ash.” The nurse interprets this statement to be evidence of which of the following?


 
RATIONALE: A client with severe depression may experience symptoms of psychosis such as hallucinations and delusions that are typically mood congruent. The statement, “My heart has stopped and my blood is black ash,” is a mood congruent somatic delusion. A delusion is a firm, false, fixed belief that is resistant to reason or fact. A hallucination is a false sensory perception unrelated to external stimuli. An illusion is a misinterpretation of a real sensory stimulus. Paranoia refers to suspiciousness of others and their actions.

CLIENT NEED: Psychosocial adaptation;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: C

 
When a client wants to read his chart, the nurse should:


 
RATIONALE: The client should be allowed to see his chart. As a client advocate, the nurse should answer questions for the client. The nurse helps the client understand that he is a primary partner in the health team. The Bill of Rights for Patients has existed since the 1960s, and every client should be aware of this document. The doctor should not need to give permission for the client to see his chart. As a client advocate, the nurse should not make excuses to put the client off in regard to seeing his chart.

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: B

 
A client with a fractured leg has been instructed to ambulate without weight bearing on the affected leg. The nurse evaluates that the client is ambulating correctly if she uses which of the following crutch walking gaits?


 
RATIONALE: The three-point gait, in which the client advances the crutches and the affected leg at the same time while weight is supported on the unaffected extremity, is the appropriate gait of choice. This allows for non-weight bearing on the affected extremity. The two-point, four-point, and swing to gaits require some weight bearing on both legs, which is contraindicated for this client.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Evaluate

CORRECT ANSWER: C

 
A client with major depression states, “Life isn’t worth living anymore. Nothing matters.” Which of the following responses by the nurse is best?


 
RATIONALE: When the client verbalizes that life isn’t worth living anymore, the nurse needs to ask the client directly about suicide by saying, “Are you thinking about killing yourself?” Asking directly does not provoke suicide but conveys concern, understanding, and the worth of the client. Commonly, the client experiences a sense of relief that someone finally hears him. It also helps the nurse plan responsible care by identifying the client who is at risk for suicide. The nurse should then evaluate the seriousness of the suicidal ideation by inquiring about the intent and plan. Stating, “Things will get better,” offers hope too soon without first evaluating the intent of the suicidal ideation. Asking, “Why do you think that way?” implies a lack of understanding and knowledge on the part of the nurse. Major depression usually is endogenous and biochemically based. Therefore, the client may not know why he doesn’t want to live. Saying, “You shouldn’t feel that way,” admonishes the client, decreases self worth, and conveys a lack of understanding.

CLIENT NEED: Psychosocial adaptation;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: A

 
A client with bipolar 1 disorder has been prescribed olanzapine (Zyprexa) 5 mg two times a day and lamotrigine (Lamictal) 25 mg two times a day. Which of the following adverse effects should the nurse report to the physician immediately? Select all that apply.


 
RATIONALE: Lamotrigine, an antiepileptic, is used as a mood stabilizer for clients with bipolar disorder and has been found to be effective for the depressive phase of bipolar disorder. Common adverse effects are dizziness, headache, sedation, tremors, nausea, vomiting, and ataxia. The development of a rash needs to be reported and evaluated by the physician because it could indicate the start of a severe systemic rash known as Stevens Johnson syndrome, a toxic epidermal necrolysis, which would necessitate the discontinuation of lamotrigine. Hyperthermia in conjunction with muscle rigidity suggests the development of neuroleptic malignant syndrome, a life-threatening complication associated with olanzapine.

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Analyze

CORRECT ANSWERS: A,D,E

 
A multigravid client at 34 weeks’ gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client’s contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews the physician orders (see chart). Which of the following orders should the nurse initiate first?


 
RATIONALE: The nurse should initiate fetal and contraction monitoring for this client upon arrival to the unit. This gives the nurse data regarding changes in fetal and maternal contraction status before completing the other orders. Next, the betamethasone would be given to begin the maturation process for the fetal lungs. Next, the nurse should start an intravenous infusion to provide a line for immediate intravenous access, if needed, and provide hydration for the client. The nurse should obtain the urine specimen prior to administering any antibiotic therapy, if ordered.

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: A

 
A multiparous client tells the nurse that she is using medroxy progesterone (Depo Provera) for contraception. The nurse should instruct the client to increase her intake of which of the following?


 
RATIONALE: The nurse should instruct the client to increase her intake of calcium because there is a slight increase in the risk of osteoporosis with this medication. Weight-bearing exercises are also advised. The drug may also impair glucose tolerance in women who are at risk for diabetes.

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: D

 
Which of the following statements made by a pregnant woman in the first trimester are consistent with this stage of pregnancy? Select all that apply.



 
RATIONALE: The first trimester is when the couple works through the psychological task of accepting the pregnancy. These statements describe the client and her partner coping with the pregnancy, how it feels, and how it will impact their lives.The feelings include pleasure, excitement, and ambivalence. Wondering what the baby will look like and planning for the baby’s room occur later in the pregnancy.

CLIENT NEED: Health promotion and maintenance;
COGNITIVE LEVEL: Analyze

CORRECT ANSWERS: A,B,E

 
The nurse is teaching a client about using topical gentamicin sulfate (Garamycin). Which of the following comments by the client indicates the need for additional teaching?


 
RATIONALE: The aminoglycoside antibiotic gentamicin sulfate should not be applied to large denuded areas because toxicity and systemic absorption are possible. The nurse should instruct the client to avoid excessive sun exposure because gentamicin sulfate can cause photosensitivity. The client should be instructed to apply the cream or ointment for only the length of time prescribed because a superinfection can occur from overuse. The client should contact the physician if the condition worsens after use.

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Evaluate

CORRECT ANSWER: D

 
A client takes hydrochlorothiazide (HCTZ) for treatment of essential hypertension. The nurse should instruct the client to report which of the following? Select all that apply.


 
RATIONALE: Hydrochlorothiazide is a thiazide diuretic used in the management of mild to moderate hypertension, and in the treatment of edema associated with: heart failure, renal dysfunction, cirrhosis, corticosteroid therapy, and estrogen therapy. It increases the excretion of sodium and water by inhibiting sodium re-absorption in the distal tubule of the kidneys. It promotes the excretion of chloride, potassium, magnesium, and bicarbonate. Side effects include: drowsiness, lethargy, and muscle weakness, but not muscle twitching. Although there may be abdominal cramping, there is not diarrhea. The client does not become confused as a result of taking this drug.

CLIENT NEED: Health promotion and maintenance;
COGNITIVE LEVEL: Analyze

CORRECT ANSWERS: B,E,F

 
A client has been taking imipramine (Tofranil) for his depression for 2 days. His sister asks the nurse, “Why is he still so depressed?” Which of the following responses by the nurse is most appropriate?


 
RATIONALE:  The nurse needs to inform the sister that it takes 2 to 4 weeks before a full clinical effect occurs with the drug. The nurse should let her know that her brother will gradually get better and symptoms of depression will improve. Telling the sister that her brother is experiencing a very serious depression does not give the sister important information about the medication. Additionally, this statement may cause alarm and anxiety. Conveying the sister’s concern to the physician does not provide her with the necessary information about the client’s medication. Telling the sister that the client’s medication may need to be changed is inappropriate because a full clinical effect occurs after 2 to 4 weeks.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.


 
RATIONALE:  For the client with grandiose delusions, the nurse should accept the client but not argue with the delusion to build trust and the client’s self-esteem. Focusing on the underlying feeling or meaning of the delusion helps to meet the client’s needs. Focusing on events and topics based in reality distracts the client from the delusional thinking. Confronting the client’s delusions or beliefs can lead to agitation in the client and the need to cling to the grandiose delusion to preserve self-esteem. Interacting with the client only when he is based in reality ignores the client’s needs and therapeutic nursing intervention. 

CLIENT NEED: Psychosocial adaptation;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWERS: A,B,C

 
Which of the following responses is most helpful for a client who is euphoric, intrusive, and interrupts other clients engaged in conversations to the point where they get up and leave or walk away?


 
RATIONALE: Saying, “When you interrupt others, they leave the area,” is most helpful because it serves to increase the client’s awareness of how others view him by giving him specific feedback about his behavior. The other statements are punitive and authoritative, possibly threatening to the client, and likely to increase defensiveness, decrease self-worth, and increase feelings of guilt.   

CLIENT NEED: Psychosocial adaptation;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: A

 
The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate (Garamycin)?


 
RATIONALE: To determine how low the gentamicin serum level drops between doses, the trough serum level should be drawn just before the administration of the next I.V. dose of gentamicin sulfate.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: D

 
Older adults with known cardiovascular disease must balance which of the following measures for optimum health?


 
RATIONALE:Health-promoting strategies for clients with a history of cardiovascular disease require knowledge in three areas: diet, exercise, and medication. Pain management and management of social activities are not usually features of health promotion activities for these clients.   

CLIENT NEED: Health promotion and maintenance;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: A

 
A 4-year-old is brought to the emergency department with sudden onset of a temperature of 103° F (39.5° C), sore throat, and refusal to drink. The child will not lie down and prefers to lean forward while sitting up. Which of the following should the nurse do next?


 
RATIONALE: The child is exhibiting signs and symptoms of possible epiglottiditis. As a result the child is at high risk for laryngospasm and airway occlusion. Therefore, the nurse should have a tracheostomy tube and setup readily available should the child experience an airway occlusion. Although acetaminophen is an antipyretic, the dosage of 600 mg to be administered rectally is too high. A typical 4-year-old weighs approximately 40 lb. The recommended dose is 125 mg. When any type of respiratory illness, and especially epiglottiditis, is suspected, putting any object, including a tongue depressor for inspection or a cotton-tipped applicator to obtain a throat culture, in the back of the mouth or throat or having the child open the mouth is inappropriate because doing so may predispose the child to laryngospasm or occlusion of the airway by a swollen epiglottis.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next?


 
RATIONALE:  The client is exhibiting temporary side effects associated with lithium therapy. Therefore, the nurse should continue the lithium and explain to the client that he is experiencing temporary side effects of lithium that will subside. Common side effects of lithium are nausea, dry mouth, diarrhea, thirst, mild hand tremor, weight gain, bloating, insomnia, and light-headedness. Immediately notifying the physician about these common side effects is not necessary.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
A client asks the nurse how long she has to take her medicine for hypothyroidism. The nurse’s response is based on the knowledge that:


 
RATIONALE:  Thyroid replacement is a lifelong maintenance therapy. The medication is usually given as one dose in the morning. It cannot be tapered or discontinued because the client needs thyroid supplementation to maintain health. The medication cannot be discontinued after the thyroid-stimulating hormone (TSH) level is normal; the dose will be maintained at the level that normalizes the TSH concentration.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: A

 
The nurse should advise which of the following clients who is taking lithium to consult with the physician regarding a potential adjustment in lithium dosage?


 
RATIONALE: A client who is beginning training for a tennis team would most likely require an adjustment in lithium dosage because excessive sweating can increase the serum lithium level, possibly leading to toxicity. Adjustments in lithium dosage would also be necessary when other medications have been added, when an illness with high fever occurs, and when a new diet begins.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: D

 
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says:


 
RATIONALE:  Traveling is usually discouraged if preterm labor has been a problem, as it restricts normal movement. A client should be able to walk around frequently to prevent blood clots and to empty her bladder at least every 1 to 2 hours. Bladder infections often stimulate preterm labor and preventing them is of great importance to this client. Contractions that recur indicate the return of preterm labor and the health care provider needs to be notified. Dehydration is known to stimulate preterm labor and encouraging the client to drink adequate amounts of water helps to prevent this problem.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Evaluate

CORRECT ANSWER: D

 
A client admitted with a gastric ulcer has been vomiting bright red blood. His hemoglobin level is 5.11 g/dL, and his blood pressure is 100/50 mm Hg. The client and his family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should collaborate with the physician and family to next:


 
RATIONALE:  The most appropriate response is to continue all treatments and attempt to stabilize the client using fluid replacement without administering blood or blood products. It is imperative that the health care team respect the client’s religious beliefs and wishes, even if they are not those of the health care team. Discontinuing all measures is not an option. The health care team should continue to provide the best care possible and does not need to notify the attorney.   

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
The parents of a child with cystic fibrosis express concern about how the disease was transmitted to their child. The nurse should explain that:


 
RATIONALE:  Cystic fibrosis is the most common inherited disease in children. It is inherited as an autosomal recessive trait, meaning that the child inherits the defective gene from both parents. The chances are one in four for each of this couple’s pregnancies.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: B

 
A client with angina shows the nurse her nitroglycerin (Nitrostat) that she carries in a plastic bag in her pocket. The nurse instructs the client that nitroglycerin should be kept in:


 
RATIONALE:  Nitroglycerin in all dosage forms (sublingual, transdermal, or intravenous) should be shielded from light to prevent deterioration. The client should be instructed to keep the nitroglycerin in the dark container that is supplied by the pharmacy, and it should not be removed or placed in another container.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: C

 
When teaching a client with bipolar disorder, mania, who has started to take valproic acid (Depakene) about possible side effects of this medication, the nurse should include which of the following in the teaching plan?


 
RATIONALE:  Valproic acid causes sedation as well as nausea, vomiting, and indigestion. Sedation is important because the client needs to be cautioned about driving or operating machinery that could be dangerous while feeling sedated from the medication. Depakene does not cause increased urination, slowed thinking, or weight loss. However, some clients may experience weight gain.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
An infant is born with facial abnormalities, growth retardation, mental retardation, and vision abnormalities. These abnormalities are probably caused by maternal:


 
RATIONALE:  These effects and others when seen after birth are known as a cluster of symptoms called fetal alcohol syndrome. Vitamin B6 and vitamin A deficiency can affect growth and development but not with these specific effects. Folic acid deficiency contributes to neural tube defects.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: A

 
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to:


 
RATIONALE:  NSAIDs irritate the gastric mucosa and should be taken with food. NSAIDs are usually taken once or twice daily. Joint exercise is not related to the drug administration. Antacids may interfere with the absorption of NSAIDs.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: D

 
The nurse should suspect that the client taking disulfiram (Antabuse) has ingested alcohol when the client exhibits which of the following symptoms?



 
RATIONALE: The client who drinks alcohol while taking disulfiram experiences sweating, flushing of the neck and face, tachycardia, hypotension, a throbbing headache, nausea and vomiting, palpitations, dyspnea, tremor, and weakness.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Analyze
 

CORRECT ANSWER: B

 
The nurse holds the gauze pledget against an I.M. injection site while removing the needle from the muscle. This technique helps to:


 
RATIONALE: Holding the gauze pledget against an I.M. injection site while removing the needle from the muscle avoids the discomfort of the needle pulling on the skin.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: C

 
A client whose condition remains stable after a myocardial infarction gradually increases his activity. Which the following conditions should the nurse assess to determine whether the activity is appropriate for the client?


 
RATIONALE: Physical activity is gradually increased after a myocardial infarction while the client is still hospitalized and through a period of rehabilitation. The client is progressing too rapidly if activity significantly changes respirations, causing dyspnea, chest pain, a rapid heartbeat, or fatigue. When any of these symptoms appears, the client should reduce activity and progress more slowly. Edema suggests a circulatory problem that must be addressed but doesn’t necessarily indicate overexertion. Cyanosis indicates reduced oxygen carrying capacity of red blood cells and indicates a severe pathology. It is not appropriate to use cyanosis as an indicator for overexertion. Weight loss indicates several factors but not overexertion.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: C

 
The nurse is conducting a counseling session with a client experiencing post traumatic stress disorder (PSTD) using a 2 way video telehealth system from the hospital to the client’s home, which is 2 hours away from the nearest mental health facility. Which of the following are expected outcomes of using telehealth as a venue to provide health care to this client? Select all that apply. The client will:


 
RATIONALE:  Telehealth is becoming an increasingly available way for nurses to conduct counseling sessions with clients who are at a distance from a health care provider or health care facility. The client saves travel time and can avoid precipitating symptoms associated with the stress disorder that might occur as a result of a visit to a health care facility. The client also can access care that might not otherwise be easily available. Treatment for PSTD is long-term, and there is no evidence to suggest that telehealth  versus face to face counseling shortens recovery time. Counseling sessions using telehealth technology are conducted on an individual basis between one client and a health care provider, but group support may be available if required as a part of a treatment plan.   

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Evaluate

CORRECT ANSWERS: A,B,D

 
When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse should use which of the following approaches?


 
RATIONALE:  When a client talks about not having a problem with alcohol, the nurse needs to point out how alcohol has gotten the client into trouble. Concrete facts are helpful in decreasing the client’s denial that alcohol is a problem. The other approaches allow the client to use defense mechanisms, such as rationalization, projection, and minimization, to explain her actions. Therefore, these approaches are not helpful.   

CLIENT NEED: Psychosocial adaptation;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
Which of the following correctly describes Medicaid?


 
RATIONALE:  Medicaid is state funded, with matching federal funds, and provides medical assistance for low-income persons without health insurance. The program for older adults is Medicare.   

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Apply


CORRECT ANSWER: C

 
The nurse is preparing a teaching plan for a 45-year-old client recently diagnosed with type 2 diabetes mellitus. What is the first step in this process?


 
RATIONALE: Before development and implementation of the teaching plan, it is vital to determine what the client currently knows regarding diabetes and what the client needs to know.   

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Create

CORRECT ANSWER: C

 
A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse begins instructing the client about the medication and the importance of monitoring his heart rate. An expected outcome of the education program will be:


 
RATIONALE:  The goal of the education program is to instruct the client to take his pulse; therefore, the expected outcome would be the ability to give a return demonstration of how to palpate the heart rate.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Evaluate

CORRECT ANSWER: A

 
A multigravid client is scheduled for a percutaneous umbilical blood sampling procedure. The nurse instructs the client that this procedure is useful for diagnosing which of the following?


 
RATIONALE:  Percutaneous umbilical blood sampling is a useful procedure for diagnosing Rh disease, obtaining fetal complete blood count, and karyo typing chromosomes to evaluate for genetic disorders. Ultrasound commonly is used to detect twins. A lecithin-sphingomyelin ratio is the procedure of choice to diagnose fetal lung maturation. A maternal blood test is used to determine the alpha feto-protein level.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: C

 
Which of the following is an adverse effect of vancomycin (Vancocin) and needs to be reported promptly?


 
RATIONALE:  The client should report tinnitus because vancomycin can affect the acoustic branch of the eighth cranial nerve. Vancomycin does not affect the vestibular branch of the acoustic nerve; vertigo and ataxia would occur if the vestibular branch were involved. Muscle stiffness is not associated with vancomycin.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: B

 
Which of the following statements indicates that the client with a peptic ulcer understands the dietary modifications he needs to follow at home?


 
RATIONALE:  Caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa. The client should avoid foods that cause discomfort; however, there is no need to follow a soft, bland diet. Eating six small meals daily is no longer a common treatment for peptic ulcer disease. Milk in large quantities is not recommended because it actually stimulates further production of gastric acid.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Evaluate

CORRECT ANSWER: D

 
The client with a nasogastric (NG) tube begins to complain of abdominal distention. Which of the following measures should the nurse implement first?


 
RATIONALE:  When a client with a NG tube exhibits abdominal distention, the nurse should first check the suction machine. If the suction equipment is functioning properly, then the nurse should take other steps, such as repositioning the tube or checking tube patency by irrigating it. If these steps are not effective, then the physician should be called.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
A male client has been diagnosed as having a low sperm count during infertility studies. After instructions by the nurse about some causes of low sperm counts, the nurse determines that the client needs further instructions when he says low sperm counts may be caused by which of the following?


 
RATIONALE:  Increased, not decreased, body temperature resulting from occupations or infections can contribute to low sperm counts caused by decreased sperm production. Heat can destroy sperm. Varicocele, an abnormal dilation of the veins in the spermatic cord, is an associated cause of a low sperm count. The varicosity increases the temperature within the testes, inhibiting sperm production. Frequent use of saunas or hot tubs may lead to a low sperm count. The temperature of the scrotum becomes elevated, possibly inhibiting sperm production. Endocrine imbalances (thyroid problems) are associated with low sperm counts in men because of possible interference with spermatogenesis.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Evaluate

CORRECT ANSWER: D

 
A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information?


 
RATIONALE:  The client should be encouraged to report painful urination or urinary retention. Lesions may appear 2 to 12 days after exposure. The client is capable of transmitting the infection even when asymptomatic, so a barrier contraceptive should be used. Drinking extra fluids will not stop the lesions from forming.   

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments?


 
RATIONALE:  The clinical findings of edema are consistent with fluid excess in the interstitial compartment. The extracellular compartment consists of fluid in two locations, the interstitial (tissue) spaces and plasma (intravascular) spaces. Fluid shifts within the extracellular compartment can occur either from the plasma space to the interstitial space, or from the interstitial space to the plasma space. When fluid shifts from the plasma space into the interstitial space, usually as a result of abnormal retention of fluids in such conditions as heart failure or renal failure, edema results. The intracellular compartment consists of fluid within the cells.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: A

 
An expected physiologic response to a low potassium level is:


 
RATIONALE:  Low potassium can cause an imbalance at the cellular level that leads to dysrhythmias and cardiac arrest. Hyperglycemia is caused by elevated blood sugar. Hypertension is unrelated to potassium levels. Increased energy is unrelated to potassium levels.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: A

 
When teaching unlicensed assistive personnel (UAP) about the importance of hand washing in preventing disease, the nurse should instruct the UAP that?


 
RATIONALE: Hand washing with the correct technique is the best method for preventing cross- contamination. The hands serve as a source of infection. Water less commercial products containing at least 60%  alcohol are as effective at killing organisms as  hand washing.   

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: B

 
The nurse is performing Leopold’s maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?


 
RATIONALE:  The third maneuver is used to identify the presenting part. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. While facing the client, the nurse places the tips of the first three fingers on the side of the woman’s abdomen above the symphysis pubis and palpates deeply around the presenting part to identify its contour and size. The first maneuver involves using the tips of the fingers of both hands to palpate the uterine fundus. The second maneuver identifies the back of the fetus, and the fourth maneuver identifies the cephalic prominence.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: C

 
A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity?


 
RATIONALE: The stored glucose of muscle glycogen is the major fuel during sustained activity. Glucose production slows as the body begins to depend on fat stores for glucose and fatty acids. Protein is not the body’s preferred energy source. Fat is a secondary source of energy. Water is not an energy source, although sufficient water is required to engage in aerobic activity without causing dehydration.   

CLIENT NEED: Health promotion and maintenance;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: B

 
A client’s chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that:


 
RATIONALE:  Fluctuation of fluid with respirations in the water-seal column indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client’s skin around the chest tube insertion site. A leak in the system is indicated when bubbling occurs in the water-seal column.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: C

 
A client with diabetes is explaining to the nurse how she will care for her feet at home. Which statement indicates that the client understands proper foot care?


 
RATIONALE:  It is important to dry the feet carefully after a bath to prevent a fungal infection. Diabetic clients should seek medical attention when they injure their toes or feet to prevent complications. Iodine is highly toxic to the tissues. Diabetic clients should inspect their feet daily and should wear shoes that support their feet while in the house.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Evaluate

CORRECT ANSWER: D

 
The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?


 
RATIONALE: Diverticular rupture causes peritonitis from the release of intestinal contents (chemicals and bacteria) into the peritoneal cavity. A rigid abdominal wall results from a diverticular cavity. The inflammatory response of the peritoneal tissue produces severe abdominal rigidity and pain, diminished intestinal motility, and retention of intestinal contents (air, fluid, and stool). Hyperactive bowel sounds, explosive diarrhea, and excessive flatulence do not indicate peritonitis.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: B

 
A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply.


 
RATIONALE: Pancreatitis, a chronic or acute inflammation of the pancreas, is a potentially life-threatening condition. Excessive alcohol intake and gallstones are the greatest risk factors. Abdominal trauma can potentiate inflammation. Hyper-lipidemia is a risk factor for recurrent pancreatitis. Hypertension and hypothyroidism are not associated with pancreatitis.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWERS: A,B,C,E

 
The nurse is beginning the shift and is now responsible for the following clients on the postpartum unit and has not yet made rounds on the clients. Additionally, the nurse is responsible for three other clients who are currently listed as stable. The nurse will also be getting a new admission in 15 minutes. For the best utilization of time and client safety, the nurse should make rounds on which of the following clients first?


 
RATIONALE:  The client most in need of validating safety is the mother who has received Methergine 1 hour ago for increased bleeding. Her bleeding level needs to be documented as having been evaluated at the beginning of the shift and to determine if it has decreased to within normal limits (i.e., saturating less than 1 pad/hour). The 3 stable clients will need to have an initial assessment by the oncoming nurse but can wait until the nurse can first assess the mother who is receiving Methergine. The mother with the 4-hour-old infant is able to breast-feed to maintain the blood glucose level, and the mother with the 3-day-old infant in the “bili blanket” is stable at this point.   

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
When performing chest percussion on a child, which of the following techniques should the nurse use?


 
RATIONALE: The nurse should firmly yet gently strike the chest wall with the hand cupped to make a hollow popping sound. A slapping sound indicates that an incorrect technique is being used. The area over the rib cage is percussed to loosen mucus from the underlying lung passages. The child should wear a thin piece of clothing (T-shirt) over the chest area to protect the skin without diminishing the effect of the percussion.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: A


 
The nurse walks into the room of a client who has a “do not resuscitate” order and finds the client without a pulse, respirations, or blood pressure. What is the most appropriate action?


 
RATIONALE:  The nurse should call to the desk to ask for assistance. The nurse needs to notify the doctor of the client’s death and the family must then be notified. A code should not be called. Nursing personnel should begin postmortem care so that the family does not walk in unannounced to find their loved one deceased and looking disarrayed.   

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: A

 
A client has his leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment?


 
RATIONALE:  One pound of weight is approximately equivalent to 3,500 calories. Removing 1,000 calories per day results in a 2-lb weight loss per week (7,000 calories divided by 7 days). If a client wanted to lose 1 lb in a 7-day period, he would need to cut out 500 calories per day (3,500 calories divided by 7 days). It is unsafe to try to lose more than 2 lb/ week.   

CLIENT NEED: Health promotion and maintenance;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: B

 
A nulligravid client calls the clinic and tells the nurse that she forgot to take her oral contraceptive this morning. Which of the following should the nurse instruct the client to do?


 
RATIONALE: The nurse should instruct the client to take the medication immediately or as soon as she remembers that she missed the medication. There is only a slight risk that the client will become pregnant when only one pill has been missed, so there is no need to use another form of contraception. However, if the client wishes to increase the chances of not getting pregnant, a condom can be used by the male partner. The client should not omit the missed pill and then restart the medication in the morning because there is a possibility that ovulation can occur, after which intercourse could result in pregnancy. Taking two pills is not necessary and also will result in putting the client off her schedule.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: A

 
The nurse recognizes that a client with pain disorder is improving when the client says which of the following?


 
RATIONALE: Pain disorder is a somato form disorder involving severe pain in one or more anatomic sites causing severe distress or impaired function. The statement, “I need to have a good cry about all the pain I’ve been in and then not dwell on it,” indicates improvement because the client has a realistic view of the physical symptoms and pain and is willing to let them go and move on. The other statements indicate the continued presence of denial, lack of insight, and the need for symptoms to manage anxiety.   

CLIENT NEED: Psychosocial adaptation;
COGNITIVE LEVEL: Evaluate

CORRECT ANSWER: A

 
A client admitted in an acute psychotic state says that she hears terrible voices in the head and thinks her neighbor is out to get her. Which of the following is the nurse’s best response?


 
RATIONALE:  The nurse needs to collect additional information about the client’s complaint of hearing voices. Assessing the content of hallucinations is essential to determine whether they are command hallucinations that the client might act on. Asking about what the neighbor has been doing or telling the client that the neighbor won’t visit  indirectly reinforces the delusion about the  neighbor. Although determining the onset and duration of the voices is important, the nurse needs to assess the content of the hallucinations first.   

CLIENT NEED: Psychosocial adaptation;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: D

 
The nurse should assess the client with severe diarrhea for which acid-base imbalance?


 
RATIONALE:  A client with severe diarrhea loses large amounts of bicarbonate, resulting in metabolic acidosis. Metabolic alkalosis does not result in this situation. Diarrhea does not affect the respiratory system.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: C

 
A nurse is planning care for a client who has heart failure. Which goal is appropriate for a client with excess fluid volume?


 
RATIONALE: Serum osmolality indicates the water balance of the body. A normal plasma osmolality between 275 and 295 mOsm/kg indicates that the fluid volume excess has been resolved. A weight reduction of 10% may not necessarily return the client to a state of normal serum osmolality. Clients with excess fluid volume do not necessarily have pain or abnormal arterial blood gas values.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: D

 
A 7-year-old child is admitted to the hospital with the medical diagnosis of acute rheumatic fever. Which of the following laboratory blood findings confirms that the child has had a streptococcal infection?


 
RATIONALE:  Exactly why rheumatic fever follows a streptococcal infection is not known, but it is theorized that an antigen-antibody response occurs to an M protein present in certain strains of streptococci. The antibodies developed by the body attack certain tissues such as in the heart and joints. Anti-streptolysin O titer findings show elevated or rising antibody levels. This blood finding is the most reliable evidence of a streptococcal infection.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: C

 
The nurse on the postpartum unit is caring for four couplets. There will be a new admission in 30 minutes. The new client is a G4 P4, Spanish speaking only client with an infant who is in the special care nursery (SCN) for fetal distress. The nurse should place the new client in a room with which of the following clients?


 
RATIONALE:  The ability to communicate with a person of the same language would be an advantage, an opportunity for socialization and support for the new mother who speaks Spanish. If a Spanish speaking mother were placed with the client who also had a baby in SCN, she would have no communication opportunity and the same would apply for rooming with the mother who has had a Caesarean section. The client who is non-English speaking does not identify the language spoken and the nurse cannot assume that it is Spanish.   

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: A

 
A client is scheduled for hip replacement surgery and is interviewed by the nurse in the preadmission testing unit. The client states that he wishes to receive his own blood for the upcoming surgery. The nurse should:


 
RATIONALE:  The nurse should call the surgeon’s office so that arrangements can be made for the client to donate a unit of his blood for possible future auto-transfusion. This must be done in sufficient time before surgery so that the client is not at risk for being anemic at the time of the scheduled procedure. The client’s request must be scheduled through the surgeon’s office because the surgeon has ultimate responsibility for the client. The nurse can document that the surgeon’s office was notified of the client’s request. Notifying the hematology laboratory or blood bank is not an appropriate response.   

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
A client needs surgery to relieve an intestinal obstruction. The nurse receives the following set of orders for the client. Which of the following orders should the nurse question before performing?


 
RATIONALE:  High colonic irrigation can increase the risk of perforation in a distended and inflamed colon. Tap water is hypotonic in the bowel and would draw increased fluid into the area. The other orders are part of standard preparation for intestinal surgery.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: A

 
After teaching a client about collecting a stool sample for occult testing, which client statement indicates effective teaching? Select all that apply.


 
RATIONALE:  When a client collects stool for occult blood, the nurse should instruct him to avoid eating meat, especially red meat, for 1 to 3 days before the sample collection because meat eliminated in the stool can lead to false-positive results. Eating foods high in fiber a few days before sample collection may be recommended because doing so improves the chances of finding occult blood if a lesion is present. The client should take stool samples from different sites of the stool for a better sample. The stool sample should be covered to protect everyone from body secretions. The specimen does not have to be sent to the laboratory immediately. Some medications, herbs, foods, and activities can lead to false results of the occult testing. For example, iron pills, turnips, and horseradish lead to false-positive results. Vitamin C leads to false-negative results. Some anti-inflammatory drugs and aspirin should be avoided due to anti-platelet properties that increase the risk of gastrointestinal bleeding.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Evaluate

CORRECT ANSWERS: A,C

 
A client who is on nothing by mouth status is constantly asking for a drink. Which of the following is the most appropriate nursing intervention?


 
RATIONALE:  The most appropriate intervention is to offer the client frequent mouth care to moisten the dry oral mucosa. Reexplaining why the client cannot drink may be helpful but will not relieve her thirst. Ice chips cannot be given to a client who is on nothing by mouth status. Diverting the client’s attention does not treat her complaint.   

CLIENT NEED: Basic care and comfort;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: C

 
A female client is admitted with fatigue, cold intolerance, weight gain, and muscle weakness. The initial nursing assessment reveals brittle nails, dry hair, constipation, and possible goiter. The client is most likely experiencing signs and symptoms of:


 
RATIONALE:  This client is demonstrating classic symptoms of hypothyroidism. Primary hypothyroidism results from pathologic changes in the thyroid gland. In this case, the thyroid gland cannot secrete sufficient amounts of thyroid hormone, leading to a decrease in cellular metabolic activity, decreased oxygen consumption, and decreased heat production. Cushing’s disease is manifested by a buffalo hump, moon face, hypertension, fatigability, and weakness, resulting from the inappropriate release of cortisol. Hyperthyroidism, or Graves’ disease, is manifested by increased appetite with weight loss, increased anxiety, hand tremors, palpitations, heat intolerance, and insomnia. A pituitary tumor can have many symptoms, depending on the location.   

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: B

 
A mother visiting the clinic for a routine visit with her 10-year-old daughter reports that her daughter has an increase in hair growth and breast enlargement. The nurse explains to the mother and daughter that after the symptoms of puberty are noticed, menstruation typically occurs within which of the following time frames?


 
RATIONALE: After the symptoms of puberty, such as increased hair growth and enlargement of the breasts, are noticed, menstruation typically begins within 30 months.

CLIENT NEED: Health promotion and maintenance;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: C

 
While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, “What are these white dots in my baby’s mouth? I tried to wash them out, but they’re still there.” After assessing the neonate’s mouth, the nurse explains that these spots are which of the following?


 
RATIONALE: Epstein’s pearls are tiny, hard, white nodules found in the mouth of some neonates. They are considered normal and usually disappear without treatment. Koplik’s spots, associated with measles in children, are patchy and bright red with a bluish-white speck in the middle. Precocious teeth are actual teeth that some neonates have at birth. Usually only one or two teeth are present. Candida albicans, or thrush, is not apparent in the mouth immediately after birth but may appear a day or two later. This infection is manifested by yellowish-white spots or lesions that resemble milk curds and bleed when attempts are made to wipe them away.

CLIENT NEED: Health promotion and maintenance;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: B

 
The nurse should assess a newborn with esophageal atresia and tracheoesophageal fistula (TEF) for which of the following? Select all that apply.


 
RATIONALE: The initial signs of esophageal atresia and TEF include lots of frothy mucus and unexplained episodes of cyanosis usually caused by overflow of mucus from the esophagus. Loose stools and poor gag reflex are not signs of TEF. Initial weight loss is common in newborns and not related to TEF.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWERS: A,B

 
Which of the following factors is most important for healing an infected decubitus ulcer?


 
RATIONALE: Adequate circulatory status is the most important factor in the healing process of an infected decubitus ulcer. Blood flow to the area must be present to bring nutrients and prescribed antibiotics to the tissues. Rest and a balanced diet are essential to health maintenance but are not the priority for healing an infected decubitus ulcer. A fluid intake of 2,000 to 3,000 mL/day, if not contraindicated, is recommended to provide hydration to the client’s tissues.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: A

 
A client is receiving digoxin (Lanoxin). His pulse range is normally 70 to 76 bpm. After assessing the apical pulse for 1 minute and finding it to be 60 bpm, the nurse should first:


 
RATIONALE: The nurse’s initial response should be to withhold the digoxin. The nurse should then notify the physician if the apical pulse is 60 bpm or lower because of the risk of digoxin toxicity. The charge nurse does not need to be notified, but the nurse needs to document the notification and follow-up in the chart.

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: B

 
While shopping at a local mall, the nurse hears a pregnant client yell, “Oh my! The baby’s coming!” After placing the client in a supine position and trying to maintain some privacy, the nurse sees that the neonate’s head is delivering. Which of the following should the nurse do first?


 
RATIONALE: In an emergency in which the neonate’s head is already delivering, the first action by the nurse should be to check for the presence of a cord around the neonate’s neck. If the cord is present, the nurse should gently remove it from around the neck. The mother should be told to breathe gently and avoid forceful bearing down efforts, which could lead to lacerations. Although blood and bodily fluid precautions are always present in client care, this is an emergency. If possible, the nurse should put on gloves. Suctioning the mouth can be done after the nurse has checked that the cord is not around the neonate’s neck. Telling the mother that help is on the way is not reassuring because emergency medical technicians may take some time to arrive. Delivery is imminent because the neonate’s head is delivering.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: B

 
The nurse is preparing a discharge plan for a 16-year-old who has fractured her femur and ulna. The client asks the nurse how quickly her fractures will heal so she can return to her normal activities. Which of the following responses is most appropriate for the nurse to make?


 
RATIONALE: The ulna heals in approximately 12 weeks. The femur takes approximately 24 weeks to heal because of the size of the bone and the muscle forces exerted on the femur. Skeletal traction does not delay healing but can actually promote healing by properly aligning the fracture.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: B

 
A client with delirium becomes very anxious and says, “I can’t stop what is happening to me. Make it stop, please!” Which of the following is the nurse’s most appropriate response?


 
RATIONALE: The client needs to know that there is a cause for the delirium, that there is hope for treatment, and that medications can help decrease anxiety. Giving medications can help the anxiety, but the client also needs an explanation about the condition. Saying that the more the client worries, the worse the delirium will get is inappropriate and most likely would add to the client’s anxiety.

CLIENT NEED: Psychosocial adaptation;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: B

 
After teaching a primigravid client at 10 weeks’ gestation about the recommendations for exercise during pregnancy, which of the following client statements indicates successful teaching?


 
RATIONALE: The client understands the instructions when she says she should avoid contact sports because they may result in injury to the client and the fetus. Learning to ski while pregnant is not recommended because injury may occur. Scuba diving should be avoided because depth pressures could cause fetal damage. Hot tubs should be avoided during the first trimester because sitting in them can result in fetal hyperthermia and fetal hypoxia. Mild exercises, such as walking, can help strengthen the muscles and prevent some discomforts such as backache.

CLIENT NEED: Health promotion and maintenance;
COGNITIVE LEVEL: Evaluate

CORRECT ANSWER: A

 
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown below. The nurse identifies that this rhythm is:


 
RATIONALE: Third-degree heart block occurs when atrial stimuli are blocked at the atrioventricular junction. Impulses from the atria and ventricles are conducted independently of each other. The atrial rate is 60 to 100 bpm; the ventricular rate is usually 10 to 60 bpm.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: D

 
The physician has ordered a chemotherapy drug to be administered to a client every day for the next week. The client is on an adult medical surgical floor but the nurse assigned to the client has not been trained to handle chemotherapy agents. What is the nurse’s most appropriate response?


 
RATIONALE: The nurse should call the oncology unit to institute a transfer. The nurse handling chemotherapy agents should be specially trained. It is an unwise use of nursing resources to send a nurse from one unit to administer medications to a client on another unit. It is better to centralize and send the client who needs chemotherapy to one unit. Even if the pharmacy mixes the agent, the drug must be administered by a specially trained nurse.

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: A

 
Which of the following nursing diagnoses should the nurse identify as a priority after surgical repair of a cleft lip?


 
RATIONALE: After surgery, the most important nursing diagnosis is Risk for infection. Surgery involves an incision, which places the infant at risk for infection. The infant with this type of procedure does have discomfort, which can be relieved with acetaminophen (Tylenol). Acute pain is an important nursing diagnosis but not the priority. The infant may be in arm restraints or have the cuff of the sleeve pinned to the diaper or pants. It is important that the infant not touch the incision line or disrupt the sutures. There is no indication for a nursing diagnosis of Impaired parenting. The parents would be reacting normally with a first reaction of shock.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: B

 
Which of the following is an appropriate outcome for a client with rheumatoid arthritis?


 
RATIONALE: An appropriate outcome for the client with rheumatoid arthritis is that he will adopt self-care behaviors to manage joint pain, stiffness, and fatigue and be able to perform activities of daily living. Range of motion (ROM) exercises can help maintain mobility, but it may not be realistic to expect the client to maintain full ROM. Depending on the disease progression, there may be further development of pain and joint deformity, even with appropriate therapy. It is important for the client to understand the importance of taking the prescribed drug therapy even if symptoms have abated.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: A

 
A client’s burn wounds are being cleaned twice a day in a hydrotherapy tub. Which of the following interventions should be included in the plan of care before a hydrotherapy treatment is initiated?


 
RATIONALE: Hydrotherapy wound cleaning is very painful for the client. The client should be medicated for pain about 30 minutes before the treatment in anticipation of the increased pain the client will experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy session. However, electrolyte loss can occur from openwounds during immersion, so the sessions should be limited to 20 to 30 minutes. There is no need to limit food or fluids 45 minutes before hydrotherapy unless it is an individualized need for a given client. Topical antibiotics are applied after hydrotherapy.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Create

CORRECT ANSWER: D

 
A health care provider has been exposed to hepatitis B through a needle stick. Which of the following drugs should the nurse anticipate administering as post exposure prophylaxis?


 
RATIONALE: Hepatitis B immune globulin is given as prophylactic therapy to individuals who have been exposed to hepatitis B. Interferon has been approved to treat hepatitis B. Hepatitis B surface antigen is a diagnostic test used to detect current infection. Amphotericin B is an anti-fungal.

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: A

 
When performing an otoscopic examination of the tympanic membrane of a 2-year-old child, the nurse should pull the pinna in which of the following directions?


 
RATIONALE: When examining the tympanic membrane of a child younger than age 3 years, the nurse should pull the pinna down and back. For an older child, the nurse should pull the pinna up and back to view the tympanic membrane.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: A

 
Which of the following findings should the nurse note in the client who is in the compensatory stage of shock?


 
RATIONALE: In the compensatory stage of shock, the client exhibits moderate tachycardia. If the shock continues to the progressive stage, decreased urinary output, hypotension, and mental confusion develops as a result of failure to perfuse and ineffective compensatory mechanisms. These findings are indications that the body’s compensatory mechanisms are failing.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: C

 
A client has been prescribed hydrochlorothiazide (HydroDIURIL) to treat heart failure. For which of the following symptoms should the nurse monitor the client?


 
RATIONALE: Hydrochlorothiazide is a thiazide diuretic. Muscle weakness can be an indication of hypokalemia. Polyuria is associated with this diuretic, not urinary retention. Confusion and diaphoresis are not side effects of hydrochlorothiazide.

CLIENT NEED: Pharmacological and parenteral therapies;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: B

 
The son of a client with Alzheimer’s disease excitedly tells the nurse, “Mom was singing one of her favorite old songs. I think she’s getting her memory back!” Which of the following responses by the nurse is most appropriate?


 
RATIONALE: The ability to remember an old song is related to long-term memory, which persists after short-term memory is lost. Therefore, the nurse should respond by providing the son with this information. Stating that the nurse is happy to hear about the change and that the client is getting better is inappropriate and inaccurate. This statement ignores the issue of long-term versus short-term memory. Telling the client not to get his hopes up because the improvement is only temporary is inappropriate. The information provided does not indicate that the client has expressive aphasia, which would be suggested by the statement that the client can’t talk to the son.

CLIENT NEED: Psychosocial adaptation;
COGNITIVE LEVEL: Analyze

CORRECT ANSWER: A

 
The nurse collects a urine specimen from a client for a culture and sensitivity analysis. Which of the following is the correct care of the specimen?


 
RATIONALE: A specimen for culture and sensitivity should be sent to the laboratory promptly so that a smear can be taken before organisms start to grow in the specimen.

CLIENT NEED: Reduction of risk potential;
COGNITIVE LEVEL: Apply

CORRECT ANSWER: A

 
A 16-year-old client is in the emergency department for treatment of minor injuries from a car accident. A crisis nurse is with her because she became hysterical and was saying, “It’s my fault. My Mom is going to kill me. I don’t even have a way home.” Which of the following should be the nurse’s initial intervention?


 
RATIONALE: The client is in a crisis and has a high anxiety level. Holding the client’s hands and encouraging the client to slow down and take a deep breath conveys caring and helps decrease anxiety. Telling the client to calm down or stop worrying offers no concrete directions for accomplishing this task. It is unknown from the data who was at fault in the accident. Therefore, it is inappropriate for the nurse to state that it wasn’t the client’s fault.

CLIENT NEED: Psychosocial adaptation;
COGNITIVE LEVEL: Synthesize

CORRECT ANSWER: A

 
The nurse is developing a community health education program about sexually transmitted diseases. Which information about women who acquire gonorrhea should be included?


 
RATIONALE: Many women who acquire gonorrhea are asymptomatic or experience mild symptoms that are easily ignored. They are not necessarily more reluctant than men to seek medical treatment, but they are more likely not to realize they have been affected. Gonorrhea is easily transmitted to all women and can result in serious consequences, such as pelvic inflammatory disease and infertility.

CLIENT NEED: Management of care;
COGNITIVE LEVEL: Create

CORRECT ANSWER: C

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