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The nurse is developing a drug therapy regimen that won't interfere with the client's lifestyle. When doing this, the nurse must consider the drug's:

1. adverse effects.
2. route of excretion.
3. peak concentration time.
4. steady-state duration of action.

RATIONALES: When developing a drug therapy regimen that won't interfere with a client's lifestyle, the nurse must consider the drug's adverse effects because these may lead to noncompliance. A drug's excretion route, peak concentration time, and steady-state duration of action are important considerations when developing a drug therapy regimen; however, they're related to the drug's physiologic effects and don't affect the client's lifestyle.

While providing care to a 26-year-old married female, the nurse notes multiple ecchymotic areas on her arms and trunk. The color of the ecchymotic areas ranges from blue to purple to yellow. When asked by the nurse how she got these bruises, the client responds, "Oh, I tripped." How should the nurse respond?

1. Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries.


2. Report suspicions of abuse to the local authorities.


3. Assist the client in developing a safety plan for times of increased violence.


4. Call the client's husband to discuss the situation.


5. Tell the client that she needs to leave the abusive situation as soon as possible.


6. Provide the client with telephone numbers of local shelters and safe houses.

RATIONALES: The nurse should objectively document her assessment findings. A detailed description of physical findings of abuse in the medical record is essential if legal action is pursued. All women suspected to be victims of abuse should be counseled on a safety plan, which consists of recognizing escalating violence within the family and formulating a plan to exit quickly. The nurse shouldn't report this suspicion of abuse because the client is a competent adult who has the right to self-determination. Nurses do, however, have a duty to report cases of actual or suspected abuse in children or elderly clients. Contacting the client's husband without her consent violates confidentiality. The nurse should respond to the client in a nonthreatening manner that promotes trust, rather than ordering her to break off her relationship.

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?


1. Inadequate vitamin D intake



2. Inadequate protein intake



3. Inadequate massaging of the affected area



4. Low calcium level

RATIONALES: Clients on bed rest suffer from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. A pressure ulcer should never be massaged.

The nurse conducts a test for the Romberg's sign. What is the correct procedure for this test?


1. Have the client stand with feet together and arms at the sides and try to balance, first with eyes open and then with eyes closed.



2. Instruct the client to walk across the room on the heels and to return walking on the toes.



3. Ask the client to touch the thumb of one hand to each finger on that hand and then repeat this action using the other hand.



4. Instruct the client to lie on the back and slowly slide the heel down the shin of the opposite leg, from the knee to ankle.

RATIONALES: To test for the Romberg's sign, which assesses balance, the nurse instructs the client to stand with feet together and arms at the sides while observing the client's ability to maintain balance — first with eyes open and then with eyes closed. Option 2 describes heel and toe walking, another test that evaluates balance. Option 3 describes a test used to evaluate motor function and range of motion. Option 4 describes a test used to assess coordination.

In a client who had major surgery 5 days ago, which assessment finding would be the best indication of a wound infection?


1. Complaints of deep, sharp incisional pain



2. Evidence of uneven wound edges



3. Thick, yellow wound drainage



4. Oral temperature of 100.6° F (38.1° C)

RATIONALES: Thick, yellow drainage is most indicative of a wound infection. Drainage is typically serosanguineous. Although an elevated temperature, pain at the incision site, and uneven wound edges may accompany an infected wound, they aren't as specific as the drainage and could be related to other problems.

Standard precautions were designed for the care of all clients in hospitals, regardless of their diagnosis or infection status. Guidelines for standard precautions include:


1. immediately recapping used needles.



2. disposing of sharp instruments in an impervious container.



3. wearing gloves only for sterile procedures.



4. substituting regular eyeglasses for eye protection.

RATIONALES: Disposing of sharp instruments in an impervious container is included in the guidelines for standard precautions. Used needles are never recapped; they should be disposed of in a sharps container. Gloves are used if contact with body fluids is anticipated. Goggles approved by the Occupational Safety and Health Organization are used for eye protection. Eyeglasses aren't an acceptable form of protection because they're open at the sides.

A nurse is caring for a client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, the nurse should avoid which route?

1. Oral
2. I.V.
3. I.M.
4. Subcutaneous (S.C.)

RATIONALES: With a platelet count of 22,000/μl, the client bleeds easily. Therefore, the nurse should avoid using the I.M. route because the area is highly vascular and can bleed readily when penetrated by a needle. The bleeding can be difficult to stop. The client already has an I.V. access, so it would be the best route, especially because I.V. morphine is effective almost immediately. Oral and S.C. routes are preferred over I.M., but they're less effective for acute pain management than I.V.

Which nursing diagnosis is commonly used to develop a care plan for managing a client's drug regimen?


1. Deficient knowledge



2. Ineffective coping mechanisms



3. Anxiety



4. Impaired home maintenance

A nurse is caring for a client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour. The client complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, the nurse should avoid which route?


1. Oral



2. I.V.



3. I.M.



4. Subcutaneous (S.C.)

After a stroke, a client develops aphasia. Which assessment finding is most typical in aphasia?


1. Arm and leg weakness



2. Absence of the gag reflex



3. Difficulty swallowing



4. Inability to speak clearly

RATIONALES: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a stroke, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.

The maximum transfusion time for a unit of packed red blood cells (RBCs) is:


1. 6 hours.



2. 4 hours.



3. 2 hours.



4. 1 hour.

RATIONALES: A unit of packed RBCs may be given over a period of between 1 and 4 hours. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Discard or return to the blood bank any blood not given within this time, according to facility policy.

Which of the following strategies should the nurse use to help assess a client's orientation?


1. Ask the client's name and city of residence and the time of day.



2. Ask the client to repeat a series of three digits spoken slowly.



3. Point to common objects and ask the client to name them.



4. Use the Glasgow Coma Scale and compute the score.

RATIONALES: To help assess orientation, the nurse asks the client direct questions about person, place, and time, such as the client's name and city of residence and the time of day or day of the week. Asking the client to repeat a series of digits assesses memory. Pointing to common objects and asking the client to name them assesses language deficits. The Glasgow Coma Scale assesses level of consciousness.

A 66-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, "How long will it take for my scars to disappear?" Which of the following statements would be the nurse's best response?


1. "The contraction phase of wound healing can take 2 to 3 years."



2. "Wound healing is very individual but within 4 months the scar should fade."



3. "With your history and the type and location of the injury, it's hard to say."



4. "If you don't develop an infection, the wound should heal anywhere between 1 and 3 years."

RATIONALES: Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client education materials. Which statement illustrates the best method of delegation?


1. Tell the nursing staff they're responsible for the review and revision and that their recommendations for improving the materials are welcome.



2. Ask the two best staff nurses to form a task force to review and revise client education materials within the next 6 weeks. Have them solicit input from clients and staff members.



3. Tell the nursing staff that the client education materials need revision. Ask the staff to select people to review the materials and make suggestions for change.



4. Ask the assistant manager to develop a plan for the review and revision of client education materials.

RATIONALES: Delegation must be done clearly and precisely. The nurse-manager must assign responsibility, identify the task to be accomplished, explain what outcomes are needed, and the time frame for completing the work. The remaining options don't give clear explanations of work to be done, don't clearly assign responsibility or the specific outcomes desired, or establish a time frame for completion of the task.

The nurse is performing wound care using surgical asepsis. Which practice violates surgical asepsis?


1. Holding sterile objects above the waist



2. Pouring solution onto a sterile field cloth



3. Considering a 1" (2.5-cm) edge around the sterile field contaminated



4. Opening the outermost flap of a sterile package away from the body

RATIONALES: Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

Which client characteristic would be an example of noncompliance?


1. Undesired drug action



2. Multiple questions



3. Failure to progress



4. Resolved symptoms

RATIONALES: Failure to progress is an example of noncompliance. Undesired drug action indicates adverse drug reaction. Multiple questions show a client's lack of knowledge about the drug. Resolved symptoms indicate that drug therapy was successful.

A client with diabetes mellitus is receiving insulin. Which statement correctly describes an insulin unit?


1. It's a measure of effect, not a standard measure of weight or quantity.



2. It's the smallest measurement in the apothecary system.



3. It's the basis for solids in the avoirdupois system.



4. It's a common measurement in the metric system.

RATIONALES: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity. In the apothecary system, the minim is the smallest liquid unit of measurement and the grain is the smallest solid unit of measurement. In the avoirdupois system, solids include the ounce and pound. In the metric system, the liter is used for liquids, the gram for solids.

The nurse is caring for a client with a hiatal hernia. The client complains of abdominal pain and sternal pain after eating. The pain makes it difficult for him to sleep. Which instructions should the nurse recommend when teaching this client?

1. Avoid constrictive clothing.


2. Lie down for 30 minutes after eating.


3. Decrease intake of caffeine and spicy foods.


4. Eat three meals per day.


5. Sleep in semi-Fowler's position.


6. Maintain a normal body weight.

RATIONALES: To reduce gastric reflux, the nurse should instruct the client to sleep with his upper body elevated; lose weight, if obese; avoid constrictive clothing, caffeine, and spicy foods; remain upright for 2 hours after eating; and eat small, frequent meals.

Performance improvement is an important component of continuous quality improvement. Which action should an effective nurse-manager take when conducting performance evaluations?


1. Conduct performance evaluations in a group setting so input from peers and subordinates is considered when evaluating a staff member's effectiveness.



2. Provide feedback on strengths as well as areas for improvement and clarify what the staff member is expected to accomplish before the next performance evaluation.



3. Document areas for improvement in writing. Areas of strength don't need to be documented because these areas are complimentary and don't describe actions the staff member must take to improve.



4. Delegate responsibility for conducting performance evaluations to primary nurses whenever possible to help them grow professionally.

RATIONALES: An effective performance evaluation provides recognition of strengths, identifies areas for improvement, and clarifies performance expectations. Performance evaluations should be done in private, not in front of others. All components of a performance evaluation should be documented in writing. Although input from staff members can be useful in preparing performance evaluations, delegating all responsibility to others is inappropriate. The nurse-manager is responsible for the performance of the staff.

Performance improvement is an important component of continuous quality improvement. Which action should an effective nurse-manager take when conducting performance evaluations?


1. Conduct performance evaluations in a group setting so input from peers and subordinates is considered when evaluating a staff member's effectiveness.



2. Provide feedback on strengths as well as areas for improvement and clarify what the staff member is expected to accomplish before the next performance evaluation.



3. Document areas for improvement in writing. Areas of strength don't need to be documented because these areas are complimentary and don't describe actions the staff member must take to improve.



4. Delegate responsibility for conducting performance evaluations to primary nurses whenever possible to help them grow professionally.

RATIONALES: An effective performance evaluation provides recognition of strengths, identifies areas for improvement, and clarifies performance expectations. Performance evaluations should be done in private, not in front of others. All components of a performance evaluation should be documented in writing. Although input from staff members can be useful in preparing performance evaluations, delegating all responsibility to others is inappropriate. The nurse-manager is responsible for the performance of the staff.

A client is being discharged after cataract surgery. After providing medication teaching, the nurse asks the client to repeat the instructions. The nurse is performing which professional role?


1. Manager



2. Educator



3. Caregiver



4. Client advocate

RATIONALES: When teaching a client about medications before discharge, the nurse is acting as an educator. The nurse acts as a manager when performing such activities as scheduling and making client care assignments. The nurse acts as a caregiver when providing direct care, including bathing clients and administering medication and prescribed treatments. The nurse acts as a client advocate when making the client's wishes known to the physician.

When obtaining a client's history, the nurse develops a genogram. What is the purpose of developing a genogram?


1. To identify genetic and familial health problems



2. To identify previously undetected diseases and disorders



3. To identify the client's reason for seeking care



4. To identify the client's chronic health problems

RATIONALES: A genogram, which organizes a family's history into a diagram or flow chart, is used to identify genetic and familial health problems. A genogram doesn't identify previously undetected diseases and disorders, the client's reason for seeking care, or chronic health problems.

A client who's a member of the Jehovah's Witnesses refuses a blood transfusion based on his religious beliefs and practices. His decision must be followed based on which ethical principle?


1. The right to die



2. Advance directive



3. The right to refuse treatment



4. Substituted judgment

RATIONALES: The right to refuse treatment is grounded in the ethical principle of respect for the autonomy of the individual. The client has the right to refuse treatment as long as he's competent and aware of the risks and complications associated with that refusal. The right to die is a difficult decision involving whether to initiate or withhold life-sustaining treatment for a client who is irreversibly comatose, vegetative, or suffering with end-stage terminal illness. Sometimes, the client has signed an advance directive, making his wishes known. An advance directive is a document used as a guideline for starting or continuing life-sustaining medical care; the client commonly has a terminal disease or disability and can't indicate his own wishes. Substituted judgment is an ethical principle used when a decision — based on what's best for the client — is made for an incapacitated client.

A client with acute renal failure is prescribed regular insulin 10 U I.V. along with 50 ml of dextrose 50%. What electrolyte imbalance is this client most likely experiencing?


1. Hypercalcemia



2. Hypernatremia



3. Hyperglycemia



4. Hyperkalemia

RATIONALES: Regular insulin I.V. administered concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. It doesn't help reverse the effects of hypercalcemia, hypernatremia, or hyperglycemia.

After a client receives an I.M. injection, he complains of burning pain at the injection site. Which nursing action would be the best to take at this time?


1. Apply a cold compress to decrease swelling.



2. Apply a warm compress to dilate the blood vessels.



3. Massage the area to promote absorption of the drug.



4. Instruct the client to tighten his gluteal muscles to promote better absorption.

RATIONALES: Applying heat increases blood flow to the area, which, in turn, increases the absorption of the medication. Cold decreases the pain but allows the medication to stay in the muscle longer. Massage is a good intervention, but applying a warm compress is better. Tightening the gluteal muscles may cause additional burning if the drug irritates muscular tissues.

Which outcome criteria would be most appropriate for the client with a nursing diagnosis of Ineffective airway clearance?


1. Presence of congestion on X-ray



2. Breath sounds clear on auscultation



3. Continued use of oxygen when necessary



4. Respiratory rate of 24 breaths/minute

RATIONALES: The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 24 breaths/minute indicate that the client is still experiencing airway problems.

The physician orders nitroglycerin, 5 mg by mouth twice a day, for a client. The drug is dispensed in 2.5-mg tablets. How many tablets will the nurse administer with each dose?


1. Two



2. Four



3. Six



4. Eight

RATIONALES: The nurse will administer two tablets with each dose. Using the ratio method, the equation to solve for X is: 5 mg : X tab :: 2.5 mg : 1 tab. Solving for X determines the quantity of the dosage form (two tablets, in this example).

The nurse refers a client with terminal cancer to a local hospice. What is the goal of this referral?


1. To provide support for the client and family in coping with terminal illness



2. To ensure that the client gets counseling regarding health care costs



3. To teach the client and family about cancer and its treatment



4. To help the client find appropriate treatment options

RATIONALES: Hospices provide supportive care for terminally ill clients and their families. Hospice care doesn't focus on counseling regarding health care costs. Most clients referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice.

The nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate?

1. Instill isotonic eye drops, as necessary.


2. Provide several small, well-balanced meals.


3. Provide rest periods.


4. Keep the environment warm.


5. Encourage frequent visitors and conversation.


6. Weigh the client daily.

RATIONALES: If the client has exophthalmos (a sign of hyperthyroidism), the conjunctivae should be moistened often with isotonic eye drops. Hyperthyroidism results in increased appetite, which can be satisfied by frequent small, well-balanced meals. The nurse should provide the client with rest periods to reduce metabolic demands. The client should be weighed daily to check for weight loss, a possible consequence of hyperthyroidism. Because metabolism is increased in hyperthyroidism, heat intolerance and excitability result. Therefore, the nurse should provide a cool and quiet environment, not a warm and busy one, to promote client comfort.

The nurse is assessing a client's abdomen. Which examination technique should the nurse use first?


1. Auscultation



2. Inspection



3. Percussion



4. Palpation

RATIONALES: Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.

The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include?


1. "The stoma should appear dark and have a bluish hue."



2. "At first, the stoma may bleed slightly when touched."



3. "The stoma should remain swollen distal to the abdomen."



4. "A burning sensation under the stoma faceplate is normal."

RATIONALES: For the first few days to a week after a client receives a colostomy, slight bleeding normally occurs when the stoma is touched because the surgical site is still fresh. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown.

When determining appropriate nursing interventions for a client with a medical diagnosis, the nurse is using which of the following?


1. Developmental anatomy



2. Applied anatomy



3. Regional anatomy



4. Descriptive anatomy

The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include?


1. "The stoma should appear dark and have a bluish hue."



2. "At first, the stoma may bleed slightly when touched."



3. "The stoma should remain swollen distal to the abdomen."



4. "A burning sensation under the stoma faceplate is normal."

A geriatric client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client?


1. Hyperthermia



2. Activity intolerance



3. Disturbed thought processes



4. Impaired physical mobility

When determining appropriate nursing interventions for a client with a medical diagnosis, the nurse is using which of the following?


1. Developmental anatomy



2. Applied anatomy



3. Regional anatomy



4. Descriptive anatomy

Which statement reflects appropriate documentation in the medical record of a hospitalized client?


1. "Small pressure ulcer noted on left leg."



2. "Client seems to be mad at the physician."



3. "Client had a good day."



4. "Client's skin is moist and cool."

RATIONALES: Documentation should include data that the nurse obtains using only observations that are heard, seen, smelled, or felt. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day doesn't provide precise enough information to be useful.

The nurse is preparing to discharge a child who has rheumatic fever. Which of the following medications is prescribed to prevent recurrence of rheumatic fever?


1. Glucocorticoids



2. Digoxin (Lanoxin)



3. Antibiotics



4. Anti-inflammatory medications

RATIONALES: Because the child with rheumatic fever is at risk for a recurrence, especially if the condition is complicated by carditis, long-term antibiotic therapy is necessary into adulthood, maybe even for life. Digoxin may be prescribed to treat heart failure but it doesn't prevent the recurrence of rheumatic fever. Corticosteroids and anti-inflammatory medications reduce inflammation in rheumatic fever but won't prevent a recurrence.

A client in a long-term care facility refuses to take his oral medications. The nurse threatens the client and tells him that, if the medication isn't taken, restraints will be applied and the medication will be given by injection. The nurse's statement constitutes which legal tort?


1. Assault



2. Battery



3. Negligence



4. Right to refuse care

RATIONALES: Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is the actual contact with one's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions below the standard of care. The client has the legal right to refuse care. In this situation, the correct action is to try to calm the client, allow him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his refusal, note the medications, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to clients refusing care.

When changing a sterile surgical dressing, the nurse first must:


1. wash the hands.



2. apply sterile gloves.



3. remove the old dressing with clean gloves.



4. open sterile packages, and moisten the dressings with sterile saline solution.

RATIONALES: To prevent the spread of microorganisms, the nurse always should wash the hands before providing client care. When changing a sterile surgical dressing, the nurse also must apply sterile gloves, remove the old dressing with clean gloves, open sterile packages, and moisten the dressings with sterile saline. However, these actions follow hand washing.

A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it's slightly concave. Additional assessment should proceed in which order?


1. Auscultation, percussion, and palpation



2. Palpation, percussion, and auscultation



3. Percussion, palpation, and auscultation



4. Palpation, auscultation, and percussion

RATIONALES: The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation. The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. Percussion and palpation can alter natural findings during auscultation.

A staff nurse on a busy pediatric unit is an excellent role model for her colleagues. She encourages them to participate in the unit's decision-making process and helps them improve their clinical skills. This nurse is functioning effectively in which role?


1. Manager



2. Autocrat



3. Leader



4. Authority

RATIONALES: A leader doesn't have formal power and authority but influences the success of a unit by being an excellent role model and by guiding, encouraging, and facilitating professional growth and development. A manager has formal power and authority from the status within the organization and such power and authority are detailed in the manager's job description. An autocrat isn't interested in guiding or encouraging staff or in being an effective role model. Authority, a characteristic of a managerial position, is given by virtue of position within an organization.

At 8 a.m., the nurse assesses a client who's scheduled for surgery at 10 a.m. During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next?


1. Check to see that the chest X-ray was done yesterday as ordered.



2. Check the serum electrolyte levels and complete blood count (CBC).



3. Notify the physician immediately of these findings.



4. Sign the preoperative checklist for this client.

A staff nurse on a busy pediatric unit is an excellent role model for her colleagues. She encourages them to participate in the unit's decision-making process and helps them improve their clinical skills. This nurse is functioning effectively in which role?


1. Manager



2. Autocrat



3. Leader



4. Authority

The nurse is preparing a teaching plan for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which of the following should the nurse include in the teaching plan?

1. Tell the client to avoid salt substitutions.


2. Tell the client that light-headedness is a common adverse effect that need not be reported.


3. Inform the client that he may have a sore throat for the first few days of therapy.


4. Advise the client to report facial swelling or difficulty breathing immediately.


5. Tell the client that blood tests will be necessary every 3 weeks for 2 months and periodically after that.


6. Advise the client not to change position suddenly to minimize orthostatic hypotension.

RATIONALES: When teaching the client about enalapril maleate, the nurse should tell him to avoid salt substitutions because these products may contain potassium that can cause light-headedness and syncope. Facial swelling or difficulty breathing should be reported immediately; the drug may cause angioedema, which would require discontinuation of the drug. The client should also be advised to change position slowly to minimize orthostatic hypotension. The nurse should tell the client to report light-headedness, especially in the first few days of therapy, so dosage adjustments can be made. The client should report signs of infection, such as sore throat and fever, because the drug may decrease white blood cell count. White blood cell and differential counts should be performed before treatment, every 2 weeks for 3 months, and periodically thereafter.

The nurse is assigned to a client with a cardiac disorder. When monitoring body temperature for this client, the nurse should avoid which route?


1. Rectal



2. Oral



3. Axillary



4. Tympanic

RATIONALES: When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature because it may stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

A client in a behavioral-health facility receives a 30-minute psychotherapy session and the provider bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:


1. unbundling.



2. overbilling.



3. upcoding.



4. misrepresentation.

RATIONALES: Upcoding is the practice of using a current procedure terminology code that is reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren't the terms used for this illegal practice.

The nurse is assessing a postoperative client. Which of the following should the nurse document as subjective data?


1. Vital signs



2. Laboratory test results



3. Client's description of pain



4. Electrocardiographic (ECG) waveforms

RATIONALES: Subjective data come directly from the client and usually are recorded as direct quotations that reflect the client's opinions or feelings about a situation. Vital signs, laboratory test results, and ECG waveforms are examples of objective data.

The physician orders heparin, 7,500 units, to be administered subcutaneously every 12 hours. The vial reads 10,000 units per milliliter. The nurse should anticipate giving how much heparin for each dose?


1. ¼ ml



2. ½ ml



3. ¾ ml



4. 1¼ ml

RATIONALES: The nurse solves the problem as follows:
10,000 units/7,500 units = 1 ml/X
10,000X = 7,500
X = 7,500/10,000 or ¾ ml

The nurse identifies a client's responses to actual or potential health problems during which step of the nursing process?

1. Assessment
2. Analysis
3. Planning
4. Evaluation

RATIONALES: The nurse identifies human responses to actual or potential health problems during the analysis step of the nursing process, which encompasses the ability of the nurse to formulate a nursing diagnosis. During the assessment step, the nurse systematically collects data about the client or family. During the planning step, the nurse develops strategies to resolve or decrease the client's problem. During the evaluation step, the nurse determines the effectiveness of the care plan.

A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention would help meet this goal?

1. Repositioning the client every 2 hours
2. Restricting fluids to 1,000 ml/24 hours 3. Administering oxygen by nasal cannula as ordered
4. Keeping the head of the bed at a 30-degree angle

RATIONALES: Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle might ease respirations and make them more effective but wouldn't help mobilize secretions.

A client exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the client's anxiety?

1. "Everything will be fine. Don't worry."
2. "Read this manual and then ask me any questions you may have."
3. "Why don't you listen to the radio?"
4. "Let's talk about what is bothering you."

RATIONALES: Anxiety may result from feelings of helplessness, isolation, or insecurity. This response helps reduce anxiety by encouraging the client to express feelings. The nurse should be supportive and develop goals together with the client to give the client some control over an anxiety-inducing situation. Because the other options ignore the client's feelings and block communication, they wouldn't reduce anxiety.

A 75-year-old client is admitted to the hospital with lower GI bleeding. His hemoglobin on admission to the emergency department is 7.3 g/dl. The physician prescribes 2 U of packed red blood cells to infuse over 1 hour each. The blood administration set has a drip factor of 10 gtt/ml. What is the flow rate in drops per minute?

RATIONALES: Each unit of packed red blood cells contains 250 ml. Each unit is to infuse over 1 hour (60 minutes).

Use the following equation:
250 ml/60 minutes = 4.16 ml.
Multiply by the drip factor:
4.16 ml × 10 gtt = 41.6 gtt/minute (42 gtt/minute).

During assessment, the nurse measures a client's respiratory rate at 32 breaths/minute with a regular rhythm. When documenting this pattern, the nurse should use which term?

1. Eupnea
2. Bradypnea
3. Apnea
4. Tachypnea

RATIONALES: A respiratory rate of 32 breaths/minute with a regular rhythm is faster than normal and should be documented as tachypnea. Eupnea is a respiratory rate of 12 to 20 breaths/minute with a regular rhythm. Bradypnea refers to a respiratory rate below 12 breaths/minute with a regular rhythm. Apnea refers to absence of breathing.

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