nclex questions - ate precy

Created by kristinstars 

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The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular
implant. Which home care measures will the nurse include in the plan? Select all that apply.

1. To avoid activities that require bending over
2. To contact the surgeon if eye scratchiness occurs
3. To place an eye shield on the surgical eye at bedtime
4. That episodes of sudden severe
pain in the eye is expected
5. To contact the surgeon if a decrease in visual acuity occurs
6. To take acetaminophen (Tylenol) for minor eye discomfort

1,3,5,6

Rationale:
After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is
usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon
because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also
instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual
acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye
from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme
dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately
notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.

1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low Fowler's side-lying position

1,2,3,4

Rationale:
Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary
edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the
accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to
ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley
catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces
venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to
the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's
response to treatment is successful

A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes
cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should
perform. Select all that apply.

1. Call a code blue.
2. Notify the registered nurse.
3. Place the infant in a prone position.
4. Prepare to administer morphine sulfate.
5. Prepare to administer intravenous fluids.
6. Prepare to administer 100% oxygen by face mask.

2,4,5,6

Rationale:
The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode.
Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among
infants whose heart defect includes the obstruction of pulmonary blood flow and communication
between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position
immediately. The registered nurse is notified, who will then contact the health care provider. The knee-
chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller
amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position
and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional
interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids,
as prescribed.

A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone
(SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be
prescribed? Select all that apply.

1. Radiation
2. Chemotherapy
3. Increased fluid intake
4. Serum sodium blood levels
5. Decreased oral sodium intake
6. Medication that is antagonistic to antidiuretic hormone (ADH)

1,2,4,6

Rationale:
Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of water are reabsorbed
by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased
serum sodium levels) and some degree of fluid retention. SIADH is managed by treating the condition
and its cause, and treatment usually includes fluid restriction, increased sodium intake, and a medication
with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored closely, because
hypernatremia can suddenly develop as a result of treatment. The immediate institution of appropriate
cancer therapy (usually either radiation or chemotherapy) can cause tumor regression so that ADH
synthesis and release processes return to normal.

A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied
to the left forearm. Choose the instructions that would be included on the list. Select all that apply.

1. Use the fingertips to lift the cast while it is drying.
2. Keep small toys and sharp objects away from the cast.
3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches.
4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold.
5. Contact the health care provider if the child complains of numbness or tingling in the extremity.
6. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.

2,5,6

Rationale:
While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used,
indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and
sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside of
the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers.
Cold fingers could indicate neurovascular impairment, and the HCP should be notified. The extremity
is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular
impairment develop.

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her
pregnancy. The nurse plans to provide which of the following information to the client?

1. "You will be isolated from your newborn after delivery."
2. "There is little risk to your baby during your pregnancy, birth, and after delivery."
3. "Vaginal deliveries can reduce neonatal infection risks,
even if you have an active lesion at birth."
4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a
cesarean delivery will be needed."

4.

Rationale:
If herpetic genital lesions are present at the time of delivery, a cesarean delivery will be necessary to
reduce the risk of infecting the neonate. In the absence of herpetic genital lesions, a vaginal delivery may
be indicated, unless there are other reasons for performing a cesarean delivery. Maternal isolation is not
necessary, but potentially exposed neonates should be cultured on the day of delivery.

A nurse is assisting with planning care for a client with an internal radiation implant. Which of the
following should be included in the plan of care? Select all that apply.

1. Wearing gloves when emptying the client's bedpan
2. Keeping all linens in the room until the implant is removed
3. Wearing a film (dosimeter) badge when in the client's room
4. Wearing a lead apron when providing d
irect care to the client
5. Placing the client in a semiprivate room at the end of the hallway

1,2,3,4

Rationale:
A private room with a private bath is essential if a client has an internal radiation implant. This is
necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify
interventions that are necessary for a client with a radiation device.

A child has been diagnosed with meningococcal meningitis. Which of the following isolation techniques
is appropriate?

1. Enteric precautions
2. Neutropenic precautions
3. No precautions are required as long as antibiotics have been started.
4. Isolation precautions for at least 24 hours after the initiation of antibiotics

4.

Rationale:
Meningococcal meningitis is transmitted primarily by droplet infection. Isolation is begun and
maintained for at least 24 hours after antibiotics are given. Options 1, 2, and 3 are incorrect.

When caring for a 3-year-old child, the nurse should provide which toy for this child?

1. A puzzle
2. A wagon
3. A golf set
4. A farm set

2.

Rationale:
Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers
need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some
appropriate toys. A puzzle with large pieces only may be appropriate. A farm set and a golf set may
contain items that the child could swallow.

The parent of a toddler asks a nurse when it is safe to place the car safety seat in a face-forward position.
Which of the following is the best nursing response?

1. When the toddler weighs 20 lb and is 1 year old
2. When the weight of the toddler is more than 40 lb
3. The seat should not be placed in a face-forward position unless there are safety locks in the car.
4. The seat should never be placed in a face-forward position because of the risk of the child unbuckling the harness.

1.

Rationale:
The transition point for switching to the forward-facing position is defined by the manufacturer of the
convertible car safety seat, but it is generally at a body weight of 9 kg (20 lb) and an age of 1 year.
Options 2, 3, and 4 are incorrect.

A nurse is caring for a client with a health care-associated infection caused by methicillin-resistant
Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the
client. Which of the following protective items will be required to perform this procedure?

1. Gloves and a gown
2. Gloves and goggles
3. Gloves, a gown, and goggles
4. Gloves, a gown, and shoe protectors

3.

Rationale:
Goggles are worn to protect the mucous membranes of the eye during interventions that may produce
splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the
use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not
necessary.

A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client's hospital gown?

1. Using a hospital gown with snaps at the sleeves
2. Disconnecting the IV tubing from the catheter in the vein
3. Checking the IV flow rate immediately after changing the hospital gown
4. Putting the bag and tubing through the sleeve, followed by the client's arm

2.

Rationale:
The tubing should not be removed from the IV catheter. With each break in the system, there is an
increased chance of introducing bacteria into the system, which can lead to infection. Options 1 and 4 are
appropriate. The flow rate should be checked immediately after changing the hospital gown, because the
position of the roller clamp may have been affected during the change.

A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice
implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The
nurse understands that which of the following is a characteristic of this type of nursing model of practice?

1. A task approach method is used to provide care to clients.
2. Managed care concepts and tools are used when providing client care.
3. Nursing staff are led by a nurse when providing care to a group of clients.
4. A single registered nurse is responsible for providing nursing care to a group of clients.

3.

Rationale:
In team nursing, nursing personnel are led by a nurse when providing care to a group of clients. Option
1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies
primary nursing.

A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to
the emergency department for treatment on the evening shift. The nurse would assign the highest priority
to which of the following clients?

1. A client complaining of muscle aches, a headache, and malaise
2. A client who twisted her ankle when she fell while rollerblading
3. A client with a minor laceration on the index finger sustained while cutting an eggplant
4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4.

Rationale:
In an emergency department, triage involves classifying clients according to their need for care, and it
includes establishing priorities of care. The type of illness, the severity of the problem, and the resources
available govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest,
limb amputation, or acute neurological deficits and those who sustained a chemical splash to the eyes
are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as
simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones
have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such
as minor lacerations, sprains, or cold symptoms are classified as nonurgent, and they are the number 3
priority.

A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse
check first?

1. A client on a ventilator
2. A client in skeletal traction
3. A postoperative client preparing for discharge
4. A client admitted on the previous shift who has a diagnosis of gastroenteritis

1.

Rationale:
The airway is always a high priority, and the nurse first checks the client on a ventilator. The clients
described in options 2, 3, and 4 have needs that would be identified as intermediate priorities.

A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of
the following statements, if made by the mother, would indicate the need for further instruction?

1. "I will give my child cough syrup if a cough develops."
2. "During an attack, I will take my child to a cool location."
3. "I will give acetaminophen (Tylenol) if my child develops a fever."
4. "I will be sure that my child drinks at least three to four glasses of fluids every day."

1.

Rationale:
Cough syrups and cold medicines are not to be given, because they may dry and thicken secretions.
During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a
fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.

A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse asks the
lawyer to describe an example that may relate to invasion of client privacy. A nursing action that indicates
a violation of this right is:

1. Threatening to place a client in restraints
2. Performing a surgical procedure without consent
3. Taking photographs of the client without consent
4. Telling the client that he or she cannot leave the hospital

3.

Rationale:
Invasion of privacy takes place when an individual's private affairs are intruded on unreasonably.
Threatening to place a client in restraints constitutes assault. Performing a surgical procedure
without consent is an example of battery. Not allowing a client to leave the hospital constitutes false
imprisonment.

The emergency room nurse is providing discharge teaching to the parents of a 2-year-old child who
sustained burns from a hot cup of coffee that had been left on the kitchen counter. The nurse evaluates
that the parents have correctly understood the teaching when they state which of the following?

1. "We will be sure to not leave hot liquids unattended."
2. "I guess my child needs to understand what the word 'hot' means."
3. "We will be sure that our child stays in his room when we work in the kitchen."
4. "We will install a safety gate as soon as we get home so that our child can't get into the kitchen."

1.

Rationale:
Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or
hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain
in the kitchen when preparing a meal and reminded to use the back burners on the stove. Pot handles
should be turned inward and toward the middle of the stove. Hot liquids should never be left unattended,
and the toddler should always be supervised. Options 2, 3, and 4 do not reflect an adequate understanding
of the principles of safety.

A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing
Kussmaul's respirations. Based on this documentation, which of the following did the nurse most likely
observe?

1. Respirations that cease for several seconds
2. Respirations that are regular but abnormally slow
3. Respirations that are labored and increased in depth and rate
4. Respirations that are abnormally deep, regular, and increased in rate

4.

Rationale:
Kussmaul's respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease
for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations
are labored and increased in depth and rate

A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care
unit who is scheduled for a hernia repair. Which of the following information about the client is of least
priority during the data collection?

1. Respiratory
2. Psychosocial
3. Neurological
4. Cardiovascular

2.

Rationale:
The psychosocial data is the least priority during the initial admission data collection. In the African-
American culture, it is considered intrusive to ask personal questions during the initial contact or meeting.
Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that
would be the priority.

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors
the client closely for which acid-base disorder that is most likely to occur in this situation?

1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis

2.

Rationale:
The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the
loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory
problems. Option 1 relates to acidosis.

A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck
and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note
in this client if hyponatremia is present?

1. Intense thirst
2. Slow bounding pulse
3. Dry mucous membranes
4. Postural blood pressure changes

4.

Rationale:
Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes
and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of
hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.

A nurse is caring for a group of clients who are taking herbal medications at home. Which of the
following clients should be instructed not to take herbal medications?

1. A 60-year-old male client with rhinitis
2. A 24-year-old male client with a lower back injury
3. A 10-year-old female client with a urinary tract infection
4. A 45-year-old female client with a history of migraine headaches

3.

Rationale:
Children should not be given herbal therapies, especially in the home and without professional
supervision. There are no general contraindications for the clients described in options 1, 2, and 4.

A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which
client is at risk for fluid volume deficit?

1. The client with cirrhosis
2. The client with a colostomy
3. The client with decreased kidney function
4. The client with congestive heart failure (CHF)

2.

Rationale:
Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations
or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, CHF, or decreased kidney function is at risk for fluid volume excess.

A postoperative client has a prescription to receive an intravenous (IV) infusion of 1000 mL normal
saline solution over a period of 10 hours. The drop (gtt) factor for the IV infusion set is 15 gtt/mL. The
nurse sets the flow rate at how many drops per minute?

answer___________________

25

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face
(the anterior half of the head) and the upper half of the anterior torso, and there were circumferential
burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which
caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn
injury?

answer_________________

36%

Rationale:
According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper
half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The subsequent burn
included the posterior half of the head, which equals 4.5%, and the upper half of the posterior torso,
which equals 9%. This totals 36%.

A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house
fire. The client attempted to save a neighbor involved in the fire but, in spite of the client's efforts, the
neighbor died. Which action would the nurse take to enable the client to work through the meaning of the
crisis?

1. Identifying the client's ability to function
2. Identifying the
client's potential for self-harm
3. Inquiring about the client's feelings that may affect coping
4. Inquiring about the client's perception of the cause of the neighbor's death

3.

Rationale:
The client must first deal with feelings and negative responses before the client is able to work through
the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not
directly address the client's feelings.

Which data indicates to the nurse that a client may be experiencing ineffective coping?

1. Constantly neglects personal grooming
2. Visits her husband's grave once a month
3. Visits the senior citizens' center once a month
4. Frequently looks at snapshots of her husband and family

1

Rationale:
Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to
a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful
to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies
an ineffective coping behavior as part of the grieving process. The remaining options identify effective
coping behaviors.

A licensed practical nurse is planning the client assignments for the day. Which of the following is the
most appropriate assignment for the nursing assistant?

1. A client who requires wound irrigation
2. A client who requires frequent ambulation
3. A client who is receiving continuous tube feedings
4. A client who requires frequent vital signs after a cardiac catheterization

2.

Rationale:
The nurse must determine the most appropriate assignment on the basis of the skills of the staff member
and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be
to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. The
client who had a cardiac catheterization will require specific monitoring in addition to that of the vital
signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.

A nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a
living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to
witness the signature. Which of the following is the appropriate nursing action?

1. Decline to sign the will.
2. Sign the will as a witness to the signature only.
3. Call the hospital lawyer before signing the will.
4. Sign the will, clearly identifying credentials and employment agency.

1.

Rationale:
Living wills are required to be in writing and signed by the client. The client's signature either must be
witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness,
including a nurse in a facility in which the client is receiving care.

An unconscious client who is bleeding profusely is brought to the emergency department after a serious
accident. Surgery is required immediately to save the client's life. With regard to informed consent for the
surgical procedure, which of the following is the best action?

1.Call the nursing supervisor to initiate a court order for the surgical procedure.
2. Try calling the client's spouse to obtain telephone consent before the surgical procedure.
3. Ask the friend who accompanied the client to the emergency department to sign the consent form.
4. Transport the client to the operating department immediately, as required by the health care provider
without obtaining an informed consent.

4.

Rationale:
Generally there are only two instances in which the informed consent of an adult client is not needed. One
instance is when an emergency is present and delaying treatment for the purpose of obtaining informed
consent would result in injury or death to the client. The second instance is when the client waives the
right to give informed consent. Options 1, 2, and 3 are inappropriate.

A client has died, and a nurse asks a family member about the funeral arrangements. The family member
refuses to discuss the issue. The nurse's appropriate action is to:

1. Show acceptance of feelings.
2. Provide information needed for decision making.
3. Suggest a referral to a mental health professional.
4. Remain with the family member without discussing funeral arrangements.

4.

Rationale:
The family member is exhibiting the first stage of grief (denial), and the nurse should remain with
the family member. Option 1 is an appropriate intervention for the acceptance or reorganization and
restitution stage. Option 2 may be an appropriate intervention for the bargaining stage. Option 3 may be
an appropriate intervention for depression.

A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the
client. The nurse determines that this medication has been prescribed to:

1. Treat thyroid storm.
2. Prevent cardiac irritability.
3. Treat hypocalcemic tetany.
4. Stimulate the release of parathyroid hormone.

3 - Treat hypocalcemic tetany.

Tamoxifen is prescribed for the client with metastatic breast carcinoma. The nurse understands that the
primary action of this medication is to:

1. Increase DNA and RNA synthesis.
2. Promote the biosynthesis of nucleic acids.
3. Increase estrogen concentration and estrogen response.
4. Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors.

4 - Compete with estradiol for binding to estrogen in tissues containing high concentrations of
receptors.

A nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is
13 mg/dL. Which medication should the nurse prepare to administer as prescribed to the client?

1. Calcium chloride
2. Calcium gluconate
3. Calcitonin (Miacalcin)
4. Large doses of vitamin D

3 - Calcitonin (Miacalcin)

The nurse on the day shift is assigned to care for the following six clients. Arrange in order of priority
how the nurse would plan to check the assigned clients.

1. Client who requires before-breakfast insulin
2. Client who requires medications at 10:00 AM
3. Client who is scheduled for physical therapy in the afternoon
4. Client who has a tracheostomy and is on a mechanical ventilator
5. Client who is scheduled for a cardiac catheterization at 9:00 AM
6. Client who has been diagnosed with diabetes mellitus and who is scheduled for discharge to home

1. Client who has a tracheostomy and is on a mechanical ventilator
2. Client who requires before-breakfast insulin
3. Client who is scheduled for a cardiac catheterization at 9:00 AM
4. Client who requires medications at 10:00 AM
5. Client who has been diagnosed with diabetes mellitus and who is scheduled for discharge to home
6. Client who is scheduled for physical therapy in the afternoon

Rationale:
The airway is always a high priority, and the nurse first assesses the client who has a tracheostomy and is on a mechanical ventilator. The remaining order of priority is guided by time guidelines. Therefore, the nurse next administers before-breakfast insulin, assesses the client who is scheduled for a cardiac catheterization at 9:00 AM, and then administers medications scheduled for 10:00 AM. Finally, the nurse checks the client who is scheduled for discharge, and this is followed by checking the client who is scheduled for physical therapy in the afternoon.

The clinic nurse is assisting to perform a focused data collection process on a client who is complaining
of symptoms of a cold, a cough, and lung congestion. Which of the following would the nurse include for
this type of data collection? Select all that apply.

1. Auscultating lung sounds
2. Obtaining the client's temperature
3. Checking the strength of peripheral pulses
4. Obtaining information about the client's respirations
5. Performing a musculoskeletal and neurological examination
6. Asking the client about a family history of any illness or disease

1, 2, 4

Rationale:
A focused data collection process focuses on a limited or short-term problem, such as the client's
complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion the
nurse would focus on the respiratory system and the presence of an infection. A complete data collection
includes a complete health history and physical examination and forms a baseline database. Checking the
strength of peripheral pulses relates to a vascular assessment, which is not related to this client's
complaints. A musculoskeletal and neurological examination also is not related to this client's
complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination
would be included in a complete data collection. Likewise, asking the client about a family history of any
illness or disease would be included in a complete assessment.

When the nurse is collecting data from the older adult, which of the following findings would be
considered normal physiological changes? Select all that apply.

1. Increased heart rate
2. Decline in visual acuity
3. Decreased respiratory rate
4. Decline in long-term memory
5. Increased susceptibility to urinary tract infections
6. Increased incidence of awakening after sleep onset

2,5, 6

Rationale:
Anatomical changes to the eye affect the individual's visual ability, which leads to potential problems
with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually
unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the
urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may
decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent,
age-related changes. Older persons experience an increased incidence of awakening after sleep onset.

The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that apply.

1. On the left side
2. With the neck flexed
3. Supine on the left side
4. With extreme hip flexion
5. In a semi-Fowler's position
6. With the head in a midline position

5,6

Rationale:
Clients who have undergone supratentorial surgery should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion, and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent the displacement of the cranial contents.

A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply.

1. Skin
2. Kissing
3. Inhalation
4. Gastrointestinal
5. Direct contact with an infected individual
6. Sexual contact with an infected individual

1,3,4

Rationale:
Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. It cannot be spread from person to person.

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.

1. A premature infant
2. A 101-year-old man
3. A client on renal dialysis
4. A client with diabetes mellitus
5. A 29-year-old woman with pneumonia
6. A client with congestive heart failure

1,2,3,6

Rationale:
Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients

A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which of the following would indicate that the client is experiencing side effects related to this medication? Select all that apply.

1. Ataxia
2. Sedation
3. Constipation
4. Bleeding gums
5. Hyperglycemia
6. Decreased platelet count

3,4,5,6

Rationale:
Dilantin causes blood dyscrasias, such as decreased platelet counts and decreased white blood cell counts; it contributes to constipation as well. Gingival hyperplasia can occur, causing gums to bleed easily, and blood glucose levels can elevate when taking phenytoin. Sedation is a side effect of barbiturates, not phenytoin. Ataxia is a side effect of benzodiazepines.

A client is scheduled for a myelogram, and the nurse provides a list of instructions to the client regarding preparation for the procedure. Which instructions should the nurse place on the list? Select all that apply.

1. Jewelry will need to be removed.
2. An informed consent will need to be signed.
3. A trained x-ray technician performs the procedure.
4. The procedure will take approximately 45 minutes.
5. A liquid diet can be consumed on the day of the procedure.
6. Solid food intake needs to be restricted only on the day of the procedure.

1,2,4

Rationale:
Client preparation for a myelogram includes instructing the client to restrict food and fluids for 4 to 8 hours before the procedure. The client is told that the procedure takes about 45 minutes. An informed consent is required because the procedure is invasive and is therefore performed by the health care provider. The client will need to remove jewelry and metal objects from the chest area. The client is also told that pretest medications may be prescribed for relaxation.

A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.

1. Monitor the client's ability to void.
2. Maintain the client in a flat position.
3. Restrict fluid intake for a period of 2 hours.
4. Monitor the client's ability to move the extremities.
5. Inspect the puncture site for swelling, redness, and drainage.
6. Maintain the client on a nothing-by-mouth (NPO) status for 24 hours.

1,2,4,5

Rationale:
Following a lumbar puncture, the client remains flat in bed for 6 to 24 hours, depending on the health care provider's prescriptions. A liberal fluid intake (not NPO status) is encouraged to replace cerebrospinal fluid removed during the procedure, unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage, and monitors the client's ability to void and move the extremities.

A nurse is told in report that a client has a positive Chvostek's sign. What other data would the nurse expect to find on data collection? Select all that apply.

1. Coma
2. Tetany
3. Diarrhea
4. Possible seizure activity
5. Hypoactive bowel sounds
6. Positive Trousseau's sign

2,3,4,6

Rationale:
A positive Chvostek's sign is indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, seizures, positive Trousseau's sign, diarrhea, hyperactive bowel sounds, and a prolonged QT interval.

A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? Select all that apply.

1. Tuck pant legs into socks.
2. Wear closed shoes when hiking.
3. Apply insect repellent containing DEET.
4. Cover the ground with a blanket when sitting.
5. Remove attached ticks by grasping with thumb and forefinger.
6. Wear long sleeves and long pants in dark colors when in high-risk areas.

1,2,3,4

Rationale:
Measures to prevent tick bites focus on covering the body as completely as possible and spraying insect repellent containing DEET on the skin and clothing. Long sleeves and pants tucked into the socks along with closed shoes will offer some protection. Light-colored clothing should be worn so that ticks would be easily visible. Hikers should not sit directly on the ground and should cover the ground with an item such as a blanket. Ticks should be removed with tweezers.

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider would likely prescribe. Select all that apply.

1. Monitor intake and output.
2. Monitor vital signs.
3. Maintain sodium-reduced diet.
4. Monitor electrolyte levels.
5. Increase water intake orally.
6. Administer sodium replacements.

1,2,3,4,5

Rationale:
Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L. Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia.

A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client's malpractice claim. Select all that apply.

1. Failure to replace body fluids
2. Increased risk of hypotension
3. Failure to teach the client adequately
4. Increased need to protect the client
5. Excessive bumetanide administration
6. Lack of follow-up nursing actions

2,3,4,6

Rationale:
To prove malpractice against a nurse, the plaintiff must prove that the nurse owed a duty to the client, that the nurse breached the duty, and that as a result harm was caused to person or property. The client has an increased risk of hypotension (option 2) because hypotension is a common adverse effect of bumetanide, this is the second dose within 4 hours, and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions (options 3, 4, and 6) after administering the bumetanide. After the first 15-minute check, the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide, a loop diuretic, was excessive. However, because this medication can cause hypotension, especially after a repeat dose, the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.

A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

1. Monitoring daily weight
2. Monitoring intake and output
3. Maintaining a low-potassium diet
4. Monitoring extremities for edema
5. Maintaining a low-sodium diet

1,2,4,5

Rationale:
The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.

A nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply.

1. Bradycardia
2. Fever
3. Sweating
4. Agitation
5. Pallor

2,3,4

Rationale:
Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply.

1. "I enjoy exercising but I need to be careful."
2. "I need to pace my activities throughout the day."
3. "I need to limit playing football to only the weekends."
4. "I should gauge my activity level by my energy level."
5. "I should exercise in the evening to encourage a good sleep pattern."

3,5

Rationale:
The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity.

A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply.

1. Scant mucus
2. Early onset cough
3. Marked weight loss
4. Purulent mucus production
5. Mild episodes of dyspnea

2,4,5

Rationale:
Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.

The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply.

1. Diuretics
2. Anticoagulants
3. Anticholinergics
4. Cardiac glycosides
5. Phosphodiesterase (PDE) inhibitors
6. Angiotensin-converting enzyme (ACE) inhibitors

1,4,5,6

Rationale:
Medications recommended for treatment of heart failure include diuretics, cardiac glycosides such as digoxin (Lanoxin), PDE inhibitors, and ACE inhibitors. Clients in heart failure do not need anticoagulants or anticholinergics.

The nurse is providing discharge teaching to the client who was given a prescription for nifedipine (Adalat) for blood pressure management. Which instructions should the nurse include? Select all that apply.

1. "Increase water intake."
2. "Increase calcium intake."
3. "Take pulse rate each day."
4. "Weigh at the same time each day."
5. "Palpitations may occur early in therapy."
6. "Be careful when rising from sitting to standing."

3,4,5,6

Rationale:
Nifedipine is a calcium-channel blocker. Its therapeutic outcome is to decrease blood pressure. Its method of action is blockade of the calcium channels in vascular smooth muscle, promoting vasodilation. Side effects that can occur early in therapy include reflex tachycardia (palpitations) and first-dose hypotension, leading to orthostatic hypotension. Weight should be checked regularly to monitor for early signs of heart failure. Also the client is taught to take his or her own pulse. Nifedipine does not affect serum calcium levels. Increased water intake is not indicated in the client with cardiovascular disease.

Which instruction should the nurse provide to the client with diabetes mellitus receiving acarbose (Precose)? Select all that apply.

1. "Take the medication at bedtime."
2. "Take the medication with each meal."
3. "Take the medication on an empty stomach."
4. "Side effects include abdominal bloating and flatus."
5. "Take some form of glucose if hypoglycemia occurs."
6. "Report symptoms such as shortness of breath or tiredness."

2,4,5,6

Rationale:
The mechanism of action of acarbose is a delay in absorption of dietary carbohydrates, thereby reducing the rise in blood glucose after a meal. To accomplish this, the medication must be taken with each meal. Because of its bacterial fermentation of unabsorbed carbohydrates in the colon, side effects such as borborygmus, cramps, abdominal distention, and flatulence can occur. The medication also can affect absorption of iron, leading to symptoms (shortness of breath, tiredness) of anemia.

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply.

1. Restrict all visitors.
2. Place the child on a low-bacteria diet.
3. Change dressings using sterile technique.
4. Encourage the consumption of fresh fruits and vegetables.
5. Perform meticulous handwashing before caring for the child.
6. Allow fresh-cut flowers in the room as long as they are kept in a vase with fresh water.

2,3,5

Rationale:
For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child's room. Meticulous handwashing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy).

The medication prescribed is atropine sulfate, 0.4 mg intramuscularly, immediately. The medication label states atropine sulfate, 0.3 mg/0.5 mL. The nurse prepares how much medication to administer the dose? Round to the nearest tenth position.

0.7

A health care provider's prescription reads "levothyroxine (Synthroid), 150 mcg orally daily." The medication label reads "levothyroxine, 0.1 mg/tablet." The nurse prepares to administer how many tablet(s) to the client?

1.5

A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client. Select all that apply.

1. Protect the stoma from water.
2. Soaps should be avoided near the stoma.
3. Wash the stoma daily using a washcloth.
4. Use diluted alcohol on the stoma to clean it.
5. Apply a thin layer of petroleum jelly to the skin surrounding the stoma.
6. Use soft tissues to clean any secretions that accumulate around the stoma.

1,2,3,5

Rationale:
The client with a stoma should be instructed to wash the stoma daily with a washcloth. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum jelly applied to the skin around the stoma helps prevent cracking. The client is instructed to protect the stoma from water.

A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply.

1. Oliguria
2. Seizures
3. Contractions
4. Proteinuria 3+
5. Muscle cramps
6. Blood pressure 168/116 mm Hg

1,4,6

Rationale:
Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.

A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply.

1. Cola is acceptable to drink on the day of the test.
2. Tea and coffee are restricted on the day of the test.
3. The test will take between 45 minutes and 2 hours.
4. The hair should be washed the evening before the test.
5. All medications need to be withheld on the day of the test.
6. A nothing-by-mouth (NPO) status is required on the day of the test.

2,3,4

Rationale:
Pre-procedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test, and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test.

A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which of the following medications are used for long-term control of tonic-clonic seizures? Select all that apply

1. Diazepam (Valium)
2. Alprazolam (Xanax)
3. Gabapentin (Neurontin)
4. Ethosuximide (Zarontin)
5. Carbamazepine (Tegretol)
6. Methylphenidate (Ritalin)

3,4,5

Rationale:
Medications that are prescribed for long-term control of tonic-clonic seizures are gabapentin, ethosuximide, and carbamazepine. Diazepam is a medication that is prescribed to halt tonic-clonic episodes, and methylphenidate is a medication used to treat attention deficit hyperactivity disorder. Both of these medications are not suitable for long-term control of a seizure condition. Alprazolam is a medication used to treat anxiety.

A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.

1. Severely anxious client
2. Pneumonia client
3. Diabetic mellitus client
4. Malnourished client
5. Asthma client
6. Renal failure client

3,4,6

Rationale:
Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1, 2, and 5 are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.

Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply.

1. Monitor for hemorrhage.
2. Administer eye medications.
3. Maintain the eye patch or shield.
4. Assist with activities of daily living.
5. Encourage coughing and deep breathing.
6. Educate regarding symptoms of retinal detachment.

1,2,3,4,6

Rationale:
An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse's assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk postsurgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.

A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

1. Monitoring daily weight
2. Monitoring intake and output
3. Maintaining a low-potassium diet
4. Monitoring extremities for edema
5. Maintaining a low-sodium diet

1,2,4,5

Rationale:
The client with Cushing's syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.

The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.

1. To avoid activities that require bending over
2. To contact the surgeon if eye scratchiness occurs
3. To place an eye shield on the surgical eye at bedtime
4. That episodes of sudden severe pain in the eye is expected
5. To contact the surgeon if a decrease in visual acuity occurs
6. To take acetaminophen (Tylenol) for minor eye discomfort

1,3,5,6

Rationale:
After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply.

1. Radiation
2. Chemotherapy
3. Increased fluid intake
4. Serum sodium blood levels
5. Decreased oral sodium intake
6. Medication that is antagonistic to antidiuretic hormone (ADH)

1,2,4,6

Rationale:
Cancer is a common cause of SIADH. In clients with SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is managed by treating the condition and its cause, and treatment usually includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH. Sodium levels are monitored closely, because hypernatremia can suddenly develop as a result of treatment. The immediate institution of appropriate cancer therapy (usually either radiation or chemotherapy) can cause tumor regression so that ADH synthesis and release processes return to normal.

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