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Which of the following groups of clients is at an increased risk for developing a wound infection?
Clients who are undernourished
The nurse assesses a client who is complaining of frequent episodes of epistaxis. The nurse knows the client has:
A client is scheduled for an excretory urography at 10 a.m. An order states to insert a saline lock I.V. device at 9:30 a.m. The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine and prilocaine cream (EMLA cream). The nurse should apply the cream at
The nurse is evaluating a client who is complaining of shortness of breath. The client's respiratory rate is 26 breaths/minute, so the nurse documents that he's tachypneic. The nurse understands that tachypnea means
respiratory rate greater than 20 breaths/minute
A client has lymphedema in both arms and the nurse must measure blood pressure using a thigh cuff. In reference to the client's baseline arm blood pressure, the nurse should expect the thigh to have a:
Higher systolic blood pressure reading.
Rationale: Systolic readings in the thigh may be 10 to 40 mm Hg higher than in the arm. Diastolic readings are the same in the arm and thigh.
The client is to receive an I.V. infusion of 3,000 ml of dextrose and normal saline solution over 24 hours. The nurse observes that the rate is 150 ml/hour. If the solution runs continuously at this rate, the infusion will be completed in:
A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations for all procedures and medications. Which of the following actions would best indicate that the client has achieved an increased level of psychological comfort?
Sleeping undisturbed for 3 hours
Rationale: Sleeping undisturbed for a period of time would indicate that the client feels more relaxed, comfortable, and trusting and is less anxious. Decreasing eye contact, asking to see family, and joking may also indicate that the client is more relaxed. However, these also could be diversions.
The nurse is administering I.M. injections to an older client. The nurse should remember that an older client has:
less subcutaneous tissue and muscle mass than a younger client.
Rationale: When administering I.M. injections, the nurse should remember that an older client has less subcutaneous tissue and muscle mass than a younger client.
Hyperkalemia can be treated with the administration of 50% dextrose and insulin. The 50% dextrose
Counteracts the effects of insulin.
Rationale: The 50% dextrose is given to counteract the effects of insulin. Insulin drives potassium into the cell, thereby lowering serum potassium levels. The dextrose doesn't directly cause the potassium excretion or any movement of potassium.
If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?
Produce a false-high measurement
Rationale: Using an undersized blood pressure cuff produces falsely elevated blood pressures because the cuff can't record brachial artery measurements unless it's excessively inflated. The sciatic nerve would be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity of the body
An Irish immigrant is 1 day postoperative following extensive abdominal surgery. The physician has ordered 100 mg of meperidine (Demerol) every 4 hours as needed for pain. The nurse notices that the client hasn't asked for pain medication since surgery. When the nurse assesses the client, he's stoic and asks to be left alone. The nurse should:
Offer him his pain medication.
Rationale: The Irish culture's usual reaction to pain is inexpressive and stoic. Irish people usually don't vocalize that they have pain and will try to hide the pain from family. The nurse should offer the pain medication so that comfort can be extended to the client.
A client in her first postpartum month has developed mastitis secondary to breast-feeding. Her nurse, a mother who developed and recovered from mastitis after her third child, says, "I remember the discomfort I had and how quickly it resolved when I began getting treatment." The therapeutic communication being used by the nurse is:
Rationale: Using self-disclosure as a therapeutic communication technique encourages an open and authentic relationship between the nurse and her client. Self-disclosure involves the nurse revealing personal information. Clarification involves the nurse asking the client for more information. Reflection is reviewing the client's ideas. Restating is the nurse's repetition of the client's main message.
An adult client, who happens to be the nurse's neighbor, is diagnosed with acquired immunodeficiency syndrome. He's assigned to the nurse's unit. The nurse tells the client's parents about the diagnosis; after all, they know their son is both the nurse's neighbor and friend. Several weeks later the nurse receives a letter from the client's attorney stating that the nurse has infringed on the client's basic legal rights and has committed an intentional tort. Which intentional tort has this nurse committed?
Breach of confidentiality
Rationale: A nurse shouldn't disclose confidential information about a client to a third party who has no legal right to know; doing so is a breach of confidentiality. Defamation of character is injuring someone's reputation through false and malicious statements. Assault and battery occurs when the nurse forces a client to submit to treatment against the client's will. A nurse commits fraud when she misleads a client to conceal a mistake she made during treatment.
When preparing to administer drugs to a client, the nurse reviews information about which branch of pharmacology that deals with the absorption, distribution, metabolism, and excretion of a drug?
Rationale: Pharmacokinetics deals with drug absorption, distribution, metabolism, and excretion in a living organism. Pharmacodynamics deals with drug action, pharmacotherapeutics deals with drug uses and intended effects, and pharmacognosy deals with the study of natural drug sources.
Which assessment finding by the nurse would prohibit application of a heating pad?
Rationale: Heat application increases blood flow; therefore, it's contraindicated in active bleeding. For this same reason, however, applying heat to a reddened abscess, edematous lower leg, or wound with purulent drainage promotes healing
After intentionally taking an overdose of amitriptyline (Elavil), a client is admitted to the emergency department. The nurse knows that the activated charcoal given to the client will:
bind with the ingested drug.
Rationale: Activated charcoal binds with the drug so that it isn't absorbed. It isn't given to promote vomiting or stimulate bowel motility, and it doesn't neutralize the drug.
A certified nursing assistant (CNA) is caring for a client with Clostridium difficile diarrhea and asks the charge nurse, "How can I keep from catching this from the client?" The nurse reminds the CNA to wash her hands and to ensure the client is placed:
On contact isolation.
Rationale: C. difficile can be transmitted from person to person by hands or waste containers such as a bedpan. When in direct contact with the client, the nurse should practice contact isolation, which includes wearing gloves and a gown. Protective isolation is used to protect a client who is immunocompromised, which isn't evident in this case. Neutropenic precautions are for clients with an absolute neutrophil count of 1,000/μl or less; this isn't evident in this case. A negative-pressure room is used when the organism is spread by the airborne route, which isn't true of C. difficile diarrhea.
A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What's the correctly written client outcome for this nursing diagnosis?
By discharge, the client correctly identifies three potassium-rich foods.
Rationale: A client outcome must be measurable, concise, realistic for the client, and obtainable through nursing management. For each client outcome, the nurse should include only one client behavior, should express that behavior in terms of client expectations, and should indicate a time frame. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable. Understanding all complications isn't measurable or specific to the nursing diagnosis listed.
The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's:
Rationale: An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee doesn't promote venous return.
A client on I.V. heparin should have which of the following laboratory values monitored closely to determine whether the therapeutic range is maintained?
Partial thromboplastin time (PTT)
Rationale: PTT is the laboratory value that gives specific information regarding the effectiveness of heparin therapy. The other tests are inappropriate.
When preparing a client with a draining vertical incision for ambulation, where should the nurse apply the thickest portion of a dressing?
At the base of the wound
Rationale: When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.
While a nurse is teaching a stress management class, a client who has been reading literature on stress states, "The book I'm reading keeps mentioning 'endorphins.' What are endorphins?" The most accurate response from the nurse would be that endorphins are:
pain-blocking chemicals produced by the body.
Rationale: Endorphins are narcotic-like substances that lock into the narcotic receptors at nerve endings in the brain and spinal cord and block the transmission of pain signals
Which change is demonstrated when a nurse helps a young mother adjust to the birth of her child?
The nurse is caring for a client receiving patient-controlled analgesia (PCA) for pain management. Which statement about PCA is true?
Pain relief is initiated by the client as needed.
The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to:
Walk from his room to the end of the hall and back before discharge.
The nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm compresses for the area. Based on the principles of heat and cold application, the nurse would:
Remove the warm compresses after 20 minutes for at least 15 minutes.
A client says to the nurse, "I know that I'm going to die." Which of the following responses by the nurse would be best?
"Why do you think you're going to die?"
A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, the nurse will:
Palpate the bladder above the symphysis pubis.
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. He reports severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, the nurse should avoid which route?
The nurse is caring for a young adult with hepatitis A. The client is crying and saying that she hates the way she looks with yellow skin. Which of the following would be the nurse's best response?
"I know you're upset; your skin will return to its normal color as you get well."
What's the most appropriate nursing diagnosis for the client with acute pancreatitis?
Deficient fluid volume
Which of the following assessments would be most supportive of the nursing diagnosis Impaired skin integrity related to purulent wound drainage?
Oral temperature of 101° F (38.3° C)
A client with terminal breast cancer is being cared for by a longtime friend who is a physician. The client has identified her twin sister as the agent in her durable power of attorney. The client loses decision-making capacity, and the twin sister says to the nurse, "There will be a different physician caring for my sister now. I've dismissed her friend." In response, the nurse should:
Abide by the wishes of the sister who is the durable power of attorney agent.
A physician writes the following order for a client: "Prednisone 5 mg P.O. daily for 3 days." When the order is transcribed on the Kardex, the nurse who transcribes the order neglects to place the limitation of 3 days on the prescription. On the 4th day after the order was instituted, a nurse administers prednisone 5 mg by mouth. During an audit of the chart, the error is identified. The person most responsible for the error is the:
Nurse who administered the erroneous dose.
Which statement accurately characterizes the Z-track method for I.M. injections?
The needle remains in place for 10 seconds after injection.
The nurse observes a client for signs of distress. Observation is which method of physical examination?
The nurse is caring for a 40-year-old woman who is a Black Muslim. Which of the following choices is a concept on which Black Muslims focus?
The nurse identifies the needs of a client with potential health problems during which step of the nursing process?
Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic and measures a temperature of 99.6° F (37.6° C), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes highest priority?
A client who is dehydrated has urinary incontinence and excoriation in the perineal area. Which of the following actions would be a priority?
Keeping the perineal area clean and dry
A client is treated in the emergency department for a severe reaction to a bee sting. Which drug should the nurse instruct the client to carry in the future to prevent an anaphylactic reaction from bee stings?
Rationale: Epinephrine is the drug of choice for anaphylactic reactions that occur at home because after proper instruction, the client or a family member can administer the drug I.M. or S.C. to counteract the hypotensive effects of histamine. All of the other options are inappropriate.
During a meal, a client with hepatitis B dislodges her I.V. line and bleeds on the surface of the over-the-bed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:
The nurse is about to administer a medication to a client with whom the nurse is unfamiliar. To verify the client's identity, the nurse should:
Check the client's identification bracelet.
The nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for planning care?
Current health promotion activities
Which of the following clients would qualify for hospice care?
A client with late-stage acquired immunodeficiency syndrome (AIDS)
In a weekly parenting class, the nurse teaches parents ways to foster healthy self-concepts in their children. Which method is most important?
Giving positive feedback
The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which of the following meals as high in protein?
Baked beans, hamburger, and milk
The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that:
inelastic skin turgor is a normal part of aging.
When discussing the Food Pyramid with a 75-year-old client, the nurse should remember that the pyramid has been modified for older people. Unlike the standard Food Pyramid, the version for elderly individuals:
includes eight 8-oz glasses of water at the base of the pyramid.
A client hasn't voided since before surgery, which took place 8 hours ago. Which action should the nurse do first?
Assess the client for bladder fullness.
A school-age child is diagnosed with influenza, and the nurse is teaching the parents about caring for the child. Which statement explains why the child should not receive aspirin or aspirin-containing medications to relieve achiness and fever?
Salicylates have been linked with Reye's syndrome in children.
While caring for a client who is immobile, the nurse documents the following information in the client's chart: "Turn client from side to back every two hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?
Risk for impaired skin integrity related to immobility
Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should:
Withhold food and fluids.
The physician prescribes the following preoperative medications to a client for I.M. administration: meperidine (Demerol), 50 mg; hydroxyzine (Vistaril), 25 mg; and glycopyrrolate (Robinul), 0.3 mg. The medications are dispensed as follows: meperidine, 100 mg/ml; hydroxyzine, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many milliliters, in total, should the nurse administer?
To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site?
Which action would be contraindicated for a client who develops a temperature of 102° F (38.9° C)?
Providing a low-calorie diet
A 46-year-old woman who recently immigrated to the United States is hospitalized on a respiratory isolation unit for multiple drug-resistant pulmonary tuberculosis. What's the appropriate way that the nurse can meet the client's love and belonging needs?
Include her family in her care.
A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
Decrease the rate of feedings.
The nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously applied topical medications before applying new medications is to:
Avoid administering more than the prescribed dose.
The nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin:
enhances protein synthesis.
The nurse inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has:
A client returns from an endoscopic procedure during which he was sedated. Before offering the client food, it's most important for the nurse to:
assess his gag reflex.
When assessing a client's incision 1 day after surgery, the nurse expects to see which of the following as signs of a local inflammatory response?
Redness and warmth
An occupational health nurse has a client who recently became blind from an industrial accident and has been receiving therapy to help him work through the loss and grief process. Which behavior by the client would most suggest that the therapy is having its intended effect?
Turning to his family, friends, and caregivers for support
When assessing a client with cellulitis of the right leg, which of the following would the nurse expect to find?
Red, swollen skin with inflammation spreading to surrounding tissues
While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which of the following types of dressings is most appropriate for the nurse to apply?
Moist sterile saline gauze
A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
Risk for aspiration related to anesthesia
Using Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?
A client is admitted to the emergency department with complaints of nausea and vomiting. Arterial blood gas studies show metabolic alkalosis. The nurse understands that alkalosis is a:
pH greater than 7.45.
After intentionally taking an overdose of hydrocodone (Vicodin), a client is admitted to the emergency department. Activated charcoal is prescribed. Before administering the drug, the nurse should ensure that the client:
Has audible bowel sounds
A client receives meperidine (Demerol) 50 mg I.M. for relief of surgical pain. Thirty minutes later, the nurse asks the client if the pain is relieved. Which step of the nursing process is the nurse using?
A parish nurse conducts socialization groups for elderly people, health screening clinics, and home visits. If the nurse prioritizes her programs according to Maslow's hierarchy of basic human needs, on which effort would she work first?
Teaching a class on scheduling and organizing accurate medication usage to prevent underdosing or overdosing
A client is receiving 125 ml/hour of continuous I.V. fluid therapy. The nurse examines the venipuncture site and finds it red and swollen. Which of the following interventions would the nurse perform first?
Discontinue the infusion.
In a client who had major surgery 5 days ago, which of the following assessment findings would be the best indication of a wound infection?
Thick, yellow wound drainage
The nurse is assigned to care for an elderly client who is confused and repeatedly attempts to climb out of bed. The nurse asks the client to lie quietly and leaves her unsupervised to take a quick break. While the nurse is away, the client falls out of bed. She sustains no injuries from the fall. Initially, the nurse should treat this occurrence as:
A risk management incident.
A 20-year-old mother of a premature neonate smoked cigarettes during her pregnancy. Her son is a client in a neonatal intensive care unit and has a diagnosis of acute respiratory distress syndrome. Because the mother is Roman Catholic, which nursing intervention would be most appropriate for the nurse to discuss with her?
Baptism of the neonate
A 74-year-old client has three grown children who each have families of their own. The client is retired and looks back on his life with satisfaction. According to Erickson, the nurse assesses that the client is in a stage of:
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which of the following contributing factors would the nurse recognize as most important?
Recent pelvic surgery
A client receiving beta-adrenergic blockers may have alterations in which of the following laboratory values?
Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?
A client is to be discharged from an acute care facility after treatment of right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step in the nursing process?
A client asks about the medication he's receiving. The nurse's reply is based on the knowledge that:
the client has a right to know the medication he's getting and its adverse effects.
Upon entering a client's room, the client frowns and states, "I've had my light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be:
"You seem upset this morning."
A client is admitted with acute chest pain. When obtaining the health history, which question will be most helpful for the nurse to ask?
"What were you doing when the pain started?"
Before administering a medication through a nasogastric (NG) tube, the nurse should do which of the following first?
Inject 10 cc of air into the NG tube and aspirate.
The nurse is to give a client a 325-mg aspirin suppository. The client has diarrhea and is in the bathroom. The best nursing approach at this time would be to:
Withhold the suppository and notify the client's physician.
A client undergoes hypersensitivity testing with the intradermal technique. When the nurse administers the allergen, what should the angle of the needle be?
The nurse accidentally administers 40 mg of propranolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, the nurse should:
complete an incident report.
A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, is withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what's an appropriate goal for this client?
Identifying one way to increase social interaction
A client is receiving an I.V. infusion of dextrose 5% in water and lactated Ringer's solution at 125 ml/hour to treat a fluid volume deficit. Which of these signs indicates a need for additional I.V. fluids?
Dark amber urine
Nursing care for a client includes removing elastic stockings once per day. What's the rationale for this intervention?
To permit veins in the legs to fill with blood
Which of the following outcome criteria would be most appropriate for the client with a nursing diagnosis of Ineffective airway clearance?
Breath sounds clear on auscultation
After a client receives an I.M. injection, he complains of burning pain in the injection site. Which nursing action would be the best to take at this time?
Apply a warm compress to dilate the blood vessels.
While monitoring an I.V. infusion, the nurse notices that the ground on the infusion pump's plug is missing. What should the nurse do first?
Obtain another pump from central supply for the infusion.
Following a fall from a horse during rodeo practice, an 18-year-old client is seen in the emergency department. He has a large, dirty laceration on his leg. The wound is vigorously cleaned, closed, and dressed. In the past, the client has received the full immunization regimen for tetanus toxoid. The nurse asks the client about his tetanus immunization history and he says, "I had my last shot when I was 11 years old." The nurse should:
plan on administering a dose of tetanus vaccine.
The physician has ordered a wet-to-dry dressing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to accomplish which action?
Debriding the wound
When developing a care plan for an older adult the nurse should consider which challenges faced by clients in this age group?
Adjusting to retirement, deaths of family members, and decreased physical strength
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?
Inadequate protein intake
After knee replacement surgery, a client is being discharged with acetaminophen and codeine tablets, 30 mg, for pain. During the client's discharge preparations, the nurse should include which instruction?
Avoid driving a car while taking the medication.
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