Question Of The Day: Infant

Q. An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child?

A. Encouraging the infant to hold a bottle
B. Keeping the infant on bed rest to conserve energy
C. Rotating caregivers to provide more stimulation
D. Maintaining a consistent, structured environment

Correct Answer: D

Explanation: The nurse caring for an infant with inorganic failure to thrive should strive to maintain a consistent, structured environment because it reinforces a caring feeding environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.

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Question Of The Day: The Nursing Process

Q. Which of the following should be included in the plan of care for a client with a surgical wound that requires a wet-to-dry dressing?

A. Place a dry dressing in the wound.
B. Use Burrow's solution to wet the dressing.
C. Pack the wet dressing tightly into the wound.
D. Cover the wet packing with a dry sterile dressing.



Correct Answer: D

Explanation: A wet-to-dry dressing should be able to dry out between dressing changes. Thus, the dressing should be moist, not dry, when applied. As the moist dressing dries, the wound will be debrided of necrotic tissue, exudate, and so forth. Normal saline is most commonly used to moisten the sponge; Burrow's solution will irritate the wound. The sponge should not be packed into the wound tightly because the circulation to the site could be impaired. The moist sponge should be placed so that all surfaces of the wound are in contact with the dressing. Then the sponge is covered and protected by a dry sterile dressing to prevent contamination from the external environment.

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Question Of The Day: Basic Physical Assessment

Q. Crackles heard on lung auscultation indicate which of the following?

A. Cyanosis.
B. Bronchospasm.
C. Airway narrowing.
D. Fluid-filled alveoli.





Correct Answer: D

Explanation: Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.

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Question Of The Day: Medication and I.V. Administration

Q. A woman is taking oral contraceptives. The nurse teaches the client to report which of the following danger signs?

A. Breakthrough bleeding.
B. Severe calf pain.
C. Mild headache.
D. Weight gain of 3 lb.




Correct Answer: B

Explanation: Women who take oral contraceptives are at increased risk for thromboembolic conditions. Severe calf pain needs to be investigated as a potential sign of deep vein thrombosis. Breakthrough bleeding, mild headache, or weight gain may be common benign side effects that accompany oral contraceptive use. Clients may be monitored for these side effects without a change in treatment.

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Question Of The Day: Basic Psychosocial Needs

Q. The health care provider at a prenatal clinic has ordered multivitamins for a woman who is 3 months' pregnant. The client calls the nurse to report that she has gone to the pharmacy to fill her prescription but is unable to buy it as it costs too much. The nurse should refer the client to:

A. The charge nurse.
B. The hospital finance office.
C. Her hospital social worker.
D. Her insurance company.

Correct Answer: C

Explanation: The social worker is available to assist the client in finding services within the community to meet client needs. This individual is able to provide the names of pharmacies within the community that offer generic substitutes or others that utilize the client's insurance plan. The charge nurse of the unit would be able to refer the client to the social worker. The hospital finance office does not handle this type of situation and would refer the client back to the unit. The client's insurance company deals with payments for health care and would refer the client back to the local setting.

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Question Of The Day: Basic Physical Care

Q. As a nurse helps a client ambulate, the client says, "I had trouble sleeping last night." Which action should the nurse take first?

A. Recommending warm milk or a warm shower at bedtime
B. Gathering more information about the client's sleep problem
C. Determining whether the client is worried about something
D. Finding out whether the client is taking medication that may impede sleep

Correct Answer: B

Explanation: The nurse first should determine what the client means by "trouble sleeping." The nurse lacks sufficient information to recommend warm milk or a warm shower or to make inferences about the cause of the sleep problem, such as worries or medication use.

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Question Of The Day: Respiratory Disorders

Q. A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

A. Nausea or vomiting
B. Abdominal pain or diarrhea
C. Hallucinations or tinnitus
D. Light-headedness or paresthesia



Correct Answer: D

Explanation: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

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Question Of The Day: Neurosensory Disorders

Q. A nurse is monitoring a client for adverse reactions to atropine (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?

A. Tachycardia
B. Increased salivation
C. Hypotension
D. Apnea


Correct Answer: A

Explanation: Systemic absorption of atropine can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. The drug also may cause dry mouth. It isn't known to cause hypotension or apnea.

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Question Of The Day: Endocrine and Metabolic Disorders

Q. A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective coping related to diabetes mellitus?

A. Recent weight gain of 20 lb (9.1 kg)
B. Failure to monitor blood glucose levels
C. Skipping insulin doses during illness
D. Crying whenever diabetes is mentioned



Correct Answer: D

Explanation: A client who cries whenever diabetes is mentioned is demonstrating ineffective coping. A recent weight gain and failure to monitor blood glucose levels would support a nursing diagnosis of Noncompliance: Failure to adhere to therapeutic regimen. Skipping insulin doses during illness would support a nursing diagnosis of Deficient knowledge related to treatment of diabetes mellitus.

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Question Of The Day: Immune and Hematologic Disorders

Q. A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

A. "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear."
B. "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal."
C. "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year."
D. "I will receive parenteral vitamin B12 therapy for the rest of my life."

Correct Answer: D

Explanation: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.

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Question Of The Day: Cardiovascular Disorders

Q. In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open heart surgery, the nurse should explain that:

A. The client will remain in the ICU for 5 days.
B. The client will sleep most of the time while in the ICU.
C. Noise and activity within the ICU are minimal.
D. The client will receive medication to relieve pain.

Correct Answer: D

Explanation: Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery, according to the Agency for Health Care Policy and Research. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replacement surgery.

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Question Of The Day: The Neonate

Q. A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The primary care provider has ordered I.V. fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4Meq/ L. The nurse should:

A. Notify the primary care provider.
B. Administer the ordered fluids.
C. Verify that the infant has urinated.
D. Have the potassium level redrawn.

Correct Answer: C

Explanation: Normal serum potassium levels are 3.5-4.5 Meq/L. Elevated potassium levels can cause life threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potassium through urination before administering the drug. Infants with pyloric stenosis frequently have low potassium levels due to vomiting. A level of 3.4Meq/l is not unexpected and should be corrected with the ordered fluids. The lab value does not need to be redrawn as the findings are consistent with the infant's condition.

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Question Of The Day: Postpartum Period

Q. Twelve hours after a vaginal delivery with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next?

A. Document this as a normal finding in the client's record.
B. Contact the physician for an order for methylergonovine (Methergine).
C. Encourage the client to ambulate to the bathroom and void.
D. Gently massage the fundus to expel the clots.

Correct Answer: C

Explanation: At 12 hours postpartum, the fundus normally should be in the midline and at the level of the umbilicus. When the fundus is firm yet above the umbilicus, and deviated to the right rather than in the midline, the client's bladder is most likely distended. The client should be encouraged to ambulate to the bathroom and attempt to void, because a full bladder can prevent normal involution. A firm but deviated fundus above the level of the umbilicus is not a normal finding and if voiding does not return it to midline, it should be reported to the physician. Methylergonovine (Methergine) is used to treat uterine atony. This client's fundus is firm, not boggy or soft, which would suggest atony. Gentle massage is not necessary because there is no evidence of atony or clots.

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Question Of The Day: Intrapartum Period

Q. The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next?

A. Tell the client to push between contractions.
B. Provide gentle support to the fetal head.
C. Apply gentle upward traction on the neonate's anterior shoulder.
D. Massage the perineum to stretch the perineal tissues.

Correct Answer: B

Explanation: During a precipitous delivery, after calling for assistance and helping the client lie down, the nurse should provide support to the fetal head to prevent it from coming out. It is not appropriate to tell the client to push between contractions because this may lead to lacerations. The shoulder should be delivered by applying downward traction until the anterior shoulder appears fully at the introitus, then upward pressure to lift out the other shoulder. Priority should be given to safe delivery of the infant over protecting the perineum by massage.

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Question Of The Day: Antepartum Period

Q. Which medication is considered safe during pregnancy?

A. Aspirin
B. Magnesium hydroxide
C. Insulin
D. Oral antidiabetic agents





Correct Answer: C

Explanation: Insulin is a required hormone for any client with diabetes mellitus, including the pregnant client. Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for use during pregnancy because these agents may cause fetal harm.

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Question Of The Day: Substance Abuse, Eating Disorders, Impulse Control Disorders

Q. A client with alcohol dependency is prescribed a B-complex vitamin. The client states, "Why do I need a vitamin? My appetite is just fine." Which of the following responses by the nurse is most appropriate?

A. "Your doctor wants you to take it for at least 4 months."
B. "You've been drinking alcohol and eating very little."
C. "The vitamin is a nutritional supplement important to your health."
D. "The amount of vitamins in the alcohol you drink is very low."

Correct Answer: C

Explanation: Stating that the vitamin is a nutritional supplement important to the client's health is the best response. The client is nutritionally depleted, and the B-complex vitamins produce a calming effect on the irritated central nervous system and prevent anemia, peripheral neuropathy, and Wernicke's encephalopathy. Although the statements about drinking alcohol and eating very little and that there is a low amount of vitamins in the alcohol consumed may be true, they fail to address the client's concerns directly and fail to provide the necessary information, as does telling the client that the doctor wants the client to take the vitamin for 4 months.

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Question Of The Day: Mood, Adjustment, and Dementia Disorders

Q. A client with major depression sleeps 18 to 20 hours per day, shows no interest in activities he previously enjoyed and reports a 17-lb (7.7-kg) weight loss over the past month. Because this is the client's first hospitalization, the physician is most likely to order:

A. phenelzine (Nardil).
B. thiothixene (Navane).
C. nortriptyline (Pamelor).
D. trifluoperazine (Stelazine).

Correct Answer: C

Explanation: Nortriptyline, a tricyclic antidepressant, is used in first-time drug therapy because it causes few anticholinergic and sedative adverse effects. Phenelzine isn't ordered initially because it may cause many adverse effects and necessitates dietary restrictions. Thiothixene and trifluoperazine are antipsychotic agents and, therefore, inappropriate for clients with uncomplicated depression.

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Question Of The Day: Anxiety Disorders

Q. A client who recently developed paralysis of the arms is diagnosed with conversion disorder after tests fail to uncover a physical cause for the paralysis. Which intervention should the nurse include in the care plan for this client?

A. Exercising the client's arms regularly
B. Insisting that the client eat without assistance
C. Working with the client rather than with the family
D. Teaching the client how to use nonpharmacologic pain-control methods

Correct Answer: A

Explanation: To maintain the integrity of the affected areas and prevent muscle wasting and contractures, the nurse should help the client perform regular passive range-of-motion exercises with his arms. The nurse shouldn't insist that the client use his arms to perform such functions as eating without assistance, because he can't consciously control his symptoms and move his arms; such insistence may anger the client and endanger the therapeutic relationship. The nurse should include family members in the client's care because they may be contributing to the client's stress or conflict and are essential to helping him regain function of his arms. The client isn't experiencing pain and, therefore, doesn't need education regarding pain management.

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Question Of The Day: Foundations of Psychiatric Nursing

Q. The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes?

A. Coordinate documentation of the incident.
B. Resolve negative feelings and attitudes.
C. Improve the use of restraint procedures.
D. Calm down before returning to the other clients.

Correct Answer: C

Explanation: Although coordinating documentation, resolving negative feelings, and calming down are goals of debriefing after a restraint, the ultimate outcome is to improve restraint procedures.

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Question Of The Day: Adolescent

Q. A 17-year-old client who has been taking an antidepressant for six weeks has returned to the clinic for a medication check. When the nurse talks with the client and her mother, the mother reports that she has to remind the client to take her antidepressant every day. The client says, "Yeah, I'm pretty bad about remembering to take my meds, but I never miss a dose because Mom always bugs me about taking it." Which of the following responses would be effective for the nurse to make to the client?

A. "It's a good thing your mom takes care of you by reminding you to take your meds."
B. "It seems there are some difficulties with being responsible for your medications that we need to address".
C. "You'll never be able to handle your medication administration at college next year if you're so dependent on her."
D. "I'm surprised your mother allows you to be so irresponsible."

Correct Answer: B

Explanation: The client and mother need to address the issue of responsibility for medication administration and only Option 2 opens that subject to discussion. Option 1 reinforces the mother's over-involvement in medication taking. Options 3 and 4 make negative comments about the client and mother that are unlikely to engage them in problem-solving about the matter. 

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Question Of The Day: School-age Child

Q. Which of the following measures should the nurse include in the care plan for a child who is receiving high-dose methotrexate (amethopterin) therapy?

A. Keeping the child in a fasting state.
B. Obtaining a white blood cell (WBC) count.
C. Preparing for radiography of the spinal canal.
D. Collecting a specimen for urinalysis.



Correct Answer: B

Explanation: Methotrexate is not highly toxic in low doses but may cause severe leukopenia at higher doses. It is customary and recommended for blood tests to be done before therapy to provide a baseline from which to study the effects of the drug on WBC count. Maintaining a fasting state, radiography of the spinal canal, and urinalysis are not necessary when this drug is administered.

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Question Of The Day: Preschooler

Q. A 4-year-old boy presents to the emergency department. His father tearfully reports that he was in the driveway and had his son on his shoulders when the child began to fall. The father grabbed him by the leg, swinging him toward the grass to avoid landing on the pavement. As the father swung his son, the child hit his head on the driveway and twisted his right leg. After a complete examination, it is determined that the child has a skull fracture and a spiral fracture of the femur. Which of the following actions should the nurse take?

A. Restrict the father's visitation.
B. Notify the police immediately.
C. Refer the father for parenting classes.
D. Record the father's story in the chart.

Correct Answer: D

Explanation: The father's story is consistent with the injuries incurred by the child; therefore, the nurse should document the cause of injury. There is no need to restrict the father's visitation, because the injuries sustained by the child are consistent with the explanation given. The police need to be notified only if there is suspicion of child abuse. The injuries incurred by this child appear accidental. There is no need to refer the father for parenting classes. The father seems upset about the accident and will not likely repeat such reckless behavior. The nurse should educate the father, however, regarding child safety.

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Question Of The Day: The Nursing Process

Q. An 18-year-old high school senior wishes to obtain birth control through her parents' insurance but does not want the information disclosed. The nurse tells the client that under the Health Information Portability and Accountability Act (HIPAA) parents:

A. Have the right to review a minor's medical records until high school graduation.
B. Have the right to review a minor's medical record if they are responsible for the payment.
C. May not view the medical record, but may learn of the visit through the insurance bill.
D. May not view the minor's medical record or the insurance bill.

Correct Answer: C

Explanation: Under HIPAA, 18-year-olds have the right to medical privacy and their medical records may not be disclosed to their parents without their permission. However, the adolescent must be made aware of the fact that information is sent to third party payers for the purpose of reimbursement. Those payers send the primary insurer, in this case the parent, a statement of benefits. HIPAA protects the right to medical privacy of all 18-year-olds regardless of their educational status. Even if parents are responsible for payment, they may not view the patient's chart without the consent of the adolescent.

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