A. Decrease in appetite.
B. Drowsiness.
C. Spasms of the diaphragm.
D. Cough and shortness of breath.
Correct Answer: D
Reason: Cough and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, difficulty in thinking clearly, and spasms of the diaphragm may occur as a result of chemotherapy; however, they are not indicative of pulmonary toxicity.
A. Two nurses in the cafeteria are discussing a client's condition.
B. The health care team is discussing a client's care during a formal care conference.
C. A nurse checks the computer for the laboratory results of a neighbor who has been admitted to another floor.
D. A nurse talks with her spouse about a client's condition.
Correct Answer: B
Reason: To provide interdisciplinary continuity of care, nurses must share relevant information during client care conferences. Nurses discussing information in the cafeteria may be overheard; this indiscretion violates HIPAA regulations. Looking up laboratory results for a neighbor is a HIPAA violation, as is discussing a client's condition with one's spouse.
A. alcoholism.
B. a manic episode.
C. situational crisis.
D. depression.
Correct Answer: C
Reason: A situational crisis results from a specific event in the life of a person who is overwhelmed by the situation and reacts emotionally. Fatigue, insomnia, and inability to make decisions are common signs and symptoms. The situational crisis may precipitate behavior that causes a crisis (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episode is characterized by euphoria and labile affect. Symptoms of depression are usually present for 2 or more weeks.
A. Attach a copy to the client's records.
B. Highlight the mistake in the client's records.
C. Include the time and date of the incident.
D. Mention the name of the nursing assistant in the client records.
Correct Answer: C
Reason: The nurse should include the date and time of the incident in the incident report, the events leading up to it, the client's response, and a full nursing assessment. To prevent legal issues, the nurse should not attach the copy of the incident report to the client's records. Also to prevent litigation, the mistake should not be highlighted in the client's records. As the client report is a legal document, it should not contain the name of the nursing assistant.
A. Discontinue the infusion.
B. Apply a warm soak to the site.
C. Stop the flow of solution temporarily.
D. Irrigate the needle with normal saline.
Correct Answer: A
Reason: Signs of infiltration include slowing of the infusion and swelling, pain, hardness, pallor, and coolness of the skin at the site. If these signs occur, the I.V. line should be discontinued and restarted at another infusion site. The new anatomic site, time, and type of cannula used should be documented. The nurse may apply a warm soak to the site, but only after the I.V. line is discontinued. Parenteral administration of fluids should not be stopped intermittently. Stopping the flow does not treat the problem, nor does it address the client's needs for fluid replacement. Infiltrated I.V. sites should not be irrigated; doing so will only cause more swelling and pain.
A. Consumers of health care cannot keep up with rapid advances in science.
B. The influence of the media and specialization have increased the complexity of managing health.
C. Nurse educators have recognized the value of communication.
D. Clients are more demanding that their rights be respected.
Correct Answer: B
Reason: Today's health care network includes many specialized areas, such as respiratory therapy, medicine, laboratory, social services, and technical monitoring, to name a few. Due to expanded media coverage of health care issues, parents are more aware of health care issues but cannot understand all the ramifications of possible health care decisions. Because of this expanded media coverage, health care consumers are more aware of advances in the science of health care. Nurses have always recognized the value of communication and that all nurses are teachers. Clients are more aware of their rights through media exposure and information disseminated by health care facilities. However, respect for the client's rights should be the nurse's concern as well and communicating with parents and children should not be impacted by a client's knowledge or demand for those rights.
A. Call for emergency assistance.
B. Attempt reinsertion of tracheostomy tube.
C. Position the client in semi-Fowler's position with the neck hyperextended.
D. Insert the obturator into the stoma to reestablish the airway.
Correct Answer: B
Reason: The nurse's first action should be to attempt to replace the tracheostomy tube immediately so that the client's airway is reestablished. Although the nurse may also call for assistance, there should be no delay before attempting reinsertion of the tube. The client is placed in a supine position with the neck hyperextended to facilitate reentry of the tube. The obturator is inserted into the replacement tracheostomy tube to guide insertion and is then removed to allow passage of air through the tube.
A. gather assessment data and notify the physician of the change in the client's status.
B. ask the physician to order an antipsychotic medication for the client.
C. consult with the social worker about the possibility of discharging the client from the facility.
D. tell the client that she'll punish him if he doesn't behave.
Correct Answer: A
Reason: A client with a head injury who experiences a change in cognition requires further assessment and evaluation, and the nurse should notify the physician of the change in the client's status. The physician should rule out all possible medical causes of the change in mental status before ordering antipsychotic medications or considering discharging the client from the facility. A nurse shouldn't threaten a client with punishment; doing so is a violation of the client's rights.
A. Verbalizing an understanding of blood glucose meter use
B. Documenting a normal blood glucose level
C. Providing documentation of previous certification
D. Demonstrating correct technique
Correct Answer: D
Reason: The best way to validate blood glucose meter use is to allow the nursing assistant to demonstrate correct technique. Verbalizing understanding doesn't demonstrate that the nursing assistant knows proper technique. Documenting a normal blood glucose level and having previous certification don't demonstrate blood glucose meter use.
A. Cool, clammy skin.
B. Warm, flushed skin.
C. Increased blood pressure.
D. Hemorrhage.
Correct Answer: B
Reason: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.
A. Rewarm the neonate gradually.
B. Rewarm the neonate rapidly.
C. Observe the neonate hourly.
D. Notify the physician when the neonate's temperature is normal.
Correct Answer: A
Reason: A neonate with a temperature of 94.1° F is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, the nurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes. Rapid rewarming may cause hyperthermia. Hourly observation isn't frequent enough because cold stress increases oxygen, calorie, and fat expenditure, putting the neonate at risk for anabolic metabolism and possibly metabolic acidosis. A neonate with cold stress requires intervention; the nurse should notify the physician of the problem as soon as it's identified.
A. Inserting an indwelling urinary catheter
B. Fundal massage
C. Administration of oxytocics
D. Pad count
Correct Answer: D
Reason: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained uterine contraction.
A. 7 weeks' gestation
B. 11 weeks' gestation
C. 17 weeks' gestation
D. 21 weeks' gestation
Correct Answer: B
Reason: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks' gestation.
A. flight of ideas and inflated self-esteem.
B. increased sleep and greater distractibility.
C. decreased self-esteem and increased physical restlessness.
D. obsession with following rules and maintaining order.
Correct Answer: A
Reason: The manic phase of bipolar disorder is characterized by recurrent episodes of a persistently euphoric and expansive or irritable mood. This phase is diagnosed if the client experiences four of the following signs and symptoms for at least 1 week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or sexual activity; physical restlessness; a decreased need for sleep; increased distractibility; and excessive involvement in activities with a high potential for painful but unrecognized consequences. Obsession with following rules and maintaining order characterizes obsessive-compulsive disorder.
A. Have a parent hold the toddler.
B. Assess the ears and mouth first.
C. Carry out the assessment from head to toe.
D. Assess motor function by having the child run and walk.
Correct Answer: A
Reason: The best strategy for assessing a toddler is to have the parent hold the toddler. Doing so is comforting to the toddler. Assessment should begin with noninvasive assessments first while the child is quiet. Typically these include assessments of the cardiac and respiratory systems. The ears and throat are typically examined last. Using a head-to-toe approach is more appropriate for an older child. For a toddler, assessment should begin with noninvasive assessments first while the child is quiet. Having a toddler run and be active may make it difficult to settle the child down after the physical exertion.
A. Have the client wear eyeglasses at all times.
B. Lightly tape the eyelid shut.
C. Instill artificial tears once every shift.
D. Clean the eyelid with a washcloth every shift.
Correct Answer: B
Reason: When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.
A. Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the physician.
B. Ask the nursing assistant to notify the physician of the low pulse oximetry level.
C. Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.
D. Complete the assessment of the new client before attending to the client who underwent laminectomy.
Correct Answer: C
Reason: Because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in her care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; she may wait until she completes the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record.
A. "Most impotence resolves in a couple of months."
B. "You could have early ejaculation with this type of surgery."
C. "We will refer you to a sex therapist because you will probably notice erectile dysfunction."
D. "Because your surgery does not involve other organs or tissues, you'll likely not notice much change in your sexual performance."
Correct Answer: D
Reason: Although there may not be a big change in sexual function with a unilateral orchiectomy, the loss of a gonad and testosterone may result in decreased libido and sterility. Sperm banking may be an option worth exploring if the number and motility of the sperm are adequate. Remember, the population most affected by testicular cancer is generally young men ages 15 to 34, and in this crucial stage of life, sexual anxieties may be a large concern.
A. "Take an extra dose of digoxin if you miss one dose."
B. "Call the physician if your heart rate is above 90 beats/minute."
C. "Call the physician if your pulse drops below 80 beats/minute."
D. "Take digoxin with meals."
Correct Answer: B
Reason: The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute — not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. The client shouldn't take digoxin with meals; doing so slows the absorption rate.
A. peripheral acrocyanosis.
B. bradycardia.
C. lethargy.
D. jaundice.
Correct Answer: C
Reason: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia — not bradycardia — is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.
A. Firm fundus at the symphysis.
B. White, thick vaginal discharge.
C. Striae that are silver in color.
D. Soft breasts without milk.
Correct Answer: A
Reason: By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle-feeding mother).
A. Dismantling the showerhead and showing the client that there is nothing in it
B. Explaining that other clients are complaining about the client's body odor
C. Asking a security officer to assist in giving the client a shower
D. Accepting these fears and allowing the client to take a sponge bath
Correct Answer: D
Reason: By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality by dismantling the shower head wouldn't be effective at this time. Explaining that other clients are complaining about his body odor or asking a security officer to assist in giving the client a shower would violate the client's rights by shaming or embarrassing him.
A. "I can still eat my favorite salty foods."
B. "When my moods fluctuate, I'll increase my dose of lithium."
C. "A good blood level of the drug means the drug concentration has stabilized."
D. "Eating too much watermelon will affect my lithium level."
Correct Answer: B
Reason: A client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice.
A. Severe sore throat, drooling, and inspiratory stridor
B. Low-grade fever, stridor, and a barking cough
C. Pulmonary congestion, a productive cough, and a fever
D. Sore throat, a fever, and general malaise
Correct Answer: A
Reason: A child with acute epiglottiditis appears acutely ill and clinical manifestations may include drooling (because of difficulty swallowing), severe sore throat, hoarseness, a high temperature, and severe inspiratory stridor. A low-grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles indicate pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis.
A. monitoring of arterial oxygen saturation (SaO2).
B. arterial blood gas (ABG) studies.
C. chest auscultation.
D. a chest X-ray.
Correct Answer: D
Reason: Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently.
A. Maintain the client on strict bed rest in a supine position for 6 hours.
B. Insert an indwelling catheter to monitor urine output.
C. Apply a sandbag to the biopsy site to prevent bleeding.
D. Administer I.V. opioid medications to promote comfort.
Correct Answer: A
Reason: After a renal biopsy, the client is maintained on strict bed rest in a supine position for at least 6 hours to prevent bleeding. If no bleeding occurs, the client typically resumes general activity after 24 hours. Urine output is monitored, but an indwelling catheter is not typically inserted. A pressure dressing is applied over the site, but a sandbag is not necessary. Opioids to control pain would not be anticipated; local discomfort at the biopsy site can be controlled with analgesics.
A. Hypoactive bowel sounds
B. Severe lower back pain
C. Sensory deficits in one arm
D. Weakness and atrophy of the arm muscles
Correct Answer: B
Reason: The most common finding in a client with a herniated lumbar disk is severe lower back pain, which radiates to the buttocks, legs, and feet — usually unilaterally. A herniated disk also may cause sensory and motor loss (such as footdrop) in the area innervated by the compressed spinal nerve root. During later stages, it may cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms.
A. Carcinoembryonic antigen (CEA) test after age 50
B. Proctosigmoidoscopy after age 30
C. Annual digital examination after age 40
D. Barium enema after age 20
Correct Answer: C
Reason: The American Cancer Society recommends an annual digital examination after age 40 for the purpose of detecting colorectal cancer. The CEA test is performed on clients who have already been treated for colorectal cancer. It helps monitor a client's response to treatment as well as detect metastasis or recurrence. Proctosigmoidoscopy is recommended every 3 to 5 years for people older than age 50. Barium enema isn't a screening test.
A. Class I.
B. Class II.
C. Class III.
D. Class IV.
Correct Answer: B
Reason: According to the New York Heart Association Cardiac Disease classification, this client would fit under Class II because she is symptomatic with increased activity (dyspnea with exertion). The New York Heart Association Cardiac Disease Classification identifies Class II clients as having cardiac disease and a slight limitation in physical activity. When physical activity occurs, the client may experience angina, difficulty breathing, palpations, and fatigue. All of the client's other symptoms are within normal limits.
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