A nurse is caring for a client who was admitted for acute alcohol delirium withdrawal 2 days ago. Which of the following findings is associated with this
... [Show More] diagnosis?
A. Increased appetite
B. Elevated Temperature
C. Bradycardia
D. Drowsiness
Elevated Temperature
Rationale: The content of this question emphasizes the concept of client-centered care through identifying findings associated with a client's diagnosis. Client-centered care focuses on the client and emphasizes the client's cultural, ethnic, and social values. The identification of expected and unexpected findings associated with a client's diagnosis assists the nurse to distinguish possible unrelated complications the client might be experiencing, which indicates the need for further investigation. The specific focus on the client enhances the provision of safe, quality nursing care. An elevated temperature is a finding associated with acute alcohol delirium.
A nurse working in a hospice facility is talking to a client's son who is distressed because his mother cries frequently and says she wants to die. Which of the following responses by the nurse is appropriate?
A. "I know this must be difficult, but your mother will calm down soon."
B. "Lets discuss some strategies you can use when this happens again."
C. Individuals near death are ready to let go toward the end."
D. "Have you determined why she is crying and saying she is ready to die?"
" Let's discuss some strategies you can use when this happens again."
Rationale: This response by the nurse offers to provide information, which can reduce anxiety and enhance decision making. This response creates a safe environment, fosters trust and respect, and is appropriate.
A nurse is caring for a client who had cerebrovascular accident 2 days ago. Which of the following is the first sign of increased intracranial pressure (ICP)?
A. pupil dilation
B. Ataxia
C. Lethargy
D Bradycardia
Lethargy
rationale: Lethargy occurs when pressure is placed on the reticular activating system within the brainstem. Along with other indicators of a change in level of consciousness, such as restlessness, irritability, and disorientation. Lethargy is the first sign of increased ICP.
A nurse working in a provider's office is reinforcing teaching with a client who is 14 weeks of gestation. The nurse should instruct the client to immediately notify the provider if she experiences which of the following?
A. facial edema
b. urinary frequency
c. acid indigestion
d. breast leakage
Facial edema
rationale: facial edema is an indication of pregnancy-induced hypertension and should be reported immediately to the provider.
A nurse is caring for a client who is receiving parenteral nutrition through a nontunneled central venous catheter and reports hearing a gurgling sound on the side of the catheter. The nurse suspects the catheter has migrated to the jugular vein. Which of the following actions should the nurse take first?
A. Notify the provider
B. Obtain a chest x-ray
C. Flush the catheter.
D. Stop the infusion.
Stop the infusion
Rationale: This prevents further damage to vessel and minimizes any additional harm to the client
A nurse is reinforcing teaching with a caregiver who has aphasia. The nurse should include which of the following communication strategies in the teaching?
A. Cue the client by providing picture cards that portray common needs.
B. Increase the volume of the voice when speaking to a client.
C. Encourage the client to limit hand gestures when communicating.
D. Vary the use of phrases and terminology in discussions.
Cue the client by providing picture cards that portray common needs.
Rationale: Using picture cards enhances communication. The nurse should include this communication strategy in the teaching.
A nurse is caring for a client who has a urinary tract infection and is prescribed ciprofloxacin (Cipro). The client exhibits urticaria and angioedema following administration of the medication. Which of the following is the first action the nurse should take?
A. Administer epinephrine (Adrenaline)
B. Elevate the lower extremities
C. Determine respiratory status
D. Apply oxygen via non-rebreather mask.
Determine respiratory status
Rationale: The client is experiencing angioedema indicating a possible anaphylactic reaction, which is life-threatening; therefore, the nurse should first determine the client's respiratory status.
A nurse is caring for a client who has an acid-base imbalance. For which of the following manifestations is metabolic alkalosis a possible complications?
A. Hyperkalemia
B. Severe diarrhea
C. Atelectasis
D. Excessive vomiting
Excessive vomiting
rationale: Metabolic alkalosis is a potential complication of excessive vomiting because of loss of acid from the body.
A nurse is caring for neonate who was delivered at 30 weeks of gestation after his mother received two injections of betamethasone (Celestone). because of administration of betamethasone to the client's mother, the nurse should monitor the neonate for which of the following effects?
A. Tachycardia
B. Sternal retractions
C. Hypoglycemia
D. Hypothermia
hypoglycemia
rationale: Betamethasone is a glucocorticoid used in the prevention of respiratory distress syndrome in premature infants. Betamethasone causes hyperglycemia in the mother, which predisposes the neonate to hypoglycemia in the first hours after delivery.
A nurse is reinforcing teaching about client consent to treatment with a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates a need for further teaching?
A. "It is necessary to have written consent for invasive procedures"
B. "Implied consent is appropriate for some aspects of nursing care"
C. It is the responsibility of the provider to obtain express consent"
D. "Informed consent should be obtained separately for each surgical procedure"
" It is the responsibility of the provider to obtain express consent"
rationale: Nurses frequently obtain express consent by witnessing a client sign a consent form after ensuring the client has received and understands necessary information regarding the procedure. This is not an appropriate statement by a newly licensed nurse and requires further teaching.
A nurse is caring for an adult client who has attempted suicide. The client tells the nurse he is calling his family to come pick him up. Which of the following actions by the nurse is appropriate when the client insists on leaving the facility against medical advice?
A. assign a security guard to stay at the client's door.
B. request a prescription from the provider for soft restraints.
C. discuss the risks associated with leaving with the client
D. remove the telephone from the client's room
discuss the risks associated with leaving with the client
rationale: Discussing risks associated with leaving is priority concern. The client should be made aware of potential negative outcomes that could occur if he chooses to leave the facility prior to physician prescribed discharge.
A nurse is caring for a child who has leukemia and is prescribed a transfusion of platelets. Which of the following should the client experience as a result of the transfusion?
A. reduced bleeding time
B. decreased plasma globulins
C. improved activity tolerance
D. increased immune functioning
Reduced bleeding time
rationale: Platelets are responsible for triggering the process of blood clotting. Clients who have leukemia are prone to bleeding because of low platelet counts and should experience a reduced bleeding time as a result of a transfusion of platelets.
A nurse working in a provider's office is reinforcing teaching with a client who is 36 weeks of gestation and has experienced a premature rupture of membranes. Which of the following statements by the client indicates a need for additional teaching?
A. "I will have my husband wear a condom during intercourse."
B. " I will check my temperature every 4 hours."
C. I will wipe rom front to back after bowel movements"
D. "I will notify my doctor if my baby moves fewer than 4 times in the 2 hour following each meal."
" I will have my husband wear a condom during intercourse"
rationale: The client who has experienced a premature rupture of membranes should not engage in sexual activity or insert anything in the vagina because of increased risk for infection.
A nurse is caring for a school-age child who is newly diagnosed with type 1 diabetes mellitus. Which of the following actions by the nurse is appropriate to prepare the child for administration of insulin?
A. Provide a toy doctor's kit to play with.
B. Keep all syringes and needles out of sight until needed.
C. Use an approach that is firm but direct.
D. Allow the child to manipulate the medical equipment.
allow the child to manipulate the medical equipment
rationale: Allowing the child to manipulate the equipment facilitates mastery and gives the child a sense of accomplishment. This action is appropriate when preparing a school-age child for a procedure.
A nurse has assigned four tasks to an assistive personnel. Which of the following should the nurse instruct the AP to perform first?
A. take an ABG specimen to the lab.
B. Transport a client to the radiology department for an xray.
C obtain a clean catch urine sample for a newly admitted client
D pass fresh water to clients
Take an ABG specimen to the lab
rationale: ABG samples are kept on ice and should be transported immediately to the lab or the specimen will deteriorate.
A nurse is caring for a client who is diabetic and is being discharged home following and above the knee amputation. which of the following health care professionals should be involved in the interdisciplinary team meeting? select all that apply.
a. dietician
b. physical therapist
c. hospice nurse
d social worker
e respiratory therapist
dietician
physical therapist
social worker
A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). Which of the following statements by the client indicates an understanding of the teaching?
A."I will only be on this medication for 4-6 months because it can lead to physical dependence"
B. I can have 1-2 alcoholic beverages each week
C I will need to stop taking Xanax 2 weeks before beginning this medication
D I can have 6-8 ounces of grapefruit juice each day
"I can have 1-2 alcoholic beverages each week"
rationale: this medication does not interfere with CNS depressants such as alcohol
A charge nurse on ped unit is making assignments for a nurse who has floated from labor and delivery unit. Which of the following clients is appropriate for charge nurse to assign.
A. A preschooler with a hip spica cast who is being discharged today
B. an infant scheduled for a surgical repair of ventricular septal defect tomorrow
C. a toddler with a fractured femur who has been in Bryants for 5 days
D an adolescent who is 2 days post op following an appendectomy.
An adolescent who is 2 days post op following an appendectomy
rationale: The care require fundamental nursing skills and knowledge
A nurse at a long term care facility is participating in quality improvement project to reduce occurrence of pressure ulcers. Which of the following audits should be conducted to determine the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile?
a. prospective audit
b. outcome audit
c. process audit
d. structure audit
outcome audit
rationale: An outcome audit is conducted to determine the actual result a specific nursing intervention has had on client outcomes. This type of audit is appropriate to use when determining the impact of a new skincare regimen on the incidence of pressure ulcers among clients who are immobile.
A nurse is caring for a child who is 24 hr. postoperative following a supratentorial craniotomy. the nurse should maintain the child in which of the following positions?
A. Prone with head of bed flat
B. Dorsal recumbent with head of bed elevated to 15 degrees
C. supine with head of bed elevated to 30 degrees
D side lying with head of bed elevated to 45 degrees.
Supine with hob elevated 30 degrees
rationale: this position facilitates drainage of cerebrospinal fluid and prevents hemorrhage by reducing blood flow to the brain.
A nurse is caring for a client who is 48 hour post op following an abdominal aortic aneurysm resection. Which of the following findings is the most urgent?
A. Absent bowel sounds
B. Serum BUN level 22 mg/dl
C. Absent dorsalis pedis pulses
D. Serum Creatinine level of 1.3.
Absent dorsalis Pedis Pulse
rationale: Absence of this pulse indicates that a graft occlusion following an abdominal aortic aneurysm repair is blocking circulation.
A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern?
A. Promoting oxygenation
B. Management of pain
C. Maintaining hydration
D. Preventing infection
Promoting oxygen
Rationale: Short-term oxygen therapy is used to prevent additional sickling and hypoxia. Massive systemic sickling has been linked to severe hypoxia and can be fatal. Rest should be encouraged to decrease expenditure of oxygen and energy.
A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first?
A. A client who has COPD with an oxygenation saturation of 90%.
B. A client who has diabetes mellitus with a hbA1C of 9%
C A client who has heart failure with 2+ pitting edema of lower extremities
D. A client who has a fever of 38.4 Celsius (101.2) with tenderness in RLQ
A client who has a fever of 38.4 (101.2) with tenderness in RLQ
rationale: This indicates possible appendicitis.
A nurse is caring for a client who has a compound fracture of the tibia and fibula and is skin traction. The client reports pain of 6 on a scale of 0-10 under the traction bandage. Which of the following actions should the nurse take?
A. Administer an analgesic.
B. Assist the client to shift positions.
C. Check pedal Pulse.
D. Distract the client with music therapy.
Check pedal Pulse
Rationale: Pressure on peroneal nerve can occur when skin traction is applied to lower extremities which can result in foot drop.
Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first?
A. Bathe a client who is scheduled for physical therapy at 9 am.
B. Perform fingersticks for glucose levels on a client who have diabetes.
C. Stock procedure rooms.
D. Distribute clean linens.
Perform fingersticks on clients with diabetes mellitus.
Rationale: To attain accurate readings, these levels should be attained prior to eating breakfast.
A nurse is caring for a group of pediatric clients. Which of the following clients requires immediate intervention?
A. A client who has cystic fibrosis and has a paroxysmal cough.
B. A client who is prescribed cromolyn sodium (Crolum) and has a peak expiratory flow rate of 79%.
C. A client who has celiac disease and abdominal distention.
D. A client who is prescribed digoxin (Lanoxin) and has 3 episodes of vomiting.
A client who is prescribed digoxin (Lanoxin) and has 3 episodes of vomiting.
Rationale: Vomiting, slow heart rate, and anorexia are clinical findings associated with digoxin toxicity which is an acute condition.
A nurse is caring for a client who has radial head fracture. Which of the following should be the priority action by the nurse following application of the cast?
A. Promote adequate intake of calcium.
B. Evaluate neurovascular status.
C. Elevate the extremity above the heart.
D. Apply ice intermittently for the first 24 hours.
Evaluate neurovascular status
Rationale: neurovascular compromise is a manifestation of compartment syndrome and must be detected in early stages to avoid permanent damage.
A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first?
A. Evaluate level of consciousness.
B. Place client on bed rest.
C. Encourage increased fluid intake.
D. Initiate continuous ECG monitoring.
Evaluate level of consciousness
Rationale: A change in level of consciousness is earliest manifestation of fat embolism syndrome.
A nurse in a provider's office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurse's priority concern?
A. A client who is 26 weeks of gestation and reporting leukorrhea.
B. A client who is 10 weeks of gestation and reporting urinary frequency.
C. A client who is 37 weeks of gestation and reporting perineal discomfort.
D. A client who is 34 weeks of gestation and reporting abdominal tenderness
A client who is 34 weeks of gestation and reporting abdominal tenderness
Rationale: Abdominal or uterine tenderness is an early clinical finding associated with abruption placenta, which could lead to an unstable status.
A school nurse is reinforcing teaching regarding bicycle safety to a group of school age children. Which of the following is the most important concept to include in the teaching?
A. Place proper lights and reflectors on the bicycle.
B. Use a properly fitted bicycle helmet.
C. wear light colored clothing at night.
D. use hand signals when turing.
Use a properly fitted bicycle helmet
Rationale: this should always be worn to prevent head injuries.
A nurse is caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first?
A. administer an anti-anxiety medication
B. Take the client to a place of seclusion.
C. Obtain an order for soft wrist restraints.
D. Engage the client in physical activity.
Engage the client in physical activity
Rationale: Gross motor activities can reduce tension and lower anxiety levels.
A nurse has been assigned to care for four clients on a med surg floor. Which of the following clients should the nurse evaluate first?
A. A client 48 hours following abdominal surgery with redness and swelling at the edges of the incision.
B. A client following knee replacement surgery complaining of pain and warmth in the calf.
C. A client admitted with cholecystitis who reports frequent nausea and vomiting
D. A client admitted with a GI bleed receiving packed RBCs for hemoglobin of 7.8 gm/dL
A client following knee replacement surgery complaining of pain and warmth in the calf
Rationale: Thromboembolism is a potentially serious complication after joint surgeries and pain, warmth and redness are clinical manifestations of thromboembolism which can lead to a pulmonary embolism. [Show Less]