NUR3125 Pearson comp exam Questions & Answers | 2022 UPDATE

The labor and delivery nurse would make it a priority to assess which two newborn body systems immediately after birth? a. Gastrointestinal and hepatic b. Urinary and hematologic c. Neurologic and temperature control d. Respiratory and cardiovascular Rationale: To begin life, the infant must make the adaptations to establish respirations and circulation. These two changes are crucial to life. All other body systems become established over a longer period of time. A primigravida client of 16 weeks' gestation states that she has not yet felt fetal movement. What is the nurse's best response? a. "Your fetus will move any day now. Call me in a week if you don't feel it." b. "Your fetus will begin moving at about 20 weeks' gestation." c. "You should have been feeling the movement already." d. "Your fetus has been moving for the past 9 weeks without you feeling it. You will feel it within a month." Rationale: The embryo’s muscles spontaneously contract beginning at 7 weeks. The mother perceives sensations of movement of the fetus from 16 to 20 weeks’ gestation. A primigravida usually perceives movement closer to 20 weeks. The client experienced an 18-hour labor with a second stage that lasted 2 hours. When the nurse brings the infant into the room 1 hour after delivery, the client tells the nurse to leave the infant in the crib and shows no interest in holding the newborn. The nurse should record which nursing diagnosis in the plan of care? a. Ineffective Individual Coping related to assuming parental role b. Powerlessness related to loss of individual choices c. Fatigue related to prolonged labor d. Anxiety related to feelings of incompetence in parenting role Rationale: Although this client is not demonstrating positive signs of bonding at this time, it is important to look at her history before concluding that she is not bonding well with her infant. This client just experienced a long labor and the influence of fatigue on the attachment process should be considered. It is important to continue to assess infant bonding with this client throughout her hospitalization to reach a nursing judgment based on evidence. A client with a strong family tendency toward hypertension denies he will get high blood pressure because he watches what he eats, gets plenty of exercise, and maintains a normal weight. When implementing the plan of care, the nurse would do which of the following? a. Praise the client and reassure him that these actions will prevent him from becoming hypertensive. b. Emphasize that no matter what he does, the client will eventually develop hypertension because of his family history. c. Recognize the client's efforts towards a healthy lifestyle and emphasis that early detection is essential to prevent complications. d. Recommend that the client request antihypertensive medications prophylactically because of his family history. Rationale: Lifestyle modifications and recognition of risk factors are important parts of prevention of longterm complications. Encouraging the client to maintain his current lifestyle and follow up with health screening would be the best plan of action A mother brings a 3-year-old child to the clinic for a well-child checkup. The child has not been to the clinic since 6 months of age. The nurse determines that which activity is the priority of care for this child? a. Assess growth and development. b. Begin dental care. c. Complete hearing screening. d. Update vaccinations. Rationale: Every time a child enters the health care system, the immunization status should be checked. Some children have uncertain history of immunization because of parental noncompliance or special circumstances such as being refugees. Once immunization status has been determined, the nurse can go on to make routine assessments. Which statement, if made by a client receiving dietary instruction for atherosclerosis, would indicate a need for further discussion? a. "Margarine has less fat than butter, so I will no longer use butter." b. "I will steam, bake, or broil my foods." c. "American cheese has 76 percent fat calories." d. "I will increase my consumption of fruits and vegetables." Rationale: Atherosclerosis indicates the need to adopt a low-fat diet. Both butter and margarine have 4 grams of fat per serving, making the client’s statement incorrect and in need of further clarification. The responses in the other options are correct. The nurse would encourage the new mother to use which breastfeeding position to enable optimal control of the newborn's head while giving the mother a full view of the infant's cheeks and jaw? a. Lying-down position b. Cradle position c. Clutch (football) position d. Across-the-lap position Rationale: The football, or clutch, position provides the mother with more control of the newborn’s head and full view of face. The nurse is teaching a class on newborn care to a group of expectant parents. In explaining why parents need to protect the infant from heat loss, the nurse should discuss which characteristic of the infant's skin that is responsible for heat loss? a. Lanugo b. Nonfunctioning sebaceous glands c. Nonfunctioning apocrine glands d. Thinner skin Rationale: At birth, the infant’s skin is thin with little subcutaneous fat. In addition, the infant has a greater proportion of body surface area relative to the amount of water present in the skin. The nurse caring for a 15-year-old primipara who delivered yesterday identifies this nursing diagnosis: Risk for altered Parenting related to knowledge deficit in newborn care. Which is the most appropriate intervention when planning this client's discharge teaching? a. Have the client watch a video on newborn care. b. Give her information about a support group for adolescent mothers. c. Demonstrate how to care for the newborn and have the client return the demonstration. d. Give the client printed instructions on newborn care. Rationale: Although all of the options may be appropriate, demonstrating newborn care will allow the client to ask questions and gain confidence as she cares for her baby. Having her return the demonstration will allow the nurse to evaluate the teaching. The clinic nurse is conducting health screenings. Which client assessment findings indicate that client teaching is needed about the risk for stroke? Select all that apply. a. Weight 205 lbs and height 5 feet 4 inches b. Blood pressure 164/92 mmHg c. Eats bran for breakfast daily d. Smokes ½ pack of cigarettes per day e. Serum cholesterol level is 172 mg/dL Rationale: • Obesity is a modifiable risk factor for stroke. • Hypertension is a modifiable risk factor for stroke. • Eating a diet containing fiber helps keep cholesterol levels low and is not a risk factor for stroke. • Cigarette smoking is a modifiable risk factor for stroke. • Hypercholesterolemia (cholesterol level greater than 200 mg) would also be a risk factor, but this client’s level is less than 200 mg/dL. The nurse doing health promotion in an ambulatory women's health clinic would plan to teach Kegel exercises to a woman with which condition? a. Menopause b. Uterine prolapse c. Urinary tract infection d. Premenstrual syndrome Rationale: Uterine prolapse is caused by weakened pelvic muscles, which can be strengthened by Kegel exercises. The other conditions are not treated with Kegel exercises. The pregnant client is 7 centimeters, 100% effaced, and at a +1 station. The fetus is in a face presentation. The nurse concludes that teaching has been effective when the client's husband makes which statement? a. "Our baby will come out face first." b. "Our baby will come out facing one hip." c. "Our baby will come out buttocks first." d. "Our baby will come out with the back of the head first." Rationale: Presentation refers to the part of the fetus that is coming through the cervix and birth canal first. Thus a face presentation occurs when the face is coming through first. The nurse would assess a 76-year-old client for which common problem that most increases the risk for major complications of heart and lung disease? a. Taking over-the-counter meds with prescription meds b. Sharing medications with family and friends c. Following directions exactly and taking medications on a regular basis d. Polypharmacy resulting from visits to multiple doctors Rationale: Polypharmacy is using multiple doctors and multiple pharmacies to get the health care needed often from a variety of specialists. The overall problem is that different doctors may not know what other doctors had ordered. Some drugs may interact with others and others may be the same drug in a different form. Overdosing and interactions become more common with this problem. A client who is 20 weeks' gestation is concerned about how to tell her 3-year-old son about her pregnancy. Which statement by the nurse would be best when counseling this client? a. "If he is not pleased with the news of a new baby, you should tell him that you are disappointed in him." b. "Tell him that he is going to have a lot of responsibilities in helping care for the baby." c. "Try to provide extra attention to him and include him in plans for the baby." d. "Tell him that he will have to stay with his grandparents when the baby is born because you will be busy with the baby." Rationale: The child should be included in planning for the new baby. Children may feel threatened by a new sibling and so may need extra time and attention. Parents should avoid putting too much responsibility on the child. The nurse is taking the health history of a 77-year-old man. Which symptom reported by the client would the nurse consider to be the most significant abnormal finding? a. Hesitation and decreased flow of urine stream b. Increased tolerance to spicy foods c. Increased isolating behaviors after his wife's death d. Slight dizziness when getting up too quickly after lying down for a while Rationale: Increasing the process of isolation from others is not a healthy adaptation, although it is common when one spouse dies that the other seems totally lost, especially if used to engaging in activities as a couple rather than singly. The fetal head is determined to be presenting in a position of complete extension. After learning of this, the nurse anticipates which of the following? a. Precipitous labor and delivery b. Prolonged labor and possible cesarean delivery c. Normal labor and spontaneous vaginal delivery d. Forceps-assisted vaginal delivery Rationale: The normal attitude of the fetal head is one of moderate flexion. Changes in fetal attitude, particularly the position of the head, present larger diameters to the maternal pelvis, which contributes to a prolonged and difficult labor and increases the likelihood of cesarean delivery. Based on the highest risks during this period of life, what would be the focus of the nurse who is setting up a health promotion booth for healthy adults in their thirties? a. Screenings for breast, cervical, uterine, and prostate cancers b. Chest x-rays for lung cancer c. Bone density test for osteoporosis d. Safety education for accident prevention Rationale: The greatest risks for healthy adults in their thirties relate to unsafe lifestyle or unhealthy lifestyle behaviors, which may include multiple sexual partners, driving at high speeds, improper diet or erratic dietary patterns, and possibly insufficient sleep. The nurse notes on the antepartal history that the client has an android pelvis. The nurse plans to assess this client carefully because of the increased risk of which of the following? a. Occiput posterior position b. Prolonged labor c. Precipitous delivery d. Developing postpartum complications Rationale: An android pelvic structure is narrow in both the anterior–posterior diameter and the lateral diameter, and can cause a prolonged labor with a large fetus or a malpositioned fetus. After reviewing the client's health history, the nurse concludes that which item is the most significant factor for development of bronchogenic carcinoma for this client? a. Asthma b. Smokeless tobacco c. Cigarette smoking d. Air pollution Rationale: Cigarette smoking is the leading cause of lung cancer. After delivery, a Chinese client states she needs to restore the balance between hot and cold forces in her body and refuses to bathe. What is the most appropriate intervention by the nurse? a. Show her a videotape on postpartum self-care. b. Recognize her cultural beliefs and respect her wishes. c. Discuss postpartum complications related to poor personal hygiene. d. Request a psychiatric consult for this client. Rationale: Chinese clients may perceive an imbalance in the hot and cold forces in the body after delivery. They will avoid sources of cold, such as wind, cold beverages, and water (even if warmed) to regain a sense of balance between these extremes. A client’s culture plays a very important part in who they are, and nurses should respect the client’s wishes as long as it will not result in harm to the client or others. The nurse is teaching a group of adults about health screenings for cancer. The nurse would include which item in the discussion? Select all that apply. a. Genetic screening is helpful in identification of cancer risks. b. Annual medical exams uncover most tumors. c. Men should perform breast and testicular self-exams (BSE, TSE) monthly. d. Annual mammograms are recommended after a total mastectomy. e. Inspection of the skin for cancer becomes less important as one ages. Rationale: • Genetic screening can identify markers for several types of cancer. • Self-exams as well as regular medical tests and exams uncover tumors. • Men need to perform BSE and TSE. One method to remind men to perform self-checks for cancer is to mark a calendar to monthly check for changes. • After a total mastectomy, women do not need mammograms. • Skin cancer risk increases with age. The nurse is leading a support group for adult children of aging parents who have come to live in their home because of deteriorating health. Which principle does the nurse encourage the group members to follow to promote quality of life for all concerned? a. Do as much as possible for aging parents to prevent problems from occurring. b. Allow independence in those things that are safe or with minimal risk of harm. c. Let the parents do whatever they want as a means to maintain their self-esteem. d. Take over responsibility for making important decisions to avoid major financial losses. Rationale: Allowing independence as long as possible gives dignity and self-worth to clients. The nurse concludes that teaching has been effective when the laboring client's partner shouts, "She's crowning!" as which of the following? a. The nurse first starts to see a little of the baby's head. b. The baby's head recedes upward between pushing contractions. c. The perineum is thin and stretching around the occiput. d. The mouth and nose are being suctioned. Rationale: Crowning is the point in time when the perineum is thin and stretching around the fetal head both between and during contractions. Delivery is imminent when crowning occurs. The client is admitted with all of the following orders to treat diabetic ketoacidosis (DKA) with severe metabolic acidosis. Which order would the nurse determine to be the first priority in managing this client? a. Start IV fluid infusion for rehydration. b. Insert an indwelling urinary catheter. c. Administer NPH insulin. d. Initiate continuous pulse oximetry. Rationale: Fluid and electrolyte replacement is the highest priority because dehydration is a key concern in DKA. When assessing the genitourinary system of a 75-year-old male client, the nurse questions the client about symptoms of which condition that is common in older men? a. Testicular cancer b. Benign prostatic hyperplasia c. Testicular torsion d. Gonorrhea Rationale: Benign prostatic hyperplasia (BPH) is the most common disorder of the aging male client. The nurse is caring for a 68-year-old male diagnosed with benign prostatic hyperplasia (BPH). Which statement by the client indicates the need for further teaching? a. “The enlarged prostate gland causes me to get up three times every night to urinate.” b. “The enlarged prostate gland may produce blood in my urine.” c. “I can get urinary tract infections because of the enlarged prostate gland.” d. “I should cut down on the fluids I drink so I won’t have to urinate so often.” Rationale: The client should increase his fluid intake (unless contraindicated) to prevent urinary tract infections and lessen dysuria. Which symptom would the nurse assess for in a child with the most common generalized seizure disorder? a. Periods of inattention and daydreaming b. Sudden loss of muscle tone and falling c. Repetitive small muscle group activity d. Tonic and clonic activity of the extremities Rationale: Tonic-clonic seizures are the most common generalized seizures. The nurse admitting a client with a history of trigeminal neuralgia (tic Douloureux) would question the client about which manifestation? a. Facial droop accompanied by numbness and tingling b. Stabbing pain that occurs with twitching of part of the face c. Aching pain and ptosis of the eyelid d. Burning pain and intermittent facial paralysis Rationale: Trigeminal neuralgia is manifested by spasms of pain that begin suddenly and last anywhere from seconds to minutes. Clients often describe the pain as stabbing or similar to an electric shock. It is accompanied by spasms of facial muscles, which cause closure of the eye and/or twitching of parts of the face or mouth. A client with uncompensated metabolic acidosis is admitted. Which laboratory value would the nurse expect to find in this client? a. pH 7.40; serum potassium 3.8 mEq/L b. pH 7.36; serum potassium 3.1 mEq/ L c. pH 7.2; serum potassium 6.2 mEq/ L d. pH 7.0; serum potassium 5.0 mEq/ L Rationale: A client in metabolic acidosis may also be hyperkalemic. As the hydrogen ions shift from the ECF to the ICF, potassium enters the ECF, leading to an increased serum potassium in addition to the low pH of acidosis. A client of 26 weeks’ gestation experiences a partial placenta abruptio. She asks, “Will this harm my baby?” What should the nurse include in a response? a. It may decrease the amount of nutrients the fetus receives. b. Cause a buildup of urine in the fetus, causing kidney damage. c. Cause the fetus to develop hydrops. d. Cause a fetal anomaly. Rationale: One of the major functions of the placenta is provision of nutrients to the fetus across the placenta membrane. An interference with the placenta circulation, such as abruptio placentae, impairs this ability. A nurse is caring for a client with pneumonia. ABG results are pH 7.49, PaCO2 32 mm Hg, HCO3 - 28 mEq/L, PaO2 89 mm Hg. How should the nurse interpret these results? a. Metabolic acidosis, uncompensated b. Metabolic alkalosis, uncompensated c. Mixed respiratory and metabolic alkalosis, compensated d. Respiratory acidosis, uncompensated Rationale: The pH is elevated, HCO3 - is elevated, and PaCO2 is low. This indicates that there is a mixed respiratory and metabolic alkalosis. A client with acute respiratory distress syndrome (ARDS) shows no improvement despite increases in the concentration of oxygen administered. What intervention should the nurse attempt which may improve ventilation-perfusion matching? a. Transfusion of packed red blood cells b. Infusion of albumin c. Positioning supine with head elevated 30 to 45 degrees d. Prone positioning Rationale: Placing the client with ARDS in a prone position allows for expansion of the posterior chest wall, which may be effective in enhancing oxygenation The nurse would place highest priority on which nursing intervention when planning to prevent atelectasis in the newly admitted postoperative client? a. Hourly coughing and deep breathing b. Assisting the client out of bed c. Administration of bronchodilators d. Supplemental oxygen Rationale: Frequent coughing and deep breathing is an easy maneuver that has great benefit to optimize ventilation in the postoperative client. A 76-year-old woman visits the ambulatory clinic with reports of having difficulty reading and doing needlework due to visual distortions with blurring of images directly in the line of vision. The peripheral vision assessment by the nurse yields normal findings. The nurse suspects that this client is experiencing which visual problem? a. Glaucoma b. Detached retina c. Cataracts d. Macular degeneration Rationale: Visual difficulty caused by distortions and impairment of central vision is common with macular degeneration. Peripheral vision in most cases is normal. An adult client arrives at the emergency department reporting chest pain and shortness of breath. The nurse concludes that which item, if present in the client’s history, could indicate the pain may be related to cardiac disease? Select all that apply. a. History of diabetes and smoking b. Recent travel out of the country c. The pain increases with activity d. The pain is reproducible when taking a deep breath e. The client is experiencing sweating and nausea when the pain is severe Rationale: • Knowledge of the cardiovascular disease risk factors and associated symptoms can assist in determining the origin of chest pain and direct the nurse to prioritize and implement appropriate care. Diabetes, smoking, and hypertension are known modifiable risk factors to cardiac disease. • Travel out of the country is an unrelated factor. • Chest pain that occurs during activity may indicate cardiac ischemia due to the increased oxygen demand. • Chest pain that increases with breathing, especially taking a deep breath, is most likely pleuritic pain. Associated symptoms of nausea and diaphoresis are known warning signs of cardiac ischemia As part of the ongoing assessment of a client who has an electrical burn, a complete blood count (CBC), electrolyte panel, and renal panel were ordered. The nurse would expect to find which result? a. Potassium level of 5.9 mEq/L b. Potassium level of 2.8 mEq/L c. Hematocrit of 28 mg/dL d. White blood cell count of 4000/mm3 Rationale: After burn injuries, an elevated potassium level (normal 3.5–5.1 mEq) is expected because of cellular tissue damage with release of intracellular potassium into the bloodstream. A parent asks the nurse what to do with rough edges of her child’s cast, which are beginning to cause excoriation on the child’s skin. Which response by the nurse describes the appropriate action to take? a. “Perform good skin care to the skin around the cast edges, with a protective barrier like petrolatum jelly.” b. “Call the physician to have the rough edges of the cast cut away.” c. “Tape a soft towel to the edge of the cast to provide some protection from the rough edges.” d. “Petal the cast edges with strips of adhesive tape, placing the tape from just inside the cast over the edge to outside the cast.” Rationale: When a cast is dry, edges that are not smooth or covered by a piece of stockinette should be covered to prevent skin irritation. This can be done by petaling the cast edges with strips of adhesive tape, beginning each strip on the inside of the cast, and folding over the edge to the outside of the cast. The nurse determines that which of the following would be the highest priority action when caring for a client who has alcohol-withdrawal delirium? a. Reality orientation b. Restraint application c. Referral to Alcoholics Anonymous. d. Replacement of fluids and electrolytes. Rationale: When intervening in delirium, highest priority is given to nursing interventions that will maintain life. Fluid and electrolyte loss caused by nausea and vomiting can be a lifethreatening condition during alcohol withdrawal, requiring replacement by intravenous therapy. A child is admitted to the nursing unit with acute renal failure (ARF). When reviewing the nursing history, the nurse notes a history of all of the following health problems. The nurse concludes that which item in the child’s history most likely precipitated the onset of ARF? a. Chickenpox b. Influenza c. Dehydration d. Hypervolemia Rationale: Dehydration results in hypovolemia, which can precipitate acute renal failure in infants and children. The surgical unit nurse would implement which most important measure for a client on the first postoperative day after repair of an abdominal aneurysm? a. Administer anticoagulant therapy. b. Position the legs in Trendelenburg position. c. Apply elastic stockings to both legs. d. Palpate peripheral pulses every 2 to 4 hours. Rationale: Pulses are assessed frequently to ensure adequate circulation is present and an occlusion or leakage of the graft has not occurred. Pulses should be marked preoperatively so the nurse has a comparison point postoperatively. Pulses may be absent for a short-term postoperatively due to vasospasm or hypothermia. Which item should the nurse discuss when teaching home care measures to the parents of a child who has bilateral bacterial conjunctivitis? a. Use of warm, moist, disposable compresses to remove crusting b. Use of oral antihistamine medication to relieve eye itching c. Use of ophthalmic corticosteroids to decrease inflammatory response d. Use of topical anesthetics applied to relieve discomfort Rationale: Crusting of dried exudate is common with bacterial conjunctivitis and it is important for the child’s vision and safety that the crusts are removed. Warm, moist wipes aid in comfort and they need to be disposable to reduce the risk of transmitting the infection to others in the home. An 18-year-old client is seen in the emergency department with sudden onset of severe scrotal pain, nausea, and an absent cremasteric reflex. The nurse should suspect onset of which condition? a. Hydrocele b. Prostatitis c. Varicocele d. Testicular torsion Rationale: Severe scrotal pain, nausea, and absent cremasteric reflex are characteristic of testicular torsion. A client admitted with exacerbation of chronic obstructive pulmonary disease (COPD) has a respiratory rate of 18, a dry cough, and arterial blood gases that reveal a pH of 7.29, CO2 of 50 mm Hg, and O2 of 72 mm Hg. The nurse identifies which nursing diagnosis as the priority? a. Impaired Gas Exchange b. Activity Intolerance c. Risk for Infection related to impaired respiratory defenses d. Ineffective Breathing Pattern Rationale: All of these nursing diagnoses are appropriate for the client with COPD; however, the primary alteration is related to impaired gas exchange because of the abnormal blood gas results. The breathing pattern is satisfactory because the rate is within normal limits, and there is no data to support activity intolerance, although it is plausible. The client is at risk for infection but actual problems take priority over potential ones. A 28-year-old female client has recently been diagnosed with systemic lupus erythematosus (SLE). Which approach by the nurse would be most helpful for the overall management of care? a. Have the client institute advance directives immediately. b. Discuss with the client lifestyle modifications that will be needed as the disease progresses. c. Ascertain information about the client’s working environment and suggest limiting work schedule to minimize potential stress. d. Establish the multidisciplinary health care team to help client identify goals. Rationale: A client who receives a diagnosis of SLE will be profoundly affected by the chronic nature of this autoimmune disease process. The establishment of a health care team using a multidisciplinary approach will help the client to identify and realize individual goals. The nurse believes a client has slight one-sided weakness and further tests muscle strength. The nurse asks the client to hold the arms up with hands supinated, as if holding a tray, and then asks the client to close the eyes. The client’s right hand moves downward slightly and turns. The nurse documents and reports that the client has which assessment finding? a. Pronator drift b. Nystagmus c. Hyperreflexia d. Ataxia Rationale: Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. During a scheduled exam the client’s glycosylated hemoglobin was found to be 9%. The client has had diabetes mellitus for 3 years. What should the nurse do at this time? a. Explore the client’s general dietary pattern for the past 4 months. b. Assess for signs of infection and client’s intake for the past 24 hours. c. Review the client’s understanding of diabetic foot care. d. Immediately give sliding scale insulin medication. Rationale: Glycosylated hemoglobin is elevated due to long-term hyperglycemia. Values greater than 8 percent indicate consistently poor control of blood glucose and the need to assess the client’s dietary pattern for the past several months in relation to the treatment plan. Which statement indicates that a client understands appropriate information about premenstrual syndrome (PMS)? a. “I have PMS all month long.” b. “My husband says if we had sex more often it would help my PMS.” c. “PMS starts about 10 days before my period.” d. “I should drink more coffee when I have PMS.” Rationale: PMS occurs only during the luteal phase of the menstrual cycle (7 to 10 days before menstrual flow begins). A 9-year-old child is being treated with methimazole (Tapazole) for Graves’ disease. She has not responded to the drug therapy as quickly as expected so a thyroidectomy is being considered. The child’s mother asks the nurse, “Why would the physician seem hesitant to encourage the surgery?” Which response by the nurse is best? a. “The surgery will leave a scar on the child’s neck and will cause problems with her self-esteem.” b. “Removal of the thyroid gland may result in permanent hypothyroidism, which will require lifelong hormone replacement therapy.” c. “The convalescent time for this surgery is 6 months.” d. “Removal of the thyroid gland causes a change in thermoregulation.” Rationale: The thyroidectomy is the third alternative treatment used when medication and iodinebased radiation therapy are unsuccessful. There is a great concern of causing hypothyroidism in the client. The other statements are not reflective of the underlying concern with performing a thyroidectomy in a child. The nurse concludes that the outcome of “restore tissue integrity” has been met in a client with a venous stasis ulcer after noting which evidence? a. Absence of bleeding b. No reports of pain c. Increased activity tolerance d. No signs of inflammation or infection Rationale: A goal of venous ulcer care is for the client to experience no signs of inflammation or infection. This is the goal directly related to tissue integrity. A child diagnosed with deficiency of growth hormone who needs replacement drug therapy comes to the clinic for treatment. Which nursing diagnosis would be most appropriate for this client? a. Imbalanced Nutrition: More Than Body Requirements b. Disturbed Body Image c. Diversional Activity Deficit d. Decreased Cardiac Output Rationale: Children with growth hormone deficiency are smaller than their peers and frequently experience problems with self-esteem and body image. While assessing the chest tube drainage system of a client, the nurse observes a slight rise and fall in the water level in the water seal. The nurse should take which action? a. Notify the physician immediately. b. Have the client cough. c. Continue to monitor the system. d. Reposition the chest tube. Rationale: The movement of the fluid, also referred to as tidaling, in the water indicates normal lung expansion and requires only continued monitoring. A 3-month-old infant is diagnosed with leukemia. Which of the following does the nurse anticipate will be part of the plan of care for this infant? a. The baby will be placed in isolation. b. Leukemia is familial and other children should be assessed. c. Immunizations will be withheld during exacerbations. d. The baby will be NPO during chemotherapy. Rationale: Immunizations should be withheld during leukemia exacerbations because the immune system is compromised and the client cannot manage an appropriate response to the immunization. To decrease skin irritation in children with the condition shown, the nurse instructs the parents do which of the following? a. Take very warm baths (not showers) daily b. Liberally apply a lotion of choice over entire body c. Use fabric softener for all clothes d. Use mild soap as needed Rationale: The illustration shows the typical appearance of skin that has eczema. Use of a mild soap such as Dove® or Tone® prevents the skin from becoming excessively dry. The nurse is taking a nursing history from the mother of a child being admitted with flare-up of celiac disease. What piece of information would the nurse expect the mother to report? a. Steatorrhea b. Increased appetite c. Cheerful behavior d. Soft, formed stools Rationale: Acute episodes are characterized by bulky, frothy stools and steatorrhea because of malabsorption, anorexia, and irritability. The mother of an infant who underwent surgery to repair hypospadias asks the nurse why the infant is double-diapered. The nurse would respond that this method of diapering will help to do which of the following? a. Protect the urinary stent that has been put in place. b. Adequately measure the urinary output. c. Provide for maximum absorption of urine. d. Provide optimal protection of perineal skin from infected urine. Rationale: A double-diapering technique will help to protect a urinary stent following repair of hypospadias or epispadias. The inner diaper collects the infant’s stool, while the outer one collects urine. The nurse would expect to find a diminished pCO2 level in the assigned client who has which physical assessment finding? a. Hyperventilation b. Hypoventilation c. Prolonged expiration d. Stridor Rationale: Carbon dioxide is eliminated from the body as exhaled gas. The faster the rate of breathing, the greater the quantity of carbon dioxide eliminated. A client who has pancreatitis is experiencing pain. After administering an analgesic, the nurse should place the client in which position to promote comfort? a. Supine b. Prone c. Left lateral decubitus d. Sitting up and leaning forward Rationale: The pain in pancreatitis is usually aggravated by lying in a recumbent position, but improved by sitting up and leaning forward or in the fetal position with the knees pulled up to the chest. This position reduces pressure caused by contact of the inflamed pancreas with the posterior abdominal wall. Parents of a 10-year-old boy with mild cerebral palsy ask the nurse about having their son join a Boy Scout troop that meets after school. The boy attends a regular grade school class. The nurse considers which of the following when formulating a response? a. The rigors of most scout events would be physically beyond this child’s capability. b. Scouting can provide children of all abilities with opportunities for recreation and socialization. c. It would be embarrassing for the child to be different from the other boys and lower his selfesteem. d. It is more important that the child conserve his energy for doing schoolwork. Rationale: While work or industry is the primary developmental task of children this age, emphasis should not be placed exclusively on school. Recreational activities are an integral part of growing up, and all efforts should be made to provide access to such programs. A 12-year-old boy with signs of precocious puberty is 5 feet 7 inches tall, has a deep voice, and has started to shave his facial hair. His friends are envious of his height and basketball skills. The boy says he expects to be over 6 feet tall and play basketball professionally. What information will the nurse use when explaining that the client will probably not reach that height? a. Neither of the child’s parents is 6 feet tall. b. The child doesn’t eat enough nutritious food. c. The early presence of sex hormones stimulates closure of the epiphyseal growth plates, resulting in short stature in the future. d. Few children attain heights above 6 feet and become professional basketball stars. Rationale: The premature secretion of testosterone promotes the closure of the epiphyseal growth plates. Many of these children appear very tall around sixth grade, but their friends eventually catch up and surpass them in linear growth. A client presents to the emergency department with a stab wound to the right upper abdominal quadrant. The client’s vital signs are BP 85/60, pulse 125, and respiratory rate of 28 breaths/minute. The nurse should immediately suspect damage to what organ? a. Stomach b. Liver c. Large intestine d. Kidney Rationale: The primary organ in the right upper quadrant of the abdominal cavity is the liver. Because of the early shock symptoms, which are presented, it would be expected that this organ has possibly been lacerated, causing extensive uncontrolled internal bleeding. A school-age child has recently been diagnosed with a seizure disorder. The parents express concern about what will happen if the child has a seizure at school; they are afraid other children will make fun of their child. What response by the nurse would be most helpful? a. The child should always wear a Medic-Alert bracelet. b. The parents should talk with the teacher about how to handle the situation. c. The child should learn about the pathophysiology of seizures so his self-esteem will not be affected. d. The parents should make an appointment with a psychiatrist to talk about their concerns. Rationale: The teacher would be the most aware of the various likely reactions of the classmates and together the parents and teacher can plan strategies to promote acceptance of this child. The nurse would conclude that hypomagnesemia has not resolved if which neuromuscular sign is still present after treatment? a. Paralysis b. Tetany c. Flaccidity d. Decreased reflexes Rationale: Effects of hypomagnesemia, such as tetany, are mainly due to increased neuromuscular responses. The client has undergone hypophysectomy using a transphenoidal approach. While changing the mustache dressing, the nurse notes clear exudate with a pale, yellow colored ring at the edge of the drainage on the dressing. What should the nurse do next? a. Document this as serous drainage and continue to monitor the client. b. Assess for headache and check the glucose level in the drainage. c. Apply an ice pack to the nasal bridge and a large, fluffy dressing. d. Lower the head of the bed to decrease the gravity pressure on the wound. The presence of halo effect indicates CSF. Glucose present in the nasal drainage also suggest that the drainage is CSF. A persistent headache indicates a CSF leak. The physician needs to be informed of these assessment findings & the client must be maintained on bedrest to stop the leak. In a child with acute renal failure, the nurse would help to prevent hyperkalemia by limiting intake of which foods in the diet? a. Potatoes, tomatoes, and oranges. b. Grains, cheese, and citrus fruits. c. Cereals, processed sugars, and wheat. d. Rice, leafy green vegetables, and carbonated beverages. Rationale: Potatoes, tomatoes, and oranges have a high level of potassium content. The others have lesser amounts of potassium in them, when considering the groupings of foods in each option. Which assessment finding would the nurse expect that would be unique to a 5-year-old client who has developmental dysplasia of the hip? a. Asymmetry of gluteal and thigh fat folds b. Positive Ortolani-Barlow maneuver c. Telescoping of the femoral head into the pelvis d. Limited abduction of the affected hip Rationale: All symptoms listed are clinical manifestations of developmental dysplasia of the hip, although the only one that would be found in a 5-year-old would be the telescoping of the femoral head into the pelvis. Other clinical signs in an older child would be lordosis and a waddling gait with a marked limp. A positive Ortolani-Barlow maneuver is found in the infant younger than 2 to 3 months of age. Limited abduction is the sign most often used for an infant older than 3 months, along with asymmetry of thigh and gluteal folds. The nurse observes a sinus rhythm pattern on the cardiac monitor of a client admitted with diarrhea and vomiting. On physical assessment, the nurse is unable to palpate a femoral pulse. The nurse would suspect that the client is demonstrating which of the following? a. Pulseless electrical activity (PEA) b. Ventricular fibrillation c. Asystole d. Ventricular tachycardia Rationale: PEA is associated with what appears to be a normal electrical conduction pattern but there is no mechanical pumping of the myocardium. Which instruction would be appropriate for the nurse to include in the discharge teaching of an adolescent after a spinal fusion? a. No contact sports will be allowed again. b. The adolescent should not bend at the waist. c. Walking is limited to only one half mile per day. d. The adolescent should not climb stairs. Rationale: Activity restrictions should be followed for 6 to 8 months following a spinal fusion. Lying, standing, sitting, walking, normal stair climbing, and gentle swimming are generally allowed following spinal fusion. Bending and twisting at the waist is not recommended, along with lifting more than 10 pounds, household chores such as vacuuming, mowing the lawn, physical education classes, and any sports besides walking. The nurse notices that an elderly nursing home resident has not been eating or drinking as much as usual. Which assessment finding would best indicate the presence of Fluid Volume Deficit? a. Clear lung fields with unlabored respirations b. Tenting and dry, flaky skin c. Increased drowsiness, mild confusion, and concentrated urine d. Hand veins that fill within 3 to 5 seconds of being lowered below the heart Rationale: Mental status changes and concentrated urine are common signs of dehydration in the elderly. Which of the following should be the highest priority of the education plan for a client being treated with medication therapy for a generalized seizure disorder? a. Take medication even if there is no seizure activity. b. Physical dependency may result from extended use of medications. c. Urine may turn pink to brown but is not harmful. d. Therapeutic effects of medications may not be seen for 2 to 3 weeks. Rationale: The client must understand the medication information as a priority item. Following a liver transplant the client is taking prednisone and other medications to prevent organ rejection. The nurse should instruct the client to make it a priority to report which manifestation to the health care provider? a. Moon face b. Diminished pigmentation c. Dysphagia d. Bleeding Rationale: Liver function includes the regulation of blood clotting and corticosteroids can impair wound healing and irritate the GI tract. Thus, the client should be instructed to report signs and symptoms of bleeding. A client has experienced a near-drowning event in salt water. The nurse anticipates that the client may experience which complication of this trauma? a. Heart block b. Renal failure c. Pulmonary edema. d. Respiratory alkalosis. Rationale: Pulmonary edema occurs as a result of fluid shifts caused by the ingestion of the hypertonic salt water. The result is fluid collecting in the interstitial spaces causing pulmonary edema. Hypoxia, hypovolemia, and acidosis occur as a result of near-drowning incidents. The client is admitted with thyroid storm. Assessment reveals: BP 188/102, HR 132 regular, RR 28 full depth and symmetrical, no urine output since admission to the emergency department 3 hours ago, alert, and anxious. What should be the high priority nursing diagnosis for this client? a. Deficient Fluid Volume related to decreased absorption as evidenced by no urine output since admission b. Anxiety related to fear as evidenced by client’s appearance c. Ineffective Breathing Pattern related to increased metabolism as evidenced by RR 28 d. Decreased Cardiac Output related to increased ventricular workload as evidenced by adverse vital signs Rationale: Tachycardia, hypertension, and tachypnea increase stroke volume and tissue demand for oxygen, leading to increased cardiac workload and possible heart failure. A client with venous stasis ulcers is being treated with an Unna boot. The nurse should include which additional interventions in the plan of care? Select all that apply. a. Assessment of peripheral pulses b. Keeping legs dependent for pain relief c. Wet to dry dressings to ulcer twice daily d. Standing as much as possible e. Elevating the legs as able Rationale: • Pulses are assessed to ensure adequate circulation with the rigid compression of the Unna boot. • Dependent position is not necessary to provide comfort. • The Unna boot is a rigid dressing that is changed every 1 to 2 weeks. • Excessive standing uses gravity to impede blood return and is not effective. • Elevating the legs helps promote venous return and is a generally helpful circulatory measure. A mother calls a clinic nurse to state that her child brought home a letter from school stating she should examine her child for nits from pediculosis capitis. She asks where she should look for these nits. What areas should the nurse tell the mother to examine? a. The forehead and scalp b. In the webs of the fingers c. The hair shafts at the nape of the neck d. In the folds of elbows Rationale: Pediculosis capitis is head lice. The nits (eggs) are usually found at the nape of the neck or behind the ears. Head lice do not move away from the scalp to lay eggs; therefore, other choices are not appropriate. A 4-year-old child has been exposed to chickenpox. After providing information about chickenpox, the nurse asks the mother to repeat back the information. Which response by the mother indicates a need for additional information? a. “During the prodromal period, my child will have pox all over his body.” b. “Chickenpox is a viral infection that can be spread to other children.” c. “I should monitor my child for Reye syndrome, which is a complication of chickenpox.” d. “My child should not visit my pregnant sister at this time.” Rationale: The prodromal period refers to the period of time between the initial symptoms and the presence of the full-blown disease. The rash would not be apparent during this time. A postoperative client who has an order for heparin 5000 units SubQ for three doses wants to know why this drug is being ordered. What information would the nurse provide to the client to best answer the question? a. “Heparin is used as a common medication in many clients who have surgery.” b. “Heparin is essential during the postoperative period to maintain adequate blood clotting levels.” c. “The injections will be given in the abdomen and are not usually associated with discomfort.” d. “Heparin is being used to prevent blood clots from forming as a result of surgery or decreased mobility.” Rationale: Low-dose heparin therapy is indicated in many postoperative clients who are immobilized to prevent the development of thromboembolic episodes. A nurse is teaching a female client newly diagnosed with Helicobacter pylori infection. The nurse anticipates that which medication will not be used after learning the client is pregnant? a. Metronizadole b. Amoxicillin c. Clarithromycin d. Ciprofloxacin Rationale: Cipro is not recommended for H Pylori infection during pregnancy. The physician has prescribed vitamin D for a client. The client asks the nurse what the medication is for. What is the best response by the nurse? a. “Vitamin D decreases intestinal absorption of calcium and phosphorus and decreases their mobilization from bone.” b. “Vitamin D helps regulate calcium and phosphorus balance.” c. “Vitamin D helps the kidneys rid the body of excess calcium and phosphorus.” d. “Vitamin D decreases blood levels of calcium and phosphorus.” Vitamin D regulates calcium and phosphorus levels by increasing blood levels, increasing intestinal absorption and mobilization from bone, and reducing renal excretion of both elements. The nurse is giving general information about antihypertensive medications to a young female client with a history of hypertension. The nurse includes that which types of antihypertensives should not be used if the client becomes pregnant? a. Vasodilators b. Diuretics c. Angiotensin converting enzyme (ACE) inhibitors d. Calcium channel blockers Rationale: Because ACE inhibitors can cause fetal harm or death, they should be discontinued as soon as pregnancy is detected. Their effect on breastfeeding infants is unknown. A client has been admitted to the hospital with chest pain. The pain has not been relieved after one dose of nitroglycerine (NTG) sublingually. Upon monitoring the vital signs (VS), the nurse notices that the blood pressure has dropped to 126/84 from 130/90. Which action should the nurse take next? a. Notify the physician. b. Obtain an electroencephalogram (EEG). c. Give another dose of nitroglycerine. d. Add a dose of nitroglycerine paste. Rationale: The standard protocol is to administer up to three doses of NTG 5 minutes apart as long as the vital signs remain stable. The nurse is administering nitrogen mustard (Mustargen) and notes swelling at the intravenous (IV) site. The nurse should take which action initially? a. Continue with infusion after trying to aspirate for a blood return. b. Stop administration and attempt to aspirate. c. Flush the line with saline. d. Obtain a new site for drug administration. Rationale: The question indicates that extravasation may be occurring. Prompt nursing action in general will minimize tissue damage; therefore nursing actions should be initially directed towards the suspicious site. The drug administration should be stopped, since failure to do so will further disperse drug into the tissue Which statement made by a client receiving ophthalmic corticosteroids indicates a need for further teaching? a. “I remove my contact lenses before instilling the medication, then put them back in after 30 minutes.” b. “I am not wearing my contact lenses for the duration of the corticosteroid treatment.” c. “I will take my medication for the length of time prescribed by my physician.” d. “I will return to my physician to have my eyes examined after my treatment is completed.” Rationale: Clients receiving ophthalmic corticosteroids have an increased risk of infection. Contact lenses should not be used during ophthalmic corticosteroid therapy. The nurse should question an order for which beta agonist used to treat respiratory disease in a client with a history of atrial fibrillation accompanied by intermittent heart rates of 100/minute or greater? a. Terbutaline (Brethine) b. Pirbuterol (Maxair) c. Isoproterenol (Isuprel) d. Metaproterenol (Alupent) Rationale: Isoproterenol stimulates beta 1 and beta 2 receptors and therefore is contraindicated and should not be used with clients with tachydysrhythmias. The nurse assesses the results of a vancomycin (Vancocin) blood level drawn just prior to the next scheduled intravenous (IV) dose. The nurse would decide to collaborate with the prescriber after drawing which conclusion about the result? a. There is a high serum level, indicating the peak level is too high. b. This test measures the highest therapeutic concentration and it is low. c. Toxicity is evident, suggesting the drug’s half-life is too short with the frequency prescribed. d. The drug level is low, indicating the drug dosage and/or frequency should be increased. A serum specimen for peak level is drawn 15 to 30 minutes after IV administration to test for toxicity. Trough drug levels measure the lowest circulating drug level, and are drawn just prior to administration of the next IV dose to measure whether minimally satisfactory therapeutic levels are being maintained. The nurse is preparing a client for discharge who will be taking lithium carbonate. Which statement best indicates the client is comfortable with being discharged on a mood-stabilizing medication? a.“I know that if I take my lithium every day I won’t have to come to the hospital again.” b.“Even though I don’t like taking medicine, I will take it daily with meals, and have my blood tests on the days I marked on my calendar. I can do my usual activities, and in a few weeks I won’t feel shaky anymore.” c.“I have a hard time taking this medicine and I don’t like the shaking, but I will take it every day with meals, have my blood tests done, and come back to the clinic next month for my check-up.” d.“I don’t want to take the medicine you will give me, but you said I have to.” Rationale: The correct response is one in which the client is honest, has an understanding of how to take the medication and what the side effects are, and knows that the side effect will subside eventually. In assessing a hospitalized client 1 hour after receiving hydralazine (Apresoline) 20 mg PO, the nurse notes that the BP is 68/42. The client has been taking this medication for several years at home without difficulty. Which factor most likely contributed to this episode of hypotension? a. Dose is excessive for this medication. b. Total intake for the previous 24 hours is 1000 mL. c. Serum potassium is 5.8 mEq/L. d. Heart rate is 145 beats per minute. Rationale: Apresoline is a vasodilator & if the client becomes dehydrated, hypotension will occur. An adult client with diabetes insipidus who has been taking desmopressin (DDAVP) intranasally comes to the clinic for a regularly scheduled appointment. The nurse assesses the client’s mental status and notes some disorientation and behavioral changes. Significant pedal edema is also present. What should be the nurse’s next action? a. Check vital signs and notify the physician. b. Have the client return in the morning for reevaluation. c. Instruct the client to limit salt intake for a few days. d. Suggest that the client change the route of administration to subcutaneous injections. Rationale: Signs of overdosage of desmopressin, an antidiuretic hormone, include blood pressure and pulse elevation, mental status changes, and water and sodium retention. Because the medication therapy needs to be interrupted, the nurse should notify the physician. A client is scheduled for an ophthalmic examination. Before administering the prescribed epinephrine solution, the nurse would assess for which condition? a. Hypotension b. Wide-angle glaucoma c. Angle-closure glaucoma d. Brow ache Rationale: Ophthalmic epinephrine is used to produce mydriasis for ocular examination. Dilation of pupil further constricts ocular fluid outflow, possibly causing an acute attack of glaucoma in a client with narrowangle (angle-closure) glaucoma. A client is experiencing seizure activity. The nurse should prepare to administer which medication according to protocol? a. Selegilene (Eldepryl) b. Diclofenac sodium (Voltaren) c. Phenytoin (Dilantin) d. Sumatriptan (Imitrex) Rationale: Phenytoin is a first-line anticonvulsant medication that is used to control seizure activity. Laboratory test results indicate a client is in the nadir period that follows administration of a chemotherapy drug. Which drug should the nurse avoid administering to this client at this time? a. Acetaminophen (Tylenol) b. Ibuprofen (Motrin) c. Diphenhydramine (Benadryl) d. Guaifenesin (Robitussin) Rationale: Red blood cells, white blood cells, and platelet counts may be decreased during the nadir period following administration of chemotherapy that has hematological toxicity. Medications that inhibit platelet aggregation should be avoided during the nadir period following antineoplastic therapy. Aspirin, ibuprofen, and indomethacin are examples of some of these agents. A client exposed to Mycobacterium tuberculosis starts on chemoprophylaxis. The nurse provides which instruction to the client? a. “You will take a single drug such as isoniazid (INH) by mouth every day for 6 to 12 months.” b. “You will be on at least two drugs effective against the tubercle bacillus for three months.” c. “You will be on combination therapy in order to prevent development of drug resistance.” d. “You will need to learn to give yourself subcutaneous injections.” Rationale: To prevent active tuberculosis after exposure, the client is initiated on a single agent regimen, usually isoniazid (INH). The nurse is making a plan of care for a client who is prescribed fluphenazine (Prolixin) 1 mg daily at bedtime. The nurse will include which intervention that applies to common side effects of the medication? a. Remind him frequently to rise slowly when getting out of bed or from a chair. b. Assess for dizziness or lightheadedness frequently during the day. c. Make sugarless hard candy, gum, and water available during the day. d. Monitor for confusion frequently. Rationale: Dry mouth occurs from the anticholinergic effects seen with fluphenazine, and the client should take measures to reduce this as much as possible. Following injection of a measles-mumps-rubella (MMR) vaccine, the nurse should make a priority assessment for which possible client manifestation? a. Wheezing b. Pain at the site c. Anxiety d. Vomiting Rationale: The nurse should assess for signs and symptoms of hypersensitivity reaction following the administration of all vaccines. Wheezing is a sign of hypersensitivity reaction and warrants immediate further assessment and emergency action to prevent possible death. The nurse is caring for a client who has just been diagnosed with Graves’ disease. Client education regarding medication therapy needs to include which of the following? a. Atropine b. Thyroxine c. Insulin d. Propylthiouracil (PTU) Rationale: Graves’ disease is caused by elevated levels of thyroid hormone. Clients experience tachycardia, nervousness, insomnia, increased heat production, and weight loss. Medication therapy with an agent such as propylthiouracil will help control the disorder. A client presents to the emergency department with inspiratory and expiratory wheezes and intercostal retractions. A diagnosis of acute bronchospasm secondary to acute bronchitis is made. Epinephrine (Bronkaid) is ordered to be given subcutaneously. The nurse would anticipate seeing the intended effect of the medication within how many minutes? a. 1 minute b. 5 minutes c. 10 minutes d. 15 minutes Rationale: Epinephrine is a beta-adrenergic agent that has beta 1-adrenergic action, causing increased heart rate and increased force of myocardial contraction. The results of subcutaneous epinephrine should be seen in 5 minutes. The effects may last up to 4 hours. The nurse would take which action to minimize pain associated with intramuscular (IM) injection of 2 mL of penicillin G benzathine (Bicillin LA) to an adult client? a. Apply cold compress to site after injection. b. Divide the dose and inject half into each deltoid. c. Limit prolonging the time taken to administer the drug by not aspirating. d. Administer the drug deep IM slowly into a large muscle such as the gluteus. Rationale: Administering very thick preparations such as penicillin G with benzathine (Bicillin LA) can be painful. To lessen the pain, IM injection into a larger gluteal muscle should be administered over 12 to 15 seconds to separate the muscle fibers more gradually. The nurse suspects that hepatotoxicity is developing in a dark-skinned client who is on an antibiotic. In what area of the body should the nurse assess for jaundice? a. Palms of the hands or soles of the feet b. Hard palate of oral cavity c. Sclera d. Conjunctivae Rationale: Jaundice in the dark-skinned client can best be observed by assessing the hard palate. A client experiences severe nausea for up to 2 weeks following her chemotherapy treatment. Which statement indicates a need for further instruction on management of nausea? a. “I need to call my doctor if I lose more than 10 percent of my body weight.” b. “I should try to eat bland, chilled foods, and drink liquids separate from my meals.” c. “I need to lie down for an hour after each meal.” d. “I should call the doctor if my nausea does not go away to see if a different anti-emetic could provide better relief.” Rationale: A client at risk for nausea should not lie down for at least 30 minutes after meals to avoid aspiration. A 70-year-old client with chronic obstructive pulmonary disease (COPD) is taking theophylline (Theo-Dur). A blood level is drawn and the result is 25 mg/dL. What explanation by the nurse helps the client understand this lab result? a. “Your dose of theophylline needs to be increased.” b. “Your blood level is low because the dose was based on total body weight instead of lean body weight.” c. “The lab value could be high because of your age. We may have to decrease the dosage of your medication.” d. “I am sure that lab value is incorrect. Theophylline levels are never that high.” Rationale: With increased age, there is an increased sensitivity to xanthines. Also, there could be other disease processes that may lead to this elevated value. The nurse provides discharge instructions to the client taking an antihypertensive medication. The nurse should explain that a hypertensive emergency (crisis) will exist if the diastolic blood pressure (BP) is greater than mm Hg? Provide a numeric response130 Rationale: In hypertensive urgencies, clients present with a systolic BP greater than 240 mm Hg and diastolic BP greater than 120 mm Hg. In hypertensive emergency/crisis, the client’s diastolic BP is greater than 130 mm Hg. The home health care nurse is visiting an elderly client who is taking a prescribed calcium channel blocker. In conducting dietary teaching, the nurse instructs the client that what food is contraindicated to take with a calcium channel blocker? a. Oranges b. Grapefruit c. Bananas d. Grapes Rationale: Calcium channel blockers should be administered with a high-fat meal; grapefruit should be avoided before and after dosing due to its ability to alter drug effects. The nurse should assess carefully a 79-year-old client who has been frequently sedated with haloperidol (Haldol) for signs of which adverse effect? a. Tardive dyskinesia b. Fecal impaction c. Respiratory depression d. Restlessness Rationale: Elderly clients have slower metabolism and elimination of drugs, causing an increased susceptibility to side and adverse effects. Frequent sedation with haloperidol can lead to the development of tardive dyskinesia, an irreversible adverse effect, and requires careful monitoring by the nurse. A client who is receiving intravenous heparin by protocol orders has an activated partial thromboplastin time (APTT) level of 140 seconds (control time is 36 seconds). What is the priority action that the nurse should institute? a. Increase the heparin dose as the APTT level is not therapeutic. Obtain a repeat APTT in 6 hours. b. Stop the heparin therapy for 6 hours, then restart the therapy at the same unit dose and obtain a repeat APTT in 6 hours. c. Stop the heparin therapy for 1 hour. Decrease the rate of infusion per protocol and restart the medication in 1 hour. Obtain a repeat APTT in 2 to 3 hours from the restart of the infusion. d. Obtain an additional APTT in 1 hour and continue to monitor the client. The effectiveness of a heparin protocol is monitored by trending APTT results to ach