HESI/Saunders Online Review for the NCLEX-RN Examination (1 Year) FINAL EXAM

A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse implement in caring for the client? Select all that apply. A) Assessing the radial pulse in the right extremity B) Using the left arm to take blood pressure readings C) Drawing predialysis blood specimens from the left arm D) Assessing the area over the AV fistula for a bruit and thrill each shift E) Placing a pressure dressing over the site after each dialysis treatment F) Administering intravenous (IV) fluids through the venous site of the AV fistula as needed - ANSWERSAnswer(s): A,B,C,D Rationale: Several precautions must be observed to ensure the function of an internal AV fistula. The nurse assesses the fistula, and the distal portion of the extremity, for adequate circulation; checks for a bruit and a thrill by means of auscultation or palpation over the access site; monitors the radial pulse in the extremity; and avoids taking blood pressure readings or drawing blood from the arm with the AV fistula. Venipuncture is avoided in the extremity bearing the AV fistula. Blood is never drawn from the AV fistula, and the AV fistula is not used for the administration of IV fluids. The AV fistula site is not covered with a pressure dressing after dialysis. A nurse is evaluating outcomes for a client with Guillain-Barré syndrome. Which of the following outcomes does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply. A) Normal deep tendon reflexes B) Improved skeletal muscle tone C) Absence of paresthesias in the lower extremities D) Clear sounds in the lower lung fields bilaterally E) Po2 of 85% and Pco2 of 40 mm Hg - ANSWERSAnswer(s): D,E Rationale: Satisfactory respiratory outcomes include clear breath sounds on auscultation, clear mentation, spontaneous breathing, normal vital capacity, and normal arterial blood gases. The ABG results listed here — a Po2 of 85% and a Pco2 of 40 mm Hg — are normal. The presence of normal deep tendon reflexes, improved skeletal muscle tone, and absence of paresthesias in the lower extremities reflect improvement in the symptoms associated with Guillain-Barré but are not specific to a respiratory outcome. A nurse on the telemetry unit is caring for a client who has had a myocardial infarction and is now attached to a cardiac monitor. The nurse, monitoring the client's cardiac rhythm, notes the rhythm depicted in the image. Which of the following nursing actions should the nurse take? (Rhythm is continuous up and down in pic) A) Calling the rapid response team B) Preparing the client for cardioversion C) Asking the client to bear down and cough D) Preparing to administer diltiazem (Cardiazem) - ANSWERSAnswer: A Rationale: This pattern indicates ventricular fibrillation (VF). Clients who have sustained a myocardial infarction are at great risk for VF. With the onset of VF the client feels faint, then immediately loses consciousness and becomes pulseless and apneic. There is no blood pressure, and heart sounds are absent. The goals of treatment are to terminate VF promptly and convert it to an organized rhythm. Because defibrillation is the immediate treatment, the nurse must call the rapid response team and initiate cardiopulmonary resuscitation. The client would not be able to bear down or cough. Cardioversion is a synchronized countershock that may be performed in emergencies for unstable ventricular or supraventricular tachydysrhythmias or electively for stable tachydysrhythmias that are resistant to medical therapies such as the administration of diltiazem (Cardiazem). A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which of the following interventions does the nurse incorporate into the plan to prevent this complication? A) Keeping a fan running in the client's room B) Keeping the linens wrinkle-free under the client C) Limiting bladder catheterization to once every 12 hours D) Avoiding the administration of enemas and rectal suppositories - ANSWERSAnswer: B Rationale: The most frequent causes of autonomic dysreflexia are a distended bladder and impacted feces in the rectum. Straight catheterization should be performed every 4 to 6 hours, and the Foley catheter should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize risk in these areas. A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further instruction? A) "I need to get more fluids and fiber into my diet." B) "I should cut my food into small pieces before I eat." C) "I need to put powder under the vest twice a day to prevent sweating." D) "I have to check the pin sites every day and watch for signs of infection." - ANSWERSAnswer: C Rationale: The client should cleanse the skin under the lambs-wool liner each day to prevent rashes or sores. Powder or lotions should be used only sparingly or not at all because they may cake, resulting in skin irritation. The client should increase intake of fluid and fiber to help prevent constipation. Food should be cut into small pieces to facilitate chewing and swallowing. The client should also use a straw for drinking. The pin sites should be checked daily for signs of infection. A nurse is caring for client with increased intracranial pressure (ICP). In which position should the nurse maintain the client? A) Supine, with the head extended B) Side-lying, with the neck flexed C) Supine, with the head turned to the side D) Head midline and elevated 30 to 45 degrees - ANSWERSAnswer: D Rationale: The client with increased ICP should be positioned with the head in a neutral midline position. It is the responsibility of the nurse to ensure that all those delivering care to the client maintain the proper positioning. The client should avoid flexing or extending the neck or turning the neck side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positioning promotes venous drainage from the cranium to keep ICP down. A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should: A) Assess the clear fluid for protein B) Check the clear fluid for the presence of glucose C) Place cotton balls or dry gauze loosely in the ears D) Use an otoscope to assess the tympanic membrane for rupture - ANSWERSAnswer: B Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because it will separate into bloody and yellow concentric rings on dressing material, a phenomenon referred to as the halo sign. It also tests positive for glucose. CSF does not contain protein. The presence of CSF indicates a disruption in the integrity of the cranium. Therefore inserting cotton balls, gauze, or an otoscope into the ear puts the client at risk for infection. A nurse is caring for a client who has just undergone cardioversion. Which of the following interventions is the nurse's priority after this procedure? A) Administering oxygen B) Monitoring the blood pressure C) Administering antidysrhythmic medications D) Monitoring the client's level of consciousness - ANSWERSAnswer: A Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and detection of dysrhythmias. The priority nursing intervention here is administering oxygen. A client with diabetes mellitus who is scheduled to have blood drawn for determination of the glycosylated hemoglobin (HbA1C) level asks the nurse why the test is necessary if he is performing blood glucose monitoring at home. The nurse tells the client that this test is used specifically to: A) Detect diabetic complications B) Assess long-term glycemic control C) Determine whether the client is at risk for hypoglycemia D) Determine whether the prescribed insulin dosage is adequate - ANSWERSAnswer: B Rationale: The HbA1C reading provides an indication of glycemic control over the preceding 3 months. An HbA1C value of less than 7% indicates good glycemic control. When increases in the blood glucose occur, some glucose molecules attach themselves to red blood cells (RBCs) and remain there for the life of the RBCs. Therefore a high value on this test is correlated with a high blood glucose level, indicating poor long-term control of blood glucose, which often leads to the development of complications in the client with diabetes mellitus. The other options are not purposes for this test. A nurse caring for a client with AIDS is monitoring the client for signs of complications. Which of the following findings would cause the nurse to suspect infection with Pneumocystis jiroveci? Select all that apply. A) Diarrhea B) Tachypnea C) Pedal edema D) Intermittent fever E) Dyspnea when ambulating F) Expectoration of frothy mucus - ANSWERSAnswer(s): B, D, E Rationale: Pneumocystis jiroveci pneumonia is a very common and severe opportunistic infection affecting the client with AIDS. Clinical manifestations include dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia, weight loss, and tachypnea. Persons with advanced disease may exhibit crackles, decreased breath sounds, and cyanosis. Diarrhea and pedal edema are not associated with this infection. Zidovudine (AZT, Retrovir) is prescribed for a client with AIDS. The nurse tells the client that it is important to report back to the clinic as scheduled for follow-up: A) Blood glucose checks B) Blood pressure checks C) Complete blood counts (CBCs) D) Electrocardiographic (ECG) studies - ANSWERSAnswer: C Rationale: Zidovudine is an antiviral medication. Common side effects include agranulocytopenia and anemia. The nurse carefully monitors CBC results for these changes. With early infection or in the client who is asymptomatic, a CBC is usually performed monthly for 3 months, then every 3 months thereafter. In clients with advanced disease, a CBC is usually performed every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. This medication does not affect the blood glucose level, blood pressure, or cardiac status. After a nonimmunocompromised client undergoes a Mantoux test for tuberculosis (TB) infection, an area of induration 6 mm wide develops. The client asks the nurse what this result means. The nurse's best response is: A) "We'll have to repeat the test, because the result is inconclusive." B) "The swollen area is small, so that means your test result is negative." C) "You've been exposed to tuberculosis, so you'll need to have a chest x-ray." D) "You need to get started on medication right away, because you've got tuberculosis." - ANSWERSAnswer: B Rationale: An area of induration of less than 10 mm is considered a negative result. An area of induration (not redness) measuring 10 mm or more in diameter 48 to 72 hours after injection in a client without immunosuppressive disease indicates exposure to and possible infection with TB. A reaction of 5 mm or greater is considered positive in immunocompromised individuals. A positive reaction does not mean that active disease is present but instead indicates exposure to TB or the presence of inactive (dormant) TB. Further testing, including a chest x-ray and sputum culture, would be required if the reaction were positive. A client's arterial blood gases (ABGs) are analyzed: pH 7.49, Paco2 31 mm Hg, Pao2 97 mm Hg, HCO3- 22 mEq/L. Which of the following acid-base disturbances does the nurse identify from these results? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis - ANSWERSAnswer: D Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH greater than 7.45. Respiratory acidosis is present when the Paco2 is greater than 45 mm Hg; respiratory alkalosis is present when the Paco2 is less than 35 mm Hg. Metabolic acidosis is present when the HCO3- is less than 22 mEq/L; metabolic alkalosis is present when the HCO3- is greater than 26 mEq/L. This client's ABG results are consistent with respiratory alkalosis. A client has just been found to have deep vein thrombosis (DVT) of the right leg. Which of the following interventions does the nurse immediately implement? A) Elevating the foot of the bed 6 inches B) Placing ice packs on and under the right leg C) Documenting the need for hourly calf measurements D) Performing passive range-of-motion exercises of the right leg - ANSWERSAnswer: A Rationale: Standard therapy for DVT consists of bed rest, leg elevation, and application of warm, moist heat to the affected leg. Elevation of the legs decreases venous pressure, which in turn relieves edema and pain. The client may have calf measurements prescribed once per shift or once per day, but they would not be obtained hourly. Placing ice packs on and under the right leg is incorrect, because heat, not cold, is usually prescribed. Passive range-of-motion exercises of the right leg would be dangerous to the client because activity after clot formation can cause pulmonary embolus. A nurse provides instruction to a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which statement by the client indicates a need for further instruction? Select all that apply. A) "I should limit activity as much as I possibly can." B) "If I have trouble breathing, I need to call the doctor." C) "I need to drink lots of fluids to keep my mucus thin." D) "I can apply Vaseline to my nose if the oxygen dries it out." E) "I should wear a scarf over my nose and mouth in cold weather." F) "If I get a flu shot, I don't have to worry about being around people with colds." - ANSWERSAnswer(s): A, D, F Rationale: Clients with COPD should be encouraged to keep up their daily activities as much as possible to help prevent muscle wasting and maintain activity tolerance. An occupational therapy consult may be useful in helping the client learn how to perform activities in ways that conserve energy. Oxygen is drying to the membranes of the nose, but the client should apply a water-soluble lubricant (K-Y Jelly) to the inside of the nose to reduce dryness and cracking rather than petroleum jelly (Vaseline), which could be inhaled. Every client with COPD should be encouraged to get a yearly flu vaccination, but because of the increased risk of infection, the client must still avoid crowds and people with infections. The remaining options are appropriate home care measures. A nurse is monitoring the neurological status of a client who underwent craniotomy 3 days ago. Which of the following signs or symptoms would prompt the nurse to notify the surgeon immediately? A) Disorientation to date B) Pupils equal and reactive at 4 mm C) Mild headache relieved by codeine sulfate Incorrect D) Pain with forward flexion of the neck onto the chest - ANSWERSAnswer: D Rationale: One of the complications of cranial surgery is meningitis. Signs of meningeal irritation include nuchal rigidity, which is characterized by a stiff neck and soreness and is especially noticeable when the neck is flexed. Pupils that are equal and reactive at 4 mm are normal. Mild headache relieved by codeine sulfate is an expected finding at this point after craniotomy. Disorientation to date is not the matter of greatest concern when the client has been hospitalized for cranial surgery. A man calls the emergency department and tells the nurse that he sustained a bee sting on his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The nurse tells the client to first: A) Place a cool compress on the sting site B) Apply an antipruritic lotion to the sting site C) Apply a topical corticosteroid to the sting site D) Take an oral antihistamine such as diphenhydramine (Benadryl) - ANSWERSAnswer: A Rationale: Treatment for a bee sting depends on the severity of the reaction. Mild reactions are treated with elevation, cool compresses, antipruritic lotions, and oral antihistamines. Rings, watches, and restrictive clothing are removed. In this situation, there is no information to indicate that the client is experiencing a severe reaction, so the nurse would first tell the client to apply a cool compress to the sting site. More severe reactions are treated with intravenous antihistamines such as diphenhydramine, subcutaneous epinephrine, and corticosteroids. A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should first: A) Ask the client to sign a no-harm contract B) Ask the client to report any suicidal thoughts immediately C) Place the client under suicide precautions with 15-minute checks D) Check the dressings that were placed over the client's wrists in the emergency department - ANSWERSAnswer: D Rationale: The nurse would first assess the physical status of the client. Therefore, the first nursing intervention is to check the dressings that have been placed over the client's wrists. The nurse would also immediately implement one-to-one suicide precautions (not 15-minute checks) for the client who has attempted suicide. The client would be asked to sign a no-harm contract, but this would not be the first action. Asking the client to report any suicidal thoughts immediately is a component of a no-harm contract. A client is receiving parenteral nutrition (PN) solution at 60 mL/hr by means of infusion pump through a subclavian central line. The client calls the nurse and complains of difficulty breathing and chest pain. The nurse notes that the client's pulse rate is increased, the blood pressure has dropped, and oxygen saturation is 89%. Use the number 1 to denote the first action and the number 4 the last. ~ Placing the client in lateral Trendelenburg position on the left side ~ Clamping the PN infusion catheter ~ Obtaining an electrocardiogram (ECG) ~ Notifying the physician - ANSWERSThe correct order is: 1) Clamping the PN infusion catheter 2) Placing the client in lateral Trendelenburg position on the left side 3) Notifying the physician 4) Obtaining an electrocardiogram (ECG)Rationale: One complication of subclavian central line insertion is embolism, air or thrombus. Signs and symptoms include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. On auscultation, the nurse would hear a loud churning sound over the pericardium. If this sign is detected, the PN infusion catheter is immediately clamped and the client placed in a lateral Trendelenburg position on the left side, which helps trap the air in the apex of the ventricle and prevents its ejection into the pulmonary arterial system. The physician would be notified. An ECG may be obtained, but this would not be the immediate action. A nurse is preparing to administer digoxin (Lanoxin) to a client with heart failure. On assessing of the client, the nurse notes an apical pulse rate of 58 beats/min and the client complains of anorexia and nausea. Which action should the nurse take first on the basis of these assessment findings? A) Contacting the physician B) Administering an as-needed antiemetic C) Checking the most recent digoxin level D) Administering the digoxin with an antacid - ANSWERSAnswer: C Rationale: Anorexia and nausea are two of the symptoms most commonly associated with digoxin toxicity. The nurse should withhold the digoxin until the physician has been consulted if the pulse rate is slower than 60 beats/min, because bradycardia is also an indication of digoxin toxicity. The nurse then checks the most recent digoxin level, which will provide additional data to report to the physician — a key follow-up nursing action. The nurse would not administer an antiemetic without further investigating the client's problem. A nurse is assessing a client who has undergone radical neck dissection for the treatment of cancer. The nurse hears this sound when auscultating over the trachea. On the basis of this finding, the priority nursing action is to: A) Contact the physician B) Assess the client's pulse oximetry C) Place the client in a supine position D) Administer a nebulizer treatment with the use of a bronchodilator - ANSWERSAnswer: A Rationale: The sound that the nurse hears is stridor. In the immediate postoperative period, the nurse assesses the client for stridor, a high-pitched musical sound heard on inspiration during auscultation over the trachea. This finding is reported immediately because it indicates airway obstruction. The client is placed in the Fowler position to facilitate breathing and promote comfort. Suctioning is performed to remove secretions that cannot be expectorated by the client. Pulse oximetry may be performed, but this is not the priority of the options provided. Administering a nebulizer treatment with a bronchodilator is not indicated at this time. A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes mellitus who received NPH and regular humulin insulin at 7:30 am. At 11 am the child suddenly complains of dizziness, headache, and a shaky feeling. The nurse immediately: A) Contacts the physician B) Gives the child milk to drink C) Arranges to have the child's lunch tray delivered early D) Prepares to administer intravenous 5% dextrose solution - ANSWERSAnswer: B Rationale: Dizziness, headache, and a shaky feeling are signs of hypoglycemia. A blood glucose reading will confirm the diagnosis and would be the initial action. However, because this is not one of the options, the nurse would give the child milk to drink because of the child's history and current symptoms indicating hypoglycemia. Other items used to treat hypoglycemia include orange juice and hard candy. The nurse would prepare to administer intravenous 5% dextrose solution if the child were not responsive enough to safely take oral fluids, but this is not indicated in the question. Arranging to have the child's lunch tray delivered early is inappropriate because the child should eat meals at basically the same time each day to achieve the best control of the diabetes. Contacting the physician would not be the immediate action. A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. The first action on the part of the nurse is: A) Calling the physician B) Inserting an oral airway C) Turning the client on her side D) Noting the time of the seizure - ANSWERSAnswer: C Rationale: If seizure activity occurs, the nurse remains with the client and presses the emergency bell for assistance. The client is turned on her side because a side-lying position permits greater circulation through the placenta and helps prevent aspiration. The nurse then notes the time and sequence of the seizure. The physician is notified that a seizure has occurred, because this is an obstetric emergency associated with cerebral hemorrhage, abruptio placentae, severe fetal hypoxia, and death. No object should be placed in the client's mouth during a seizure. An airway may be inserted after the seizure, and the client's mouth and nose are suctioned to prevent aspiration. Oxygen may be administered by way of face mask during the seizure to increase oxygenation of the placenta and all maternal organs. A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 35 mg/dL. The nurse would first: A) Ask the mother to breastfeed the newborn Incorrect B) Bottle-feed the newborn with diluted glucose C) Start an intravenous line for the administration of glucose D) Ask the laboratory to perform a blood glucose test immediately - ANSWERSAnswer: D Rationale: The normal blood glucose level in a newborn is 40 mg/dL or higher. Glucose levels of less than 40 to 45 mg/dL measured with bedside glucose screening should be reported and verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose must be verified by the laboratory. Some infants need IV glucose to maintain glucose balance and prevent damage to the brain. A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which of the following actions should the nurse perform? Select all that apply. A) Placing the woman in knee-chest position B) Administering oxygen at 2 to 4 L/min by nasal cannula C) Administering terbutaline (Brethine) to stop contractions D) With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part E) Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution - ANSWERSAnswer: A, D, E Rationale: When the umbilical cord is protruding, one of the first interventions the nurse should perform is to relieve compression of the cord by exerting upward pressure on the presenting part with two gloved fingers inserted vaginally. The cord must be protected from drying out and from becoming compressed. Therefore it should be wrapped with towels soaked in warm, sterile normal saline solution. The client is placed in an extreme Trendelenburg or modified Sims position or knee-chest position to ease compression. Oxygen should be administered by way of face mask at a rate of 8 to 10 L/min. A physician's prescription is needed for terbutaline, but this medication is usually not given in these circumstances. A nurse provides information to the mother of a child with diarrhea about signs and symptoms that indicate the need to call the physician. Which statement by the mother indicates the need for further instruction? A) "I'll call the doctor if she gets dizzy and acts sick." B) "I'll call the doctor if she has severe stomach cramps." C) "I'll call the doctor if her temperature is 102° or higher." D) "I'll call the physician if she goes longer than 6 hours without urinating." - ANSWERSAnswer: C Rationale: The mother should call the physician if a fever higher than 100° F, especially one that persists for more than 72 hours, develops. The mother should not wait until the temperature reaches 102° F. The remaining statements are all accurate because the findings indicate possible dehydration and hypovolemia. Additionally, severe abdominal cramps could indicate the presence of an acute problem. A nurse is preparing to administer an injection of vitamin K to a newborn. At which site would the nurse select to administer the medication? 1) area of greater trochanter 2) area of the femoral vein 3) lateral aspect of the middle third of the vastus lateralis 4) patellar area - ANSWERSAnswer: 3 Rationale: The preferred injection site for the administration of vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle (the newborn's thigh). This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication. Option 1 is the area of the greater trochanter. Option 2 is the area of the femoral vein. Option 4 is the patellar area. A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of: A) Refusal to suck Incorrect B) Frequent diarrhea C) Recurrent otitis media D) Inability to pass stools - ANSWERSAnswer: C Rationale: GER is regurgitation of gastric contents back into the esophagus. The three types of GER are physiologic, functional, and pathologic. Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER. Refusal to suck, diarrhea, and inability to pass stools are not associated with GER. In caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the child most closely for signs of: A) Anemia B) Renal failure C) Thrombus formation D) Gastrointestinal disturbances - ANSWERSAnswer: C Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. A generalized immune response affects the smooth muscle cells of the vascular walls. These vascular changes, along with the increase in platelets that occurs as part of the disease, can cause thrombus formation, myocardial infarction, and death in some children. Anemia, renal failure, and gastrointestinal disturbances are not specifically associated with this disorder. A nurse provides dietary instructions to the mother of a child with iron-deficiency anemia. The nurse should tell the mother that the food highest in iron is: A) Milk B) Cheese C) Orange juice D) Cream of Wheat - ANSWERSAnswer: D Rationale: Foods high in iron include liver, dried beans, Cream of Wheat, iron-fortified cereal, apricots and prunes (and other dried fruits), egg yolks, and dark-green leafy vegetables. Milk and cheese are high in calcium. Orange juice is high in vitamin C. A nurse provides home care instructions to an adolescent with sickle cell disease about measures to prevent vaso-occlusive crisis. The nurse should tell the adolescent to: A) Restrict fluid intake B) Take ibuprofen (Motrin) for discomfort C) Take acetylsalicylic acid (aspirin) immediately if a fever develops D) Be sure to spend plenty of time in the fresh air and sun each day - ANSWERSAnswer: B Rationale: The adolescent with sickle cell disease is advised to take acetaminophen (Tylenol) or ibuprofen (Motrin) if discomfort occurs. The use of aspirin is avoided. The adolescent is instructed to contact the physician if a fever develops. Dehydration is avoided, and the adolescent is instructed to consume adequate fluids. Cold and heat stress and prolonged exposure to the sun are avoided because they can cause dehydration, which may precipitate a crisis. A nurse reviewing the record of a child with suspected acute poststreptococcal glomerulonephritis notes that the child recently had a streptococcal throat infection that was treated with antibiotics. Which of the following physician prescriptions that will confirm the presence of acute poststreptococcal glomerulonephritis does the nurse expect to find? A) Throat culture B) Blood urea nitrogen (BUN) C) Antistreptolysin (ASO) titer D) White blood cell (WBC) count - ANSWERSAnswer: C Rationale: Immunologic studies are important in diagnosing acute poststreptococcal glomerulonephritis. The ASO titer, which indicates the presence of antibodies to streptococcal bacteria, may be increased. Culture of the throat may be helpful in isolating the bacterium, but this test is only useful if the infection is recent and the child has not received antibiotics. The BUN level would be increased if renal insufficiency was present. The WBC count is usually normal. Throat culture, BUN and WBC count would not confirm the presence of acute poststreptococcal glomerulonephritis. A nurse is caring for the client who begins to exhibit seizure activity while in bed. Which of the following actions does the nurse implement to care for the client? Select all that apply. A) Observing and timing the seizure B) Loosening any restrictive clothing C) Turning the client's head to the side D) Removing the pads on the side rails E) Inserting an airway into the client's mouth F) Removing objects that might injure the client from the vicinity - ANSWERSAnswer: A, B, C, F Rationale: Client safety is a priority for the client experiencing a seizure. Nursing actions during a seizure include providing privacy, loosening restrictive clothing, removing the pillow, raising the padded side rails on the bed, removing objects that might cause injury to the client, and placing the client on the side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. (The nurse should not insert anything into the client's mouth.) The nurse also observes, documents, and times the seizure. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head against injury; and moves furniture that may injure the client if he or she were to come in contact with it during the seizure. Which of the following infection-control measures would the nurse implement for a client in whom smallpox is diagnosed? Select all that apply. A) Enteric B) Droplet C) Contact D) Standard E) Protective isolation - ANSWERSAnswer: B, C, E Rationale: Smallpox is transmitted from person to person in infected aerosols and air droplets spread by way of face-to-face contact with an infected person after fever has begun, especially if the infected person is also coughing. The disease can also be transmitted in contaminated clothes and bedding, although the risk of infection from this source is much lower. Therefore droplet and contact precautions are necessary. Standard precautions are implemented for the care of all clients. Enteric precautions are implemented if the infectious agent is transmitted by way of contact with feces. Protective isolation is implemented when the client is neutropenic and needs to be protected from infection. A nurse is caring for a client in labor who is receiving an oxytocin (Pitocin) infusion. The nurse notes that the client is experiencing uterine hypertonicity. The nurse should immediately: Contact the physician Stop the oxytocin infusion Correct Check the client's blood pressure Place the client in a side-lying position - ANSWERSAnswer: B Rationale: If uterine hypertonicity or a nonreassuring fetal heart pattern occurs, the nurse must intervene to increase fetal oxygenation. The oxytocin infusion is stopped immediately and the infusion rate of the nonadditive IV solution is increased. The client is placed in a side-lying position, and oxygen is administered with the use of a snug face mask at 8 to 10 L/min. The physician is notified of the adverse reactions, the nursing interventions implemented, and the client's response to the interventions. The client's blood pressure is monitored closely. A physician prescribes morphine sulfate, gr 1/8 intramuscular stat, for a client with cancer. The medication ampule reads, "Morphine sulfate 10 mg/mL." How many milliliters of medication does the nurse prepare to administer the correct dose? - ANSWERSCorrect Responses 0.75 .75 Rationale: It is necessary to convert gr 1/8 to mg. After converting grains to milligrams, use the formula to calculate the correct dose. Formula: Desired/Available X Tablet = Tablets per dose 75mg/10mg X 1ml= 7.5/10= 0.75 or .75 An emergency department nurse is caring for an older client who may have been physically abused by her caregiver. In planning care for the client, the nurse makes a priority of: A) Notifying the police department B) Obtaining psychiatric help for the caregiver C) Contacting adult protective services to investigate the situation D) Telling the caregiver that he or she is not allowed to care for the client - ANSWERSAnswer: C Rationale: If physical abuse or neglect is suspected, the priority nursing actions are to assess the client, treat any physical injuries, and ensure that the client is safe. Once these measures have been taken, referral to adult protective services is appropriate. The nurse also notifies the physician. Although there are laws requiring healthcare professionals to report suspected elder abuse to local authorities, calling the police at this point is premature. Telling the caregiver that he or she is no longer allowed to care for the client could trigger aggressive behavior on the part of the caregiver. Although the nurse may be involved in obtaining psychiatric assistance for the caregiver, this is not the priority action. A nurse responds to an external disaster in a large city involving an explosion at a shopping mall. Numerous victims require treatment. Which victim will the nurse attend to first? A) A victim with multiple bruises who is alert and oriented B) A victim who has sustained multiple lacerations with minor bleeding Incorrect C) A victim who is alert and wandering around yelling that he cannot see D) A victim with a crush injury to the abdomen who has no pulse or blood pressure - ANSWERSAnswer: C Rationale: The nurse determines which victim will be attended to first on the basis of the acuity level of the victims involved in the disaster. The victim who must be treated immediately because of the threat to life, limb, or vision is categorized as emergent and is the priority. The victim who requires treatment but whose life, limb, or vision is not threatened if care can be provided within 1 to 2 hours is considered urgent and is the second priority. Victims who require evaluation and possible treatment but for whom time is not a critical factor are categorized as nonurgent and are the third priority. A victim who is deceased after sustaining multiple serious injuries is not the priority. A nurse on the day shift receives the client assignment for the day. Which assigned client will the nurse assess first? A) A client who has been fitted with a closed chest tube drainage system B) A client with a nasogastric tube who underwent bowel resection 2 days ago C) A client who was admitted during the night because of congestive heart failure Correct D) A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m. - ANSWERSAnswer: C Rationale: The nurse would first assess the client who was admitted during the night because of congestive heart failure. This client's problem is directly related to airway, breathing, and circulation, and the nurse would need to determine that the interventions administered on admission and during the night were effective. The nurse would next assess the client who has been fitted with a closed chest tube drainage system. This client's problem also involves airway; however, there is no indication that this client is experiencing any acute problems. The nurse would next assess the client with a nasogastric tube who underwent bowel resection 2 days ago to ensure that the client is comfortable and that the nasogastric tube is functioning. The nurse would then assess the client scheduled for a barium enema to ensure that this client understands the reason for the diagnostic test. A nurse assesses the chest tube drainage system of a client who has undergone surgery and notes intermittent bubbling in the water seal chamber. One hour later, the nurse notes the presence of continuous bubbling in the chamber. On the basis of this finding, the nurse would first check: A) The chest tube connection sites B) For bubbling in the suction-control chamber C) The amount of drainage in the collection chamber D) The amount of suction being applied to the chest tube system - ANSWERSAnswer: A Rationale: Continuous bubbling in the water seal chamber indicates that air is leaking into the drainage system or pleural cavity. The nurse must locate the source of the air leak and would first check all of the chest tube connection sites. If a break in the tubing or a loose connection is found, the nurse tightens the connection or seals the break with tape. The remaining options are unrelated to continuous bubbling in the water seal chamber. A nurse on the day shift is assigned to care for four clients. Which client will the nurse assess first after receiving report from the night shift? A) A client scheduled for an electrocardiogram (ECG) at 11 am B) A client on nothing-by-mouth (NPO) status who is for bronchoscopy at 9 am C) A client who has undergone above-the-knee amputation who is scheduled for discharge home D) A client who had a seizure at 2 a.m. and was treated with intravenous (IV) diazepam (Valium) and phenytoin (Dilantin) - ANSWERSAnswer: D Rationale: Airway is always a high priority, and the nurse must first assess the client who had a seizure during the night and was treated with IV diazepam (Valium) and phenytoin (Dilantin). The nurse would next assess the client scheduled for bronchoscopy to ensure that the client understands the test. The client scheduled for discharge would be assessed third for discharge needs, followed by the client scheduled for an ECG. As a nurse is providing care, the client suddenly experiences a tonic-clonic seizure. The nurse would immediately: A) Call the physician B) Turn the client to the side C) Restrain the client's limbs D) Insert an airway in the client's mouth - ANSWERSAnswer: B Rationale: When a client experiences a seizure, the nurse must immediately turn the client to the side and protect the client from injury. The nurse would maintain the client's airway and suction the client as needed but would not place an airway in the client's mouth. The physician is also notified, but turning the client to the side is the immediate action. Restrictive clothing is loosened, but restraints are not