ATI Predator

Explanation:

Correct Answer: (C) The client develops a postoperative fever.

A postoperative fever is a clinical change in the client's condition that requires assessment, clinical judgment, and potential intervention by a registered nurse. New or unexpected changes in a client's condition fall within the RN's scope of practice as they require comprehensive assessment and critical thinking to determine the cause and appropriate response.

Why Other Options are Incorrect:

A. Routine wound care is a task that can be delegated to licensed practical nurses or trained nursing assistants depending on the facility policy. It does not require transfer of care to an RN unless complications arise.

B. A therapeutic effect from treatment is an expected and positive outcome. There is no clinical concern that necessitates transferring care to an RN.

D. Strict measurement of intake and output is a task that can be performed and monitored by unlicensed assistive personnel or practical nurses under supervision. It does not independently require RN-level care unless abnormal findings are identified.

1. A nurse is collecting data from a client who has pneumonia and a prescription for cefazolin. Which of the following findings should the nurse report to the provider prior to administering the initial dose? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Exhibit 1 - Diagnostic Results: WBC 16,000/mm³ (5,000 to 10,000/mm³) Chest x-ray left lower lobe density

A. Allergies

B. Temperature

C. Chest x-ray

D. WBC count

Explanation:

Correct Answer: (A) Allergies

Before administering the first dose of any antibiotic, especially cefazolin (a cephalosporin), the nurse must check the client's allergy history. Clients with a penicillin allergy may have cross-sensitivity to cephalosporins, which could result in a serious allergic reaction including anaphylaxis. Reporting known allergies to the provider before the initial dose is a critical safety step.

Why Other Options are Incorrect:

B. An elevated temperature is expected in a client with pneumonia and is not a finding that requires reporting before administering the antibiotic. In fact, treating the infection with cefazolin is part of addressing the fever.

C. The chest x-ray showing left lower lobe density is consistent with the existing diagnosis of pneumonia and is an expected finding. It does not need to be reported before administering the antibiotic as it confirms the diagnosis already made.

D. The elevated WBC count of 16,000/mm³ indicates infection and is an expected finding in pneumonia. It supports the need for antibiotic treatment and does not require reporting prior to the initial dose.

1. A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.

Exhibit 1 - Nurses' Notes:

Day 1: Alert and oriented x3, bilateral breath sounds clear and present throughout, extremities warm, bilateral pedal pulses 2+, weight 60 kg (132 lb), urine output 520 mL/8 hr

Day 7: Alert and oriented x3, breath sounds with scattered crackles heard bilaterally, extremities cool, bilateral pedal pulses 1+, weight 61.24 kg (135 lb), urine output 160 mL/8 hr

A. Weight

B. Pedal pulses

C. Temperature

D. Orientation

E. Potassium

F. Chest x-ray

G. Urine output

Explanation:

Correct Answers: (A) Weight, (B) Pedal pulses, (F) Chest x-ray, (G) Urine output

Comparing Day 1 to Day 7 reveals several concerning changes that require further action:

Weight increased from 60 kg to 61.24 kg, indicating fluid retention of approximately 1.24 kg (nearly 3 lb) in one week, which suggests fluid accumulation and possible worsening of the client's condition.

Pedal pulses decreased from 2+ to 1+, indicating reduced peripheral perfusion. Combined with cool extremities, this suggests compromised circulation and possible fluid shifts or cardiac concerns.

Chest x-ray should be obtained because the new finding of bilateral crackles on Day 7 compared to clear breath sounds on Day 1 suggests fluid accumulation in the lungs such as pulmonary edema. A chest x-ray would confirm this finding and guide treatment.

Urine output dropped significantly from 520 mL/8 hr to 160 mL/8 hr, which falls below the minimum acceptable output of 30 mL/hr (240 mL/8 hr). This indicates oliguria and possible renal compromise or fluid imbalance requiring immediate intervention.

Why Other Options do not require further action:

C. Temperature is not mentioned as changed between Day 1 and Day 7, so it does not independently require further action based on the information provided.

D. Orientation remains alert and oriented x3 on both days, showing no change that requires further action.

E. Potassium is not referenced in the nurses' notes for either day, so there is no documented change to act upon based on the available exhibit data.

1. A nurse is assisting with the care of a client in the clinic. The client has the following laboratory results:

• Nonfasting blood glucose 105 mg/dL (74 to 106 mg/dL)
• HbA1c 8.2% (good diabetic control less than 7%)
• Hemoglobin 13.1 g/dL (12 to 18 g/dL)
• Potassium 3.5 mEq/L (3.5 to 5 mEq/L)

The client is prescribed metformin for type 2 diabetes. Which of the following nursing interventions is the priority when caring for this client?

A. Monitor the client's heart rate every 4 hours for bradycardia

B. Educate the client on recognizing signs and symptoms of hypoglycemia

C. Administer a potassium supplement to correct the low potassium level

D. Encourage the client to increase dietary iron intake to improve hemoglobin levels

Explanation:

Correct Answer: (B) Educate the client on recognizing signs and symptoms of hypoglycemia

The client's HbA1c of 8.2% indicates poorly controlled diabetes, and metformin is being used to manage blood glucose levels. The priority nursing intervention is to educate the client about hypoglycemia symptoms such as dizziness, sweating, confusion, and shakiness, as blood glucose management increases this risk.

Why Other Options are Incorrect:

• A. Monitor the client's heart rate every 4 hours for bradycardia Bradycardia is associated with metoprolol (a beta-blocker), not metformin. There is no indication the client is on metoprolol.
• C. Administer a potassium supplement to correct the low potassium level The potassium level of 3.5 mEq/L is at the lowest end of the normal range but does not require supplementation at this point without a physician's order.
• D. Encourage the client to increase dietary iron intake to improve hemoglobin levels The hemoglobin level of 13.1 g/dL is within the normal range (12 to 18 g/dL), so there is no indication for iron supplementation.

1. A nurse is caring for a client on the medical surgical unit following an abdominal hysterectomy. At 1400, the client was resting quietly and denied pain. At 1600, the client requests pain medication. At 1630, the nurse reassesses the client and documents the following findings:

• Pinpoint pupils
• Somnolent
• Decreased respiratory effort with bilateral crackles
• Heart rate 50/min
• Respiratory rate 10/min
• Blood pressure 98/58 mmHg

Which of the following actions should the nurse take first?

A. Reposition the client to a high Fowler's position to improve breathing

B. Administer naloxone (Narcan) as per the prescribed protocol

C. Notify the physician of the change in the client's condition

D. Apply supplemental oxygen via nasal cannula at 2L/min

Explanation:

Correct Answer: (B) Administer naloxone (Narcan) as per the prescribed protocol

The client is displaying classic signs of opioid toxicity, including pinpoint pupils, somnolence, decreased respiratory effort, bradycardia, and hypotension. These findings indicate that the pain medication administered at 1600 has caused respiratory depression. The priority action is to administer naloxone (Narcan), an opioid antagonist, to reverse the effects of the opioid immediately, as respiratory depression is life-threatening.

Why Other Options are Incorrect:

• A. Reposition the client to a high Fowler's position to improve breathing While repositioning may slightly improve breathing, it does not address the underlying cause of opioid-induced respiratory depression and is not the priority action.
• C. Notify the physician of the change in the client's condition Notifying the physician is important, but it is not the first action. The nurse must first intervene to reverse the opioid toxicity before making the call, as every second counts in respiratory depression.
• D. Apply supplemental oxygen via nasal cannula at 2L/min Supplemental oxygen may be used as a supportive measure, but it does not reverse opioid toxicity. Naloxone must be given first to address the root cause of the deterioration.

1. A nurse is caring for a client who has hypertension and a prescription for a 2-gram sodium diet. Which of the following foods should the nurse recommend as having the lowest amount of sodium?

A. Cheddar cheese

B. Salad dressing

C. Frozen fruit

D. Hot dogs

Explanation:

Correct Answer: (C) Frozen fruit

Frozen fruit is naturally low in sodium as it contains little to no added salt, making it the safest choice for a client on a 2-gram sodium diet.

Why Other Options are Incorrect:

• A. Cheddar cheese Cheese is a processed dairy product that contains high amounts of sodium, making it unsuitable for a low-sodium diet.
• B. Salad dressing Most commercial salad dressings contain high levels of sodium as a preservative and flavoring agent, making them inappropriate for a 2-gram sodium diet.
• D. Hot dogs Hot dogs are highly processed meats with very high sodium content, making them one of the worst choices for a client on a sodium-restricted diet.

1. A nurse is caring for a client who has a new prescription for oxycodone. Which of the following medications should the nurse remind the client to take regularly to prevent a common adverse effect of oxycodone?

A. Lorazepam

B. Docusate sodium

C. Ranitidine

D. Gabapentin

Explanation:

Correct Answer: (B) Docusate sodium

Oxycodone is an opioid analgesic that commonly causes constipation by slowing gastrointestinal motility. Docusate sodium is a stool softener that should be taken regularly to prevent opioid-induced constipation, which is one of the most common and predictable adverse effects of opioid therapy.

Why Other Options are Incorrect:

• A. Lorazepam Lorazepam is a benzodiazepine used for anxiety and seizures. Combining it with oxycodone increases the risk of CNS and respiratory depression and is not used to prevent opioid side effects.
• C. Ranitidine Ranitidine is an H2 blocker used to reduce stomach acid. While GI upset can occur with opioids, constipation is the primary concern, not acid reflux.
• D. Gabapentin Gabapentin is used for neuropathic pain and seizures. It does not prevent any common adverse effects of oxycodone and may increase sedation risk when combined with opioids.

1. A nurse is assisting in the care of a client at the clinic. The client presents at 10 weeks of gestation and reports abdominal cramping and moderate, bright red vaginal bleeding. The cervix is open upon vaginal exam. The client has a history of type 1 diabetes mellitus and recurrent chlamydia infections. Laboratory results show hCG level 30 IU/L (Positive if greater than 25 IU/L), Hgb 12 g/dL (11 to 16 g/dL), and Hct 35% (33% to 47%). Which of the following conditions is the client most at risk for developing?

A. Molar pregnancy

B. Spontaneous abortion

C. Ectopic pregnancy

D. Cervical dilation incompetence

Explanation:

Correct Answer: (C) Ectopic pregnancy

The client is at greatest risk for ectopic pregnancy due to her history of recurrent chlamydia infections. Chlamydia is a sexually transmitted infection that can cause scarring and damage to the fallopian tubes, significantly increasing the risk of ectopic pregnancy. Additional supporting findings include abdominal cramping, bright red vaginal bleeding, an open cervix, and a relatively low hCG level of 30 IU/L, which is inconsistent with a normally progressing pregnancy at 10 weeks gestation.

Why Other Options are Incorrect:

• A. Molar pregnancy A molar pregnancy typically presents with abnormally high hCG levels and grape-like uterine tissue. The client's hCG level of 30 IU/L is too low to suggest a molar pregnancy.
• B. Spontaneous abortion While an open cervix and vaginal bleeding can suggest a spontaneous abortion, the history of recurrent chlamydia infections is a stronger risk factor pointing toward ectopic pregnancy as the priority concern.
• D. Cervical dilation incompetence Cervical incompetence typically presents as painless cervical dilation in the second trimester without bleeding. This client is only 10 weeks gestation and has pain and bleeding, making this diagnosis unlikely.

1. A nurse is reinforcing discharge teaching with a client following a gastrectomy. Which of the following foods should the nurse instruct the client to consume to prevent dumping syndrome?

A. Poached eggs

B. Ice cream

C. Peppermints

D. Coleslaw

Explanation:

Correct Answer: (A) Poached eggs

Poached eggs are high in protein and low in simple sugars, making them ideal for preventing dumping syndrome. After a gastrectomy, clients should eat small, frequent meals that are high in protein and low in simple carbohydrates and sugars to slow gastric emptying and prevent dumping syndrome.

Why Other Options are Incorrect:

• B. Ice cream Ice cream is high in sugar and fat, which accelerates gastric emptying and triggers dumping syndrome symptoms such as nausea, diarrhea, and dizziness.
• C. Peppermints Peppermints are high in sugar content and can worsen dumping syndrome by rapidly increasing blood glucose levels and accelerating gastric emptying.
• D. Coleslaw Coleslaw typically contains high amounts of sugar in its dressing, making it an inappropriate food choice for a client trying to prevent dumping syndrome.

1. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?

A. Seizures

B. Tachycardia

C. Elevated temperature

D. Cramping

Explanation:

Correct Answer: (A) Seizures

Seizures are the priority finding in acute alcohol withdrawal as they represent the most life-threatening complication. Alcohol withdrawal seizures can progress to status epilepticus, which can be fatal if not treated immediately. Using the ABCs (Airway, Breathing, Circulation) framework, seizures pose the greatest immediate threat to the client's safety and neurological integrity.

Why Other Options are Incorrect:

• B. Tachycardia While tachycardia is a common finding in alcohol withdrawal, it is not immediately life-threatening compared to seizures and can be managed with medications such as beta-blockers.
• C. Elevated temperature Elevated temperature is a sign of autonomic instability in alcohol withdrawal but is not as immediately dangerous as seizures requiring urgent intervention.
• D. Cramping Cramping is a common but minor symptom of alcohol withdrawal and does not pose an immediate life-threatening risk to the client.

1. A nurse is assisting with the care of a client in a clinic. A 16-year-old client reports to the clinic with their friend. The client's friend informs the nurse that the client has not been themselves lately. Their parents and a sibling died due to injuries sustained when a tornado moved through their town 1 month ago. The client was the only survivor in their family and witnessed the death of their parents and sibling. At 0910, the client appears anxious but answers questions appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorms, but the client states they have always been afraid of thunderstorms. The client states they have been smoking marijuana for about 1 month because it helps clear their mind. Client also states they have no desire to attend school. Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require immediate follow-up by the nurse.

A. Attends school regularly

B. Friend reporting client is not themselves

C. Heart rate 99/min

D. Blood pressure 122/80 mmHg

E. Witnessing the death of their parents and sibling

F. Smoking marijuana to clear their mind

G. Client experiences nightmares

H. Startles easy during thunderstorm

Explanation:

Correct Answer: (B) Friend reporting client is not themselves, (E) Witnessing the death of their parents and sibling, (F) Smoking marijuana to clear their mind, (G) Client experiences nightmares

These four findings are consistent with Post-Traumatic Stress Disorder (PTSD) and require immediate follow-up:

• B. Friend reporting client is not themselves — A change in personality or behavior noted by someone close to the client is a significant red flag indicating psychological distress requiring immediate assessment.
• E. Witnessing the death of their parents and sibling — This is a severe traumatic event that is a direct trigger for PTSD and requires immediate psychological intervention and follow-up.
• F. Smoking marijuana to clear their mind — Substance use as a coping mechanism in a minor is a serious concern indicating the client is struggling to manage trauma and requires immediate intervention.
• G. Client experiences nightmares — Recurring nightmares are a hallmark symptom of PTSD and indicate the client is re-experiencing the traumatic event, requiring immediate mental health follow-up.

Why Other Options are Incorrect:

• A. Attends school regularly — The client actually states they have no desire to attend school, which would be a concern, but regular attendance itself is not a finding requiring follow-up.
• C. Heart rate 99/min — While slightly elevated, a heart rate of 99/min is within acceptable limits and not an immediate priority finding.
• D. Blood pressure 122/80 mmHg — This is within normal range for a 16-year-old and does not require immediate follow-up.
• H. Startles easy during thunderstorm — The client reports having always been afraid of thunderstorms, making this a pre-existing condition rather than a new finding related to the trauma.

1. A nurse is assisting in the care of a child who is brought to the emergency department. The caregiver reports the child was eating fish and suddenly began crying stating, "There is something sticking me in my throat." The nurse notes stridor, mild wheezing, blood-tinged mucus, and the child vomited a small amount of emesis. Which of the following actions should the nurse anticipate as the priority intervention for this child?

A. Encourage the child to drink water to help dislodge the fish bone

B. Prepare the child for an endoscopic exam to locate and remove the foreign body

C. Place a nasogastric tube to low-intermittent suction to clear the airway

D. Encourage the child to consume soft foods to push the fish bone down

Explanation:

Correct Answer: (B) Prepare the child for an endoscopic exam to locate and remove the foreign body

The child is presenting with classic signs of a foreign body airway obstruction including stridor, wheezing, blood-tinged mucus, gagging, and vomiting. An endoscopic exam is the gold standard intervention for locating and safely removing a foreign body such as a fish bone lodged in the throat. This is the most anticipated and appropriate priority intervention to prevent complete airway obstruction.

Why Other Options are Incorrect:

• A. Encourage the child to drink water to help dislodge the fish bone Encouraging fluids is contraindicated as it can cause the child to aspirate, worsen the obstruction, or push the fish bone deeper into the airway, increasing the risk of complete obstruction.
• C. Place a nasogastric tube to low-intermittent suction to clear the airway Placing a nasogastric tube is nonessential in this situation as it does not address the fish bone lodged in the throat and could cause additional trauma to the already irritated mucous membranes.
• D. Encourage the child to consume soft foods to push the fish bone down Encouraging food intake is contraindicated as it poses a significant risk of worsening the airway obstruction and increasing the risk of aspiration in a child who is already gagging and vomiting.

1. A nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning. Which of the following actions should the nurse take?

A. Discontinue use and tag the IV pump

B. Plug the IV pump's cord into a different outlet

C. Replace the IV pump's tubing

D. Clear the settings and reset the IV pump

Explanation:

Correct Answer: (A) Discontinue use and tag the IV pump

When medical equipment is found to be malfunctioning, the nurse should immediately discontinue use of the equipment and tag it to indicate it is out of service. This follows standard safety protocols to protect the client from harm and ensures the equipment is sent for repair or inspection by biomedical engineering.

Why Other Options are Incorrect:

A. Already identified as correct above.

B. Plug the IV pump's cord into a different outlet — Changing the outlet does not address the malfunctioning screen and could put the client at further risk by continuing to use faulty equipment.

C. Replace the IV pump's tubing — Replacing the tubing does not address the malfunctioning screen as the issue is with the pump itself, not the tubing.

D. Clear the settings and reset the IV pump — Resetting the pump does not guarantee safe operation of a malfunctioning device and could result in incorrect IV fluid delivery, putting the client at risk.

1. A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?

A. Administer pain medication on a routine schedule

B. Follow facility protocol when performing a procedure on the client

C. Keep an agreement made with the client to administer an antiemetic medication

D. Include the client's input when setting treatment goals

Explanation:

Correct Answer: (D) Include the client's input when setting treatment goals

Autonomy is the client's right to make decisions about their own care. Including the client's input when setting treatment goals directly promotes autonomy by respecting the client's wishes and ensuring their values and preferences are incorporated into the plan of care, which is especially important in terminal illness.

Why Other Options are Incorrect:

A. Administer pain medication on a routine schedule — While pain management is important, administering medication on a routine schedule without the client's input does not specifically promote autonomy.

B. Follow facility protocol when performing a procedure on the client — Following facility protocol promotes safety and standard of care but does not specifically address the client's autonomy or individual decision-making.

C. Keep an agreement made with the client to administer an antiemetic medication — While keeping agreements promotes trust, it reflects the ethical principle of fidelity rather than autonomy.

1. A nurse is collecting data from a client who is at 20 weeks of gestation and has been taking ferrous sulfate. For which of the following findings should the nurse monitor as a common adverse effect of iron supplementation and report to the provider?

A. Dry mouth

B. Tinnitus

C. Hematuria

D. Constipation

Explanation:

Correct Answer: (D) Constipation

Constipation is one of the most common adverse effects of iron supplementation such as ferrous sulfate. Iron slows gastrointestinal motility, leading to hard, difficult-to-pass stools. Nurses should monitor for this and educate clients to increase fluid and fiber intake to manage this side effect.

Why Other Options are Incorrect:

A. Dry mouth — Dry mouth is not a common adverse effect of ferrous sulfate and is more commonly associated with anticholinergic medications.

B. Tinnitus — Tinnitus is not associated with iron supplementation. It is more commonly linked to medications such as aspirin or aminoglycoside antibiotics.

C. Hematuria — Blood in the urine is not a known adverse effect of ferrous sulfate. It would indicate a urinary tract problem requiring separate investigation.

1. A charge nurse is reinforcing teaching with a newly licensed nurse about performing a 12-lead ECG. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. "This test is a sonogram of the heart."

B. "The client should hold their breath during the test."

C. "The client needs to sign an informed consent for this test."

D. "The test records electrical impulses of the heart."

Explanation:

Correct Answer: (D) "The test records electrical impulses of the heart."

A 12-lead ECG is a non-invasive diagnostic test that records the electrical activity of the heart through electrodes placed on the skin. This statement correctly demonstrates understanding of the purpose and function of an ECG.

Why Other Options are Incorrect:

A. "This test is a sonogram of the heart." — A sonogram of the heart refers to an echocardiogram, which uses sound waves to create images of the heart. An ECG records electrical activity, not sound waves.

B. "The client should hold their breath during the test." — The client should breathe normally and remain still during an ECG. Holding the breath is not required and movement or breathing changes could affect the reading.

C. "The client needs to sign an informed consent for this test." — A 12-lead ECG is a non-invasive, routine diagnostic test that does not require informed consent, unlike surgical procedures or invasive tests.

1. A nurse is caring for a client who reports having an allergy to penicillin. Which of the following manifestations indicates an allergic reaction to penicillin?

A. Nausea

B. Angioedema

C. Insomnia

D. Diarrhea

Explanation:

Correct Answer: (B) Angioedema

Angioedema, which is characterized by swelling of the deep layers of the skin particularly around the eyes, lips, and throat, is a classic manifestation of an allergic reaction to penicillin. It can progress to anaphylaxis and is considered a true allergic response requiring immediate intervention.

Why Other Options are Incorrect:

A. Nausea — Nausea is a common gastrointestinal side effect of penicillin but is not an indicator of an allergic reaction. It is a predictable adverse effect rather than an immune-mediated response.

C. Insomnia — Insomnia is not associated with penicillin use or allergic reactions to the medication.

D. Diarrhea — Diarrhea is a common side effect of penicillin due to disruption of normal gut flora but does not indicate an allergic reaction.

1. A nurse is collecting data from a client who has macular degeneration. Which of the following findings should the nurse expect?

A. Client reports sharp pain

B. Astigmatism

C. Loss of central vision

D. Nystagmus

Explanation:

Correct Answer: (C) Loss of central vision

Macular degeneration is a progressive eye condition that affects the macula, the central part of the retina responsible for sharp, central vision. The hallmark finding is loss of central vision, making it difficult for clients to read, recognize faces, or perform tasks requiring fine visual detail.

Why Other Options are Incorrect:

A. Client reports sharp pain — Macular degeneration is typically painless. Sharp eye pain is more associated with conditions such as acute angle-closure glaucoma or corneal abrasion.

B. Astigmatism — Astigmatism is a refractive error caused by an irregularly shaped cornea or lens and is not associated with macular degeneration.

D. Nystagmus — Nystagmus refers to involuntary rhythmic eye movements and is associated with neurological conditions or inner ear disorders, not macular degeneration.

1. A nurse on a mental health unit is collecting data from a client who has an anxiety disorder. Which of the following actions by the client should the nurse identify as the use of displacement?

A. Punching the bed pillow when the staff denies the use of the telephone

B. Writing a short story depicting themselves as a superhero

C. Blaming their parent for a lack of attention received during childhood

D. Having an aggressive outburst when meal selection is unavailable

Explanation:

Correct Answer: (D) Having an aggressive outburst when meal selection is unavailable

Displacement is a defense mechanism in which a person redirects their emotions from the original source of stress to a less threatening or unrelated target. Having an aggressive outburst over meal selection when the underlying issue is anxiety demonstrates displacement, as the client is transferring their emotional frustration onto an unrelated situation.

Why Other Options are Incorrect:

A. Punching the bed pillow when the staff denies the use of the telephone — This action more closely represents sublimation, where the client redirects aggressive energy into a safer, more acceptable physical outlet such as hitting a pillow rather than a person.

B. Writing a short story depicting themselves as a superhero — This represents fantasy, a defense mechanism where the client escapes reality by imagining themselves in a more powerful or idealized role.

C. Blaming their parent for a lack of attention received during childhood — This represents rationalization or projection, where the client attributes their current difficulties to past parental behavior rather than taking responsibility.

1. A nurse is assisting with the admission of a client who has Hodgkin's disease and is receiving chemotherapy. Because a private room is not available, the nurse should recommend that the client share a room with another client who has which of the following diagnoses?

A. Community-acquired pneumonia

B. Paget's disease

C. Herpes zoster

D. Clostridioides difficile colitis

Explanation:

Correct Answer: (B) Paget's disease

Clients receiving chemotherapy are immunocompromised and at high risk for infection. Paget's disease is a non-infectious bone disorder that poses no risk of transmission to an immunocompromised client, making it the safest rooming option.

Why Other Options are Incorrect:

A. Community-acquired pneumonia — Pneumonia is an active respiratory infection that can be transmitted to an immunocompromised client, significantly increasing their risk of developing a life-threatening infection.

C. Herpes zoster — Herpes zoster is a viral infection caused by the reactivation of the varicella-zoster virus. It is highly contagious to immunocompromised clients and can cause severe, disseminated disease.

D. Clostridioides difficile colitis — C. difficile is a highly contagious bacterial infection spread through contact with contaminated surfaces and feces. It poses an extreme risk to immunocompromised clients and requires contact precautions.

1. A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

A. Slurred speech

B. Chvostek's sign

C. Constipation

D. Hypertension

Explanation:

Correct Answer: (A) Slurred speech

Gentamicin is an aminoglycoside antibiotic known for its serious adverse effects of ototoxicity and nephrotoxicity. Slurred speech can be an indication of vestibular toxicity caused by gentamicin, which affects the eighth cranial nerve leading to hearing loss, tinnitus, and vestibular disturbances including difficulty speaking clearly.

Why Other Options are Incorrect:

B. Chvostek's sign — Chvostek's sign indicates hypocalcemia and is not a known adverse effect of gentamicin therapy.

C. Constipation — Constipation is not a recognized adverse effect of gentamicin. It is more commonly associated with opioid medications or iron supplementation.

D. Hypertension — Hypertension is not a direct adverse effect of gentamicin. Nephrotoxicity from gentamicin may affect kidney function, but hypertension is not the primary manifestation to monitor.

1. A nurse is reinforcing discharge teaching to a client who has bronchitis about a prescription for albuterol. Which of the following statements should the nurse make?

A. "You can expect to be drowsy after taking this medication."

B. "The medication will help open up your airways so you can breathe easier."

C. "The medication will help thin the mucus your airways produce."

D. "You must wait 10 seconds between each inhalation."

Explanation:

Correct Answer: (B) "The medication will help open up your airways so you can breathe easier."

Albuterol is a short-acting beta-2 agonist bronchodilator that works by relaxing the smooth muscles of the airways, causing bronchodilation and making it easier for the client to breathe. This statement accurately describes the mechanism and purpose of albuterol therapy.

Why Other Options are Incorrect:

A. "You can expect to be drowsy after taking this medication." — Albuterol actually causes stimulant-like effects such as tremors, nervousness, and tachycardia due to its beta-agonist properties. Drowsiness is not an expected side effect.

C. "The medication will help thin the mucus your airways produce." — Thinning mucus is the action of mucolytics such as guaifenesin, not albuterol. Albuterol works by dilating the airways, not by altering mucus consistency.

D. "You must wait 10 seconds between each inhalation." — The standard recommendation is to wait at least 60 seconds between puffs of an inhaler, not 10 seconds. This statement contains incorrect information that could compromise the effectiveness of the medication.

1. A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following actions should the nurse take to assist the client from the bed to a wheelchair?

A. Ask the client to reach around the nurse's neck for support

B. Place the wheelchair on the left side of the client

C. Pivot the client on the foot closest to the chair

D. Reach under the client's arms to pull them up

Explanation:

Correct Answer: (B) Place the wheelchair on the left side of the client

For a client with right-sided hemiplegia, the wheelchair should be placed on the client's strong side, which is the left side. This allows the client to use their unaffected left leg and arm to assist with the transfer, promoting safety and maximizing the client's functional ability during the transfer.

Why Other Options are Incorrect:

A. Ask the client to reach around the nurse's neck for support — This action is unsafe for both the client and the nurse as it places excessive strain on the nurse's neck and back and could cause injury to both parties.

C. Pivot the client on the foot closest to the chair — The client should pivot on their stronger, unaffected foot, which in this case is the left foot, regardless of which foot is closest to the chair.

D. Reach under the client's arms to pull them up — Pulling a client up from under their arms can cause shoulder injury, particularly to the affected side, and is considered an unsafe transfer technique.

1. A nurse is caring for a client who has dehydration. Which of the following findings should the nurse expect?

A. Bradycardia

B. Postural hypotension

C. Peripheral edema

D. Distended neck veins

Explanation:

Correct Answer: (B) Postural hypotension

Postural hypotension, also known as orthostatic hypotension, is a classic finding in dehydration. When a client is dehydrated, there is decreased circulating blood volume, which causes a drop in blood pressure particularly when changing positions from lying to standing, resulting in dizziness and lightheadedness.

Why Other Options are Incorrect:

A. Bradycardia — Dehydration typically causes tachycardia as the heart compensates for the decreased blood volume by beating faster to maintain cardiac output. Bradycardia is not an expected finding in dehydration.

C. Peripheral edema — Peripheral edema is associated with fluid overload or conditions such as heart failure and kidney disease, not dehydration. Dehydration results in decreased fluid in the tissues.

D. Distended neck veins — Distended neck veins indicate increased venous pressure associated with fluid overload or right-sided heart failure. In dehydration, neck veins would appear flat due to decreased blood volume.

1. A nurse is assisting in the care of a client on a postpartum unit. The client had an uncomplicated vaginal delivery 24 hours ago. Which of the following data collection findings should the nurse report to the primary RN immediately?

A. Calf edematous and tender

B. Nipple tenderness with breastfeeding

C. Hemorrhoids on the rectal area

D. Moderate lochia rubra on the pad

Explanation:

Correct Answer: (A) Calf edematous and tender

An edematous and tender calf 24 hours postpartum is a warning sign of deep vein thrombosis (DVT), which is a life-threatening complication of the postpartum period. Pregnancy and delivery increase the risk of blood clots due to hypercoagulability, venous stasis, and vascular injury. This finding requires immediate reporting to the primary RN for further assessment and intervention.

Why Other Options are Incorrect:

B. Nipple tenderness with breastfeeding — Nipple tenderness is a normal and expected finding in the early days of breastfeeding as the client and baby establish a feeding routine. It does not require immediate reporting.

C. Hemorrhoids on the rectal area — Hemorrhoids are a common and expected finding following vaginal delivery due to pushing during labor. They are uncomfortable but not an emergency requiring immediate reporting.

D. Moderate lochia rubra on the pad — Moderate lochia rubra is a normal finding within the first 24 hours postpartum as the uterus sheds its lining. It becomes a concern only if it is excessive or saturates more than one pad per hour.

1. A nurse is assisting in planning an education session for a client. Which of the following findings should the nurse identify as a potential barrier to the client's learning?

A. Reports pain as 8 on a scale of 0 to 10

B. Reports anticipation about upcoming discharge

C. Participated in physical therapy 2 hours ago

D. Has 2+ pitting edema in the lower extremities

Explanation:

Correct Answer: (A) Reports pain as 8 on a scale of 0 to 10

A pain level of 8 out of 10 is a significant barrier to learning as severe pain impairs the client's ability to concentrate, retain information, and actively participate in education. Pain management should be addressed before initiating any teaching session to ensure the client is in an optimal state to receive and process information.

Why Other Options are Incorrect:

B. Reports anticipation about upcoming discharge — Anticipation about discharge is actually a motivating factor that can enhance learning as the client is likely eager to receive information needed to care for themselves at home.

C. Participated in physical therapy 2 hours ago — Participation in physical therapy 2 hours prior does not constitute a significant barrier to learning. The client has had sufficient time to rest and can engage in education.

D. Has 2+ pitting edema in the lower extremities — While pitting edema indicates fluid retention, it does not directly impair the client's cognitive ability to participate in an education session.

1. A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

A. Observe the client's behavior every 2 hours

B. Keep the client's door shut when they are in the room

C. Ensure the client swallows each dose of medication

D. Limit the personal toiletries in the client's room to cologne

Explanation:

Correct Answer: (C) Ensure the client swallows each dose of medication

For a client who has recently attempted suicide, the nurse must ensure that all medications are swallowed and not hoarded or stored for a potential overdose attempt. This is a critical safety measure known as medication check or mouth check, which is standard practice in psychiatric and mental health settings for clients at risk of self-harm.

Why Other Options are Incorrect:

A. Observe the client's behavior every 2 hours — A client who has recently attempted suicide requires continuous observation or checks every 15 minutes at minimum, not every 2 hours. Every 2 hours is insufficient to ensure client safety.

B. Keep the client's door shut when they are in the room — Keeping the door shut would prevent staff from being able to monitor the client and could provide opportunity for self-harm. The door should remain open or staff should have visual access at all times.

D. Limit the personal toiletries in the client's room to cologne — Cologne and other toiletries such as razors, glass bottles, and sharp objects should be removed or restricted. However, cologne itself contains alcohol and could be ingested or used for self-harm, making it an inappropriate item to keep in the room.

1. A nurse is assisting in caring for a client who is in Buck's traction. Which of the following actions should the nurse take?

A. Ensure the weights are hanging freely

B. Maintain the elevation of the head of the bed

C. Check the client's skin twice daily for manifestations of breakdown

D. Monitor capillary refill once per day

Explanation:

Correct Answer: (A) Ensure the weights are hanging freely

In Buck's traction, it is essential that the weights hang freely and do not touch the floor or bed frame. The weights must be free-hanging at all times to maintain the correct amount of traction force needed to immobilize the fracture, reduce muscle spasms, and promote proper alignment of the affected extremity.

Why Other Options are Incorrect:

B. Maintain the elevation of the head of the bed — In Buck's traction, the head of the bed should be kept flat or elevated no more than 30 degrees to maintain proper counter-traction. Elevating the head of the bed too much can compromise the effectiveness of the traction.

C. Check the client's skin twice daily for manifestations of breakdown — Skin assessment in a client with Buck's traction should be performed every 8 hours or more frequently, not just twice daily, due to the high risk of pressure injuries from the traction device and prolonged immobility.

D. Monitor capillary refill once per day — Capillary refill and neurovascular checks should be performed every 1 to 2 hours in a client with traction to detect early signs of compartment syndrome or circulatory compromise. Once per day is far too infrequent.

1. A nurse is caring for a client who is 2 days postoperative. Which of the following findings should the nurse identify as an indication of postoperative infection?

A. Edema to the area around the incision site

B. Serous drainage in the closed suction collection device

C. Urine output is 40 mL/hr

D. WBC count 8,000/mm³ (5,000 to 10,000 mm³)

Explanation:

Correct Answer: (A) Edema to the area around the incision site

Edema, redness, warmth, and tenderness around an incision site are classic signs of a postoperative wound infection. At 2 days postoperative, localized swelling and inflammation around the incision are abnormal findings that indicate the beginning of an infectious process requiring prompt assessment and intervention.

Why Other Options are Incorrect:

B. Serous drainage in the closed suction collection device — Serous drainage, which is clear to pale yellow fluid, is a normal expected finding in a closed suction drainage device in the early postoperative period. It becomes a concern only if it becomes purulent, foul-smelling, or excessively bloody.

C. Urine output is 40 mL/hr — A urine output of 40 mL/hr is within the acceptable range of at least 30 mL/hr and does not indicate infection. It reflects adequate renal perfusion.

D. WBC count 8,000/mm³ — A WBC count of 8,000/mm³ falls within the normal range of 5,000 to 10,000/mm³ and does not indicate infection. An elevated WBC above the normal range would be more suggestive of an infectious process.

1. A nurse is documenting client care in the nurses' notes and notices that a space was left blank. Which of the following actions should the nurse take?

A. Draw a horizontal line through the space and sign at the end of the line

B. Place the date at the beginning of the space, followed by double lines

C. Leave the space as it is within the entry

D. Black out the line with a felt-tip pen

Explanation:

Correct Answer: (A) Draw a horizontal line through the space and sign at the end of the line

When a blank space is left in nurses' notes, the correct documentation practice is to draw a single horizontal line through the blank space and sign at the end of the line. This prevents anyone from adding unauthorized information into the blank space, maintaining the integrity and legal validity of the medical record.

Why Other Options are Incorrect:

B. Place the date at the beginning of the space, followed by double lines — This is not the correct protocol for handling blank spaces in documentation. Simply placing a date does not prevent unauthorized additions to the record.

C. Leave the space as it is within the entry — Leaving a blank space in medical documentation is incorrect as it creates an opportunity for unauthorized information to be inserted, which could compromise the legal integrity of the medical record.

D. Black out the line with a felt-tip pen — Blacking out any part of a medical record is considered falsification of documentation and is both unethical and illegal. It implies that information is being hidden or altered.

1. A nurse is caring for a client who was recently diagnosed with depression. The client's partner asks when he will get better. Which of the following is an appropriate response by the nurse?

A. "The important thing is that he gets better, not how long it takes."

B. "Tell me what you know about depression."

C. "We've seen steady improvement in other clients who are depressed."

D. "No one really knows the answer to that question."

Explanation:

Correct Answer: (B) "Tell me what you know about depression."

This response uses a therapeutic communication technique by assessing the partner's current level of understanding before providing education. It opens dialogue, acknowledges the partner's concern, and allows the nurse to address any misconceptions while providing individualized and relevant information about the client's condition and prognosis.

Why Other Options are Incorrect:

A. "The important thing is that he gets better, not how long it takes." — This response dismisses the partner's concern and does not address their question. It is non-therapeutic as it minimizes the partner's feelings and need for information.

C. "We've seen steady improvement in other clients who are depressed." — This response gives false reassurance by comparing the client to others. Each client's experience with depression is unique and this statement does not address the specific prognosis of this client.

D. "No one really knows the answer to that question." — While recovery timelines for depression can vary, this response is dismissive and unhelpful. It closes down communication and leaves the partner without any meaningful information or support.

1. A nurse is caring for a client who is immobile and is requesting assistance with a bedpan. Identify the sequence of actions the nurse should take to position the client on the bedpan.

A. Apply a small amount of powder to the buttocks

B. Position the client on the bedpan

C. Roll the client onto their side

D. Elevate the head of the bed

Explanation:

Correct Answer: Correct sequence is D → C → A → B

The correct order of steps is as follows:

D. Elevate the head of the bed — The head of the bed should first be elevated to a comfortable position to assist with positioning and make it easier to roll the client.

C. Roll the client onto their side — The client is rolled onto their side to allow access to the buttocks area for proper bedpan placement.

A. Apply a small amount of powder to the buttocks — Powder is applied to reduce friction and skin irritation when the bedpan is placed against the skin.

B. Position the client on the bedpan — After rolling and applying powder, the bedpan is positioned correctly under the client's buttocks and the client is rolled back onto it.

1. A nurse is caring for a client who has dependent personality disorder. Which of the following manifestations should the nurse expect?

A. Impulsive

B. Submissive

C. Reclusive

D. Perfectionistic

Explanation:

Correct Answer: (B) Submissive

Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. Clients with this disorder have difficulty making everyday decisions without reassurance from others and fear being left alone to care for themselves, resulting in a submissive demeanor and strong reliance on others.

Why Other Options are Incorrect:

A. Impulsive — Impulsivity is more characteristic of borderline personality disorder or antisocial personality disorder, not dependent personality disorder.

C. Reclusive — Reclusiveness and social withdrawal are more characteristic of schizoid personality disorder, where individuals prefer to be alone and have little interest in social relationships.

D. Perfectionistic — Perfectionism is the hallmark of obsessive-compulsive personality disorder (OCPD), where clients are preoccupied with orderliness, rules, and control rather than dependence on others.

1. A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?

A. "I will no longer need a regular gynecological examination."

B. "I should expect my periods to resume in 1 month."

C. "I am thankful I am done having children."

D. "I will have a large scar on my stomach after this procedure."

Explanation:

Correct Answer: (C) "I am thankful I am done having children."

This statement demonstrates that the client understands a key outcome of a hysterectomy, which is the permanent loss of the ability to conceive children. Informed consent requires the client to understand the nature of the procedure, its risks, benefits, and consequences. Acknowledging that she will no longer be able to have children shows she has been informed about and accepted this permanent outcome.

Why Other Options are Incorrect:

A. "I will no longer need a regular gynecological examination." — This is incorrect. Even after a hysterectomy, clients still require regular gynecological examinations to monitor vaginal cuff health and screen for other conditions. This statement indicates a misconception and lack of informed understanding.

B. "I should expect my periods to resume in 1 month." — A hysterectomy results in the permanent cessation of menstruation. Expecting periods to resume indicates a serious misunderstanding of the procedure, meaning informed consent has not been achieved.

D. "I will have a large scar on my stomach after this procedure." — A vaginal hysterectomy is performed through the vagina and does not leave an abdominal scar. This statement indicates the client does not understand the nature of the specific procedure being performed.

1. A nurse on a mental health unit is caring for a client who is in wrist restraints following a violent outburst. Which of the following actions should the nurse take?

A. Document observations of the client every 15 min

B. Obtain a new prescription for restraints every 48 hr

C. Secure the restraints to the side rail

D. Tie the restraints with a tight knot

Explanation:

Correct Answer: (A) Document observations of the client every 15 min

When a client is in restraints, the nurse is required to monitor and document the client's status every 15 minutes. This includes circulation, skin integrity, range of motion, nutrition, hydration, and the client's psychological status. This ensures client safety and complies with legal and facility standards for restraint use.

Why Other Options are Incorrect:

B. Obtain a new prescription for restraints every 48 hr — Restraint prescriptions must be renewed every 24 hours, not every 48 hours. Allowing restraints to continue for 48 hours without a new order violates legal and safety standards.

C. Secure the restraints to the side rail — Restraints should never be secured to the side rail as lowering the side rail could cause injury to the client. Restraints must be secured to the bed frame.

D. Tie the restraints with a tight knot — Restraints should be tied using a quick-release knot to allow for rapid removal in an emergency. A tight knot could delay removal and compromise client safety.

1. A nurse is preparing to administer an injection of 0.25 mg subcutaneous terbutaline to a client who is in preterm labor. The amount available is 1 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

Answer: 0.25 mL

Explanation:

Using the formula: Dose desired ÷ Dose available = Volume to administer

0.25 mg ÷ 1 mg/mL = 0.25 mL

The nurse should administer 0.25 mL of terbutaline subcutaneously.

1. A nurse is discussing hand hygiene with an assistive personnel (AP). Which of the following statements by the AP indicates an understanding of the teaching?

A. "I will rub my hands together until they are dry when using an alcohol-based hand rub."

B. "I will use a nail brush to clean under my artificial nails."

C. "I should adjust the water temperature so that it is as hot as I can tolerate it when rinsing my hands."

D. "I should wash my hands for 10 seconds."

Explanation:

Correct Answer: (A) "I will rub my hands together until they are dry when using an alcohol-based hand rub."

When using an alcohol-based hand rub, the correct technique is to apply the product and rub hands together covering all surfaces until the hands are completely dry. This ensures adequate contact time for the alcohol to effectively kill microorganisms on the hands.

Why Other Options are Incorrect:

B. "I will use a nail brush to clean under my artificial nails." — Artificial nails are not permitted in healthcare settings as they harbor microorganisms that cannot be adequately removed even with a nail brush. Healthcare workers should maintain short, natural nails.

C. "I should adjust the water temperature so that it is as hot as I can tolerate it when rinsing my hands." — Water temperature does not affect the effectiveness of hand washing. Excessively hot water can damage the skin and increase the risk of dermatitis. Warm or comfortable temperature water is recommended.

D. "I should wash my hands for 10 seconds." — The recommended duration for hand washing with soap and water is at least 20 seconds, not 10 seconds. Ten seconds is insufficient to effectively remove microorganisms from the hands.

1. A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

A. The client tells the nurse he prefers a snack before bedtime

B. The client requests to perform ADLs later in the day

C. The client is unable to grasp eating utensils

D. The client requires reinforcement of teaching about the purpose of his medications

Explanation:

Correct Answer: (C) The client is unable to grasp eating utensils

The inability to grasp eating utensils following a stroke indicates a significant functional deficit that requires interprofessional collaboration. This finding should be reported to the team as it requires the expertise of occupational therapy to assess fine motor skills, recommend adaptive equipment, and develop a plan to restore or compensate for this lost function.

Why Other Options are Incorrect:

A. The client tells the nurse he prefers a snack before bedtime — Personal food preferences are a routine nursing care matter that does not require reporting to the entire interprofessional team. The nurse can accommodate this preference independently.

B. The client requests to perform ADLs later in the day — Adjusting the timing of activities of daily living is a routine scheduling matter that the nurse can address independently without involving the interprofessional team.

D. The client requires reinforcement of teaching about the purpose of his medications — Medication teaching reinforcement is within the nurse's scope of practice and does not require escalation to the full interprofessional team unless there are complex issues such as non-compliance or cognitive impairment affecting understanding.

1. A nurse is reviewing arterial blood gas results for a client who has metabolic acidosis. Which of the following values should the nurse expect?

A. PaO2 64 mm Hg (80 to 100 mm Hg)

B. HCO3- 20 mEq/L (22 to 26 mEq/L)

C. PaCO2 32 mm Hg (35 to 45 mm Hg)

D. pH 7.48 (7.35 to 7.45)

Explanation:

Correct Answer: (B) HCO3- 20 mEq/L (22 to 26 mEq/L)

In metabolic acidosis, the primary disturbance is a decrease in bicarbonate (HCO3-). A bicarbonate level of 20 mEq/L is below the normal range of 22 to 26 mEq/L, which is the hallmark finding of metabolic acidosis. The kidneys are unable to retain sufficient bicarbonate to buffer the excess acid in the body, resulting in a decreased pH and low bicarbonate level.

Why Other Options are Incorrect:

A. PaO2 64 mm Hg — A PaO2 of 64 mm Hg indicates hypoxemia and is below the normal range of 80 to 100 mm Hg. While hypoxemia can contribute to acidosis, it is not the defining characteristic of metabolic acidosis specifically.

C. PaCO2 32 mm Hg — A PaCO2 of 32 mm Hg is below the normal range of 35 to 45 mm Hg, which indicates respiratory alkalosis or compensatory hyperventilation. In metabolic acidosis, the body compensates by blowing off CO2 through increased respirations, so this could be a compensatory finding, but it is not the primary expected value.

D. pH 7.48 — A pH of 7.48 is above the normal range of 7.35 to 7.45, indicating alkalosis, not acidosis. In metabolic acidosis the pH would be below 7.35.

1. A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?

A. Occasional small clots in the urine

B. Frequent urge to urinate

C. Urine output of 300 mL over 8 hr

D. Dark red urine

Explanation:

Correct Answer: (D) Dark red urine

Dark red urine 1 day following a transurethral resection of the prostate (TURP) indicates arterial bleeding, which is an abnormal and serious finding requiring immediate reporting to the provider. While some light pink-tinged urine with occasional small clots is expected in the early postoperative period, dark red urine suggests significant hemorrhage that needs prompt medical intervention.

Why Other Options are Incorrect:

A. Occasional small clots in the urine — Small clots in the urine are an expected finding following TURP due to the surgical trauma to the prostate tissue. This does not require immediate reporting unless clots become large or obstruct the catheter.

B. Frequent urge to urinate — Bladder irritation and the frequent urge to urinate are expected following TURP due to the presence of the urinary catheter and the surgical procedure on the prostate. This is a normal postoperative finding.

C. Urine output of 300 mL over 8 hr — A urine output of 300 mL over 8 hours equals approximately 37.5 mL/hr, which is within the acceptable minimum range of 30 mL/hr. This does not require immediate reporting.

1. A nurse is reinforcing teaching to the guardians of a 4-year-old child about the expected reactions of immunizations. Which of the following statements should the nurse include?

A. "Your child could develop hives."

B. "Your child could become hyperactive."

C. "Your child could experience tenderness at the injection site."

D. "Your child could have a temperature over 102.2 degrees Fahrenheit."

Explanation:

Correct Answer: (C) "Your child could experience tenderness at the injection site."

Local tenderness, redness, and swelling at the injection site are the most common and expected reactions following immunizations. This is a normal inflammatory response to the vaccine and should be included in routine teaching for guardians.

Why Other Options are Incorrect:

A. "Your child could develop hives." — Hives are a sign of an allergic reaction to the vaccine, not an expected normal reaction. If hives develop, the guardian should seek immediate medical attention as this could indicate anaphylaxis.

B. "Your child could become hyperactive." — Hyperactivity is not a known or expected reaction to immunizations. This is a common misconception, particularly regarding vaccines such as MMR, which has been scientifically disproven to cause behavioral changes.

D. "Your child could have a temperature over 102.2 degrees Fahrenheit." — A low-grade fever up to 102.2°F is an expected reaction following immunizations. A temperature exceeding 102.2°F is considered abnormal and should be reported to the provider as it may indicate a more serious reaction.

1. A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?

A. Place the child in a supine position

B. Administer an oral antiepileptic medication

C. Offer the child sips of clear fluids

D. Check the child for oral injuries

Explanation:

Correct Answer: (D) Check the child for oral injuries

Immediately following a tonic-clonic seizure, the nurse should assess the child for oral injuries such as tongue lacerations or broken teeth that may have occurred during the seizure. This post-ictal assessment is a priority nursing action to identify any injuries sustained during the seizure activity.

Why Other Options are Incorrect:

A. Place the child in a supine position — Following a seizure, the child should be placed in a lateral recovery position, not supine, to prevent aspiration of secretions or vomit during the post-ictal phase.

B. Administer an oral antiepileptic medication — Oral medications should never be administered immediately following a seizure as the child may still have impaired swallowing reflexes and level of consciousness during the post-ictal phase, creating a risk of aspiration.

C. Offer the child sips of clear fluids — Offering fluids immediately following a seizure is contraindicated as the child's swallowing reflexes and consciousness level may be impaired, significantly increasing the risk of aspiration.

1. A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply.)

A. Ask the provider to spell out the name of the medication

B. Record the date and time of the telephone prescription

C. Request that the provider confirm the read-back of the prescription

D. Withhold the medication until the provider signs the prescription

E. Instruct another nurse to record the prescription in the medical record

Explanation:

Correct Answers: (A), (B), and (C)

A. Ask the provider to spell out the name of the medication — Asking the provider to spell the medication name prevents errors caused by similar-sounding drug names and ensures accurate transcription of the prescription.

B. Record the date and time of the telephone prescription — Documentation of the date and time is a legal requirement for telephone prescriptions and ensures an accurate and complete medical record.

C. Request that the provider confirm the read-back of the prescription — Reading back the prescription to the provider and having them confirm its accuracy is a required safety practice that reduces the risk of transcription errors and medication mistakes.

Why Other Options are Incorrect:

D. Withhold the medication until the provider signs the prescription — Telephone prescriptions are legally valid and can be administered before the provider's signature is obtained. The provider is typically required to sign the prescription within 24 to 48 hours per facility policy, but withholding the medication could harm the client.

E. Instruct another nurse to record the prescription in the medical record — The nurse who receives the telephone prescription is responsible for documenting it in the medical record. Delegating this task to another nurse who was not present during the call is inappropriate and could lead to documentation errors.

1. A nurse is contributing to the plan of care for a client who has dysphagia. Which of the following interventions should the nurse include?

A. Tilt the client's head forward during meals

B. Encourage socialization during mealtimes

C. Provide three large meals per day

D. Elevate the head of the client's bed to 30°

Explanation:

Correct Answer: (A) Tilt the client's head forward during meals

Tilting the client's head forward, also known as the chin-tuck maneuver, is a standard intervention for clients with dysphagia. This position narrows the airway entrance and widens the esophageal opening, directing food and liquid away from the airway and reducing the risk of aspiration during swallowing.

Why Other Options are Incorrect:

B. Encourage socialization during mealtimes — While socialization is generally beneficial, clients with dysphagia should remain focused on eating and swallowing during meals. Distractions during mealtimes increase the risk of aspiration and choking.

C. Provide three large meals per day — Clients with dysphagia should receive small, frequent meals rather than three large meals. Large meals increase fatigue during eating and the risk of aspiration due to the greater volume of food that must be swallowed.

D. Elevate the head of the client's bed to 30° — For clients with dysphagia, the head of the bed should be elevated to at least 90° or the client should be sitting fully upright during meals to use gravity to assist with safe swallowing and reduce aspiration risk. A 30° elevation is insufficient and increases aspiration risk.

1. A nurse is reinforcing discharge teaching with a client who will be starting a new prescription for digoxin. Which of the following instructions should the nurse include?

A. "Limit your intake of foods high in potassium."

B. "Check your pulse for 1 minute before taking digoxin."

C. "Take your digoxin regularly every 6 hours."

D. "You should not take digoxin if you become pregnant."

Explanation:

Correct Answer: (B) "Check your pulse for 1 minute before taking digoxin."

Digoxin is a cardiac glycoside that slows the heart rate. Clients must check their pulse for a full minute before taking digoxin and should withhold the dose and notify their provider if the pulse is below 60 beats per minute. This is a critical safety measure to prevent digoxin toxicity and life-threatening bradycardia.

Why Other Options are Incorrect:

A. "Limit your intake of foods high in potassium." — Hypokalemia actually increases the risk of digoxin toxicity. Clients on digoxin should maintain adequate potassium levels, and if they are also taking diuretics, they may need to increase potassium-rich foods in their diet rather than limiting them.

C. "Take your digoxin regularly every 6 hours." — Digoxin is typically prescribed once daily, not every 6 hours. Taking digoxin every 6 hours would result in toxic accumulation of the drug in the body, leading to serious adverse effects.

D. "You should not take digoxin if you become pregnant." — While digoxin use during pregnancy requires careful monitoring, it is not automatically contraindicated and is sometimes used during pregnancy to treat certain fetal arrhythmias. This statement is inaccurate and should not be included in teaching.

1. A nurse is collecting data from a client who has bipolar disorder. Which of the following findings should the nurse expect?

A. Well-groomed appearance

B. Flight of ideas

C. Command hallucinations

D. Ritualistic behavior

Explanation:

Correct Answer: (B) Flight of ideas

Flight of ideas is a hallmark manifestation of bipolar disorder, particularly during a manic episode. It is characterized by rapid, continuous speech where the client jumps quickly from one topic to another with loose or minimal connections between thoughts, reflecting the accelerated thought processes associated with mania.

Why Other Options are Incorrect:

A. Well-groomed appearance — During a manic episode, clients with bipolar disorder often exhibit poor hygiene, disheveled appearance, and inappropriate or flamboyant dress due to decreased attention to self-care. A well-groomed appearance is not a typical finding.

C. Command hallucinations — Command hallucinations, where voices instruct the client to perform actions, are more characteristic of schizophrenia and psychotic disorders rather than bipolar disorder.

D. Ritualistic behavior — Ritualistic and repetitive behaviors are more characteristic of obsessive-compulsive disorder (OCD), not bipolar disorder.

1. A nurse is using the assistance of an interpreter to reinforce discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take when working with an interpreter?

A. Speak in third person

B. Use humor to decrease tension

C. Speak in short sentences

D. Talk directly to the interpreter

Explanation:

Correct Answer: (C) Speak in short sentences

When working with an interpreter, the nurse should speak in short, clear sentences to allow the interpreter adequate time to accurately translate each segment of information. This promotes effective communication, reduces the risk of important information being lost or mistranslated, and ensures the client fully understands the discharge teaching.

Why Other Options are Incorrect:

A. Speak in third person — The nurse should always speak in the first person and address the client directly, not refer to the client in the third person. Speaking in third person is disrespectful and creates a barrier between the nurse and the client.

B. Use humor to decrease tension — Humor should be avoided when working with interpreters as jokes and idiomatic expressions are often difficult to translate accurately across different languages and cultures, and may be misunderstood or considered offensive.

D. Talk directly to the interpreter — The nurse should always speak directly to the client, not to the interpreter. Talking to the interpreter rather than the client depersonalizes the interaction and undermines the therapeutic nurse-client relationship.

1. A nurse is reinforcing discharge teaching with a client who has a new diagnosis of tuberculosis. Which of the following instructions should the nurse include in the teaching?

A. "You should schedule a tuberculin skin test every 6 months."

B. "You should obtain a chest x-ray every 3 months."

C. "You should stop taking your antituberculin medication after 2 weeks."

D. "You should have a sputum examination every 4 weeks."

Explanation:

Correct Answer: (D) "You should have a sputum examination every 4 weeks."

Sputum examinations are performed regularly throughout tuberculosis treatment to monitor the effectiveness of antituberculin therapy and determine when the client is no longer infectious. Monthly sputum examinations every 4 weeks are the standard monitoring protocol for clients undergoing tuberculosis treatment.

Why Other Options are Incorrect:

A. "You should schedule a tuberculin skin test every 6 months." — Tuberculin skin tests are used for screening purposes in people who have not been diagnosed with TB. Once a client has been diagnosed with tuberculosis, the tuberculin skin test will always be positive and is no longer useful as a monitoring tool.

B. "You should obtain a chest x-ray every 3 months." — While chest x-rays are part of tuberculosis monitoring, every 3 months is not the standard frequency. Chest x-rays are typically obtained at the beginning of treatment and periodically throughout, but sputum examination is the primary monitoring method.

C. "You should stop taking your antituberculin medication after 2 weeks." — Tuberculosis treatment requires a full course of medication lasting a minimum of 6 to 9 months. Stopping medication after only 2 weeks, even if symptoms improve, leads to treatment failure and the development of drug-resistant tuberculosis.

1. A nurse is reinforcing teaching with a client about a low-sodium diet. Which of the following foods should the nurse recommend?

A. Canned tuna

B. Green olives

C. Bologna sandwich

D. Scrambled eggs

Explanation:

Correct Answer: (D) Scrambled eggs

Scrambled eggs are naturally low in sodium and are an appropriate food choice for a client on a low-sodium diet. When prepared without added salt, eggs contain minimal sodium and provide an excellent source of protein for clients who need to restrict their sodium intake.

Why Other Options are Incorrect:

A. Canned tuna — Canned tuna contains high amounts of sodium due to the salt used in the canning and preservation process. Clients on a low-sodium diet should choose fresh or low-sodium canned tuna instead.

B. Green olives — Green olives are cured and packed in brine, making them extremely high in sodium. They are one of the worst food choices for a client on a sodium-restricted diet.

C. Bologna sandwich — Bologna is a highly processed deli meat that contains very high levels of sodium as a preservative. Combined with bread, which also contains sodium, a bologna sandwich is an inappropriate food choice for a low-sodium diet.

1. A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?

A. Keep a loose, absorbent dressing over the client's surgical site

B. Encourage the client to use the overbed trapeze

C. Caution the client to avoid a prone position while in bed

D. Maintain abduction of the client's residual limb with a pillow

Explanation:

Correct Answer: (B) Encourage the client to use the overbed trapeze

Encouraging the client to use the overbed trapeze promotes upper body strength, independence, and mobility. Using the trapeze allows the client to reposition themselves in bed, assists with transfers, and begins building the upper extremity strength needed for future prosthetic use and ambulation, directly promoting progression toward independence.

Why Other Options are Incorrect:

A. Keep a loose, absorbent dressing over the client's surgical site — The residual limb should be wrapped with a firm, elastic compression bandage rather than a loose dressing to shape the stump for eventual prosthetic fitting. A loose dressing does not promote mobility or independence.

C. Caution the client to avoid a prone position while in bed — The prone position is actually encouraged for clients following an above-the-knee amputation to prevent hip flexion contractures, which would impair future ambulation with a prosthesis. Avoiding the prone position is incorrect advice.

D. Maintain abduction of the client's residual limb with a pillow — The residual limb should be maintained in adduction and extension, not abduction, to prevent hip abduction contractures that would interfere with prosthetic fitting and ambulation.

1. A nurse is collecting data from a client who has acute cholecystitis. Which of the following findings should the nurse expect?

A. Increased abdominal discomfort prior to meals

B. Discomfort with urination

C. Pain radiating to the jaw

D. Pain in the right upper abdomen

Explanation:

Correct Answer: (D) Pain in the right upper abdomen

Acute cholecystitis is inflammation of the gallbladder, which is located in the right upper quadrant of the abdomen. The hallmark finding is severe pain in the right upper abdomen, often accompanied by nausea, vomiting, and fever. The pain may also radiate to the right shoulder or scapula due to referred pain from diaphragmatic irritation.

Why Other Options are Incorrect:

A. Increased abdominal discomfort prior to meals — Pain associated with cholecystitis typically occurs after meals, particularly after consuming fatty foods, as the gallbladder contracts to release bile in response to fat ingestion. Pain before meals is not a characteristic finding.

B. Discomfort with urination — Discomfort with urination is associated with urinary tract infections or kidney stones, not cholecystitis. The gallbladder is not part of the urinary system.

C. Pain radiating to the jaw — Pain radiating to the jaw is a classic symptom of a myocardial infarction, not cholecystitis. While cholecystitis pain can radiate to the right shoulder or back, jaw radiation is not an expected finding.

1. A nurse is assisting with the plan of care for a client who has burns to their lower extremities. Which of the following actions should the nurse include in the plan?

A. Apply dressings with sterile gloves

B. Cleanse the most contaminated wounds first

C. Use hydrogen peroxide for wound cleaning

D. Perform dressing changes every other day

Explanation:

Correct Answer: (A) Apply dressings with sterile gloves

Burn wounds are highly susceptible to infection due to the loss of the skin's protective barrier. Applying dressings with sterile gloves maintains a sterile technique during wound care, minimizing the introduction of microorganisms into the wound and reducing the risk of serious infection and sepsis.

Why Other Options are Incorrect:

B. Cleanse the most contaminated wounds first — Wound care should always begin with the least contaminated wound and progress to the most contaminated to prevent cross-contamination between wounds. Cleansing the most contaminated wound first increases the risk of spreading bacteria to cleaner wounds.

C. Use hydrogen peroxide for wound cleaning — Hydrogen peroxide is cytotoxic to new tissue and destroys granulation tissue and fibroblasts needed for wound healing. It is contraindicated for burn wound care and should not be used.

D. Perform dressing changes every other day — Burn wound dressings typically require more frequent changes, often daily or as ordered by the provider, depending on the type of dressing used and the amount of drainage. Every other day changes are insufficient for most burn wounds and increase infection risk.

1. A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?

A. Hypersomnia

B. Amyloid plaque

C. Urinary tract infection

D. High cholesterol

Explanation:

Correct Answer: (C) Urinary tract infection

Urinary tract infections are one of the most common precipitating causes of delirium, particularly in older adults. The systemic inflammatory response and the release of cytokines during an infection can directly affect brain function, leading to acute confusion, disorientation, and restlessness characteristic of delirium.

Why Other Options are Incorrect:

A. Hypersomnia — Hypersomnia, which is excessive sleepiness, is not a recognized risk factor for delirium. Sleep deprivation and insomnia are more commonly associated with the development of delirium.

B. Amyloid plaque — Amyloid plaque accumulation in the brain is the hallmark pathological feature of Alzheimer's disease, which is a form of chronic, progressive dementia. It is not a direct risk factor for acute delirium.

D. High cholesterol — High cholesterol is a cardiovascular risk factor associated with atherosclerosis and heart disease but is not a recognized direct risk factor for the development of delirium.

1. A nurse is caring for a client who has chronic kidney failure. An assistive personnel reports that the client has a blood pressure of 190/110 mm Hg. Which of the following actions should the nurse take first?

A. Report the blood pressure reading to the charge nurse

B. Remeasure the client's blood pressure

C. Instruct the client to remain in bed

D. Administer an antihypertensive medication

Explanation:

Correct Answer: (B) Remeasure the client's blood pressure

The first action the nurse should take is to remeasure the blood pressure to verify the accuracy of the reading. Before initiating any intervention, the nurse must confirm the finding by retaking the blood pressure, ideally in both arms, to ensure the reading is accurate and not the result of equipment malfunction, incorrect cuff placement, or positioning error.

Why Other Options are Incorrect:

A. Report the blood pressure reading to the charge nurse — While reporting is important, the nurse must first verify the accuracy of the blood pressure reading before escalating to the charge nurse. Reporting an unverified reading could result in unnecessary interventions.

C. Instruct the client to remain in bed — While keeping the client in bed may be appropriate for safety, it is not the first priority action. Verifying the blood pressure reading must occur before determining appropriate interventions.

D. Administer an antihypertensive medication — Administering medication without first verifying the blood pressure reading and obtaining a provider's order is inappropriate. The nurse must confirm the finding and notify the provider before any medication is given.

1. A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse identify as an expected outcome of treatment?

A. The client develops lanugo

B. The client's blood pressure is 88/59 mm Hg

C. The client's heart rate is 54/min

D. The client resumes menstruation

Explanation:

Correct Answer: (D) The client resumes menstruation

Resumption of menstruation is an expected and positive outcome of treatment for anorexia nervosa. Amenorrhea, the absence of menstruation, occurs in clients with anorexia nervosa due to severely low body weight and malnutrition, which disrupts the hypothalamic-pituitary-ovarian axis. As the client achieves a healthier weight and nutritional status through treatment, menstruation resumes, indicating physiological recovery.

Why Other Options are Incorrect:

A. The client develops lanugo — Lanugo is fine, downy hair that develops on the body as a physiological response to extreme malnutrition and low body fat in anorexia nervosa. It is a sign of the disease, not a treatment outcome. Successful treatment would result in the disappearance of lanugo as the client regains weight.

B. The client's blood pressure is 88/59 mm Hg — A blood pressure of 88/59 mm Hg indicates hypotension, which is a complication of severe malnutrition and dehydration associated with anorexia nervosa. This finding indicates the disease is worsening, not improving with treatment.

C. The client's heart rate is 54/min — A heart rate of 54/min indicates bradycardia, which is a dangerous cardiac complication of anorexia nervosa resulting from electrolyte imbalances and malnutrition. This finding indicates a deteriorating condition, not a positive treatment outcome.

1. A nurse is collecting data from a newborn who was born 24 hours ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?

A: A newborn with blotchy, red rash with small white or yellow pustules scattered across the trunk and body Image

B: A newborn with small white bumps concentrated on the nose and cheeks Image

C: A newborn with a raised, dark red lesion on the abdomen Image

D: A newborn appearing jaundiced with yellow skin discoloration on the face

Explanation:

Correct Answer: Image 1 — The newborn with blotchy red rash with small white or yellow pustules scattered across the trunk and body

Erythema toxicum is a common, benign newborn rash that typically appears within the first 24 to 72 hours of life. It is characterized by blotchy, erythematous macules with small white or yellow pustules surrounded by red halos, most commonly appearing on the trunk, face, and extremities. It is a normal finding in newborns and requires no treatment as it resolves spontaneously within one to two weeks.

Why Other Options are Incorrect:

Image 2 — Small white bumps concentrated on the nose and cheeks — This presentation describes milia, which are tiny white cysts caused by blocked sebaceous glands. Milia appear as small, white, pearly bumps primarily on the nose and cheeks and are a separate normal newborn finding distinct from erythema toxicum.

Image 3 — A raised, dark red lesion on the abdomen — This presentation is more consistent with a hemangioma or umbilical granuloma, which are vascular lesions requiring further assessment and monitoring. This is not characteristic of erythema toxicum.

Image 4 — Yellow skin discoloration on the face — This presentation describes neonatal jaundice caused by elevated bilirubin levels. Jaundice presents as yellow discoloration of the skin and sclera and is a separate condition requiring monitoring and possible phototherapy, not erythema toxicum.

1. A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

A. Sounds are high-pitched

B. Sounds are soft and at a rate of 1/min

C. Can be a result of a paralytic ileus

D. Indicates decreased motility

Explanation:

Correct Answer: (A) Sounds are high-pitched

Hyperactive bowel sounds are loud, high-pitched, rushing sounds that indicate increased gastrointestinal motility. They are commonly heard in conditions such as diarrhea, gastroenteritis, early bowel obstruction, and following the administration of laxatives. The high-pitched, rushing quality is the key characteristic that distinguishes hyperactive bowel sounds.

Why Other Options are Incorrect:

B. Sounds are soft and at a rate of 1/min — Soft bowel sounds at a rate of 1/min describe hypoactive bowel sounds, which indicate decreased gastrointestinal motility. Normal bowel sounds occur at a rate of 5 to 30 times per minute.

C. Can be a result of a paralytic ileus — Paralytic ileus results in absent or hypoactive bowel sounds due to the cessation of intestinal peristalsis, not hyperactive sounds. Hyperactive sounds would not be expected with a paralytic ileus.

D. Indicates decreased motility — Hyperactive bowel sounds indicate increased, not decreased, gastrointestinal motility. Decreased motility is associated with hypoactive or absent bowel sounds.

1. A home health nurse is completing a home safety visit for a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse take?

A. Set the water heater to 54.4°C (130°F)

B. Replace burned-out light bulbs

C. Run extension cords under throw rugs

D. Ensure the client wears soft-soled slippers

Explanation:

Correct Answer: (B) Replace burned-out light bulbs

Replacing burned-out light bulbs improves visibility throughout the home, which is a critical safety measure for a client who has had a CVA. Adequate lighting reduces the risk of falls, which is a major concern for CVA clients who may have residual deficits such as hemiplegia, visual field deficits, and impaired balance and coordination.

Why Other Options are Incorrect:

A. Set the water heater to 54.4°C (130°F) — Water heater temperatures should be set at no higher than 48.9°C (120°F) to prevent scalding injuries. CVA clients may have decreased sensation or impaired reflexes, making them particularly vulnerable to burns at higher water temperatures.

C. Run extension cords under throw rugs — Running extension cords under throw rugs creates a significant fire hazard and tripping risk. Both extension cords and throw rugs should be removed or secured properly in the home of a CVA client to prevent falls.

D. Ensure the client wears soft-soled slippers — While footwear is important for safety, soft-soled slippers without proper grip and support can increase the risk of slipping and falling. CVA clients should wear well-fitted, non-skid footwear that provides adequate support rather than loose slippers.

1. A nurse is caring for a client who has major depressive disorder and recently started taking antidepressants. Which of the following client statements should the nurse identify as the priority?

A. "I barely have enough energy to get out of bed in the morning."

B. "I am giving away my belongings to my friends."

C. "I have lost interest in having sexual intercourse with my partner."

D. "I feel guilty about how my depression is affecting my family."

Explanation:

Correct Answer: (B) "I am giving away my belongings to my friends."

Giving away personal belongings is a significant warning sign of suicidal ideation and intent. This behavior indicates the client may be preparing for death and requires immediate priority assessment and intervention. When a client who has recently started antidepressants begins giving away possessions, the nurse must conduct an immediate suicide risk assessment and notify the provider, as antidepressants can initially increase energy levels before mood improves, which can increase the risk of acting on suicidal thoughts.

Why Other Options are Incorrect:

A. "I barely have enough energy to get out of bed in the morning." — Fatigue and low energy are expected symptoms of major depressive disorder. While this requires monitoring, it does not represent an immediate safety concern compared to giving away belongings.

C. "I have lost interest in having sexual intercourse with my partner." — Loss of interest in sexual activity is a common symptom of major depressive disorder and can also be a side effect of antidepressant medications. While this requires follow-up, it is not an immediate safety priority.

D. "I feel guilty about how my depression is affecting my family." — Feelings of guilt are a common symptom of major depressive disorder. While this requires therapeutic communication and support, it does not represent an immediate safety concern compared to the act of giving away belongings.