QUESTION: "The nurse planning care for a child in vaso-occlusive crisis because of sickle cell disease would include increasing fluid intake in the list of interventions because:"
CHOICES
( O ) a.) Decreased blood viscosity prevents the sickling process.
( X ) b.) Children with sickle cell disease lose more water than is normal through diaphoresis.
( X ) c.) Hemodilution increases normal red blood cell life span.
( X ) d.) Increasing fluid intake increases hemolysis.
RATIONALE: Treatment of a child in vaso-occlusive crisis from sickle cell disease includes measures to prevent further sickling. Sickling occurs in the presence of decreased oxygen tension and alterations in pH. The hard sickle-shaped cells catch on each other and can eventually occlude vessels; that decreases oxygenation of the area and increases the sickling process. Increasing fluids will increase hemodilution and prevent the clumps of sickle cells from occluding vessels. Children in sickle cell crisis do not lose more water than normal through diaphoresis. The life span of a normal red blood cell is 120 days; there is no way to increase this life span. Hemolysis refers to the breakdown of red blood cells, something to be avoided in a child with sickle cell disease. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 704 _ about (MC)
QUESTION: "A toddler with croup is given a Vaponefrin updraft because of increasing respiratory distress. The nurse evaluates the treatment as being effective when the child's:"
CHOICES
( X ) a.) Color is normal.
( O ) b.) Retractions are less severe.
( X ) c.) Heart rate is 100 bpm.
( X ) d.) Pulse oximeter reads 90.
RATIONALE: Vaponefrin is epinephrine in an inhalant form. It is given to decrease inflammation in the upper airway through vasoconstriction. It also has bronchodilator effects. In the case of croup, epinephrine is used to increase the opening of the narrowed airway. A decrease in the severity of retractions is the only answer indicating a change that reflects an increase in the airway opening. Color could have remained the same before and after the treatment. It is most important to assess for ease of respirations. Heart rate could have remained the same before and after the treatment. In addition, epinephrine normally increases heart rate. Oximeter readings could have remained the same before and after the treatment. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 709 _ about (MC)
QUESTION: "A school-aged child is admitted to the hospital with newly diagnosed, insulin-dependent diabetes mellitus. On admission at 10:00 AM, his blood sugar is 180 mg/dL. His urine tests negative for ketones. He receives 10 units of regular humulin insulin subcutaneously at 10:30 AM. The nurse should plan to:"
CHOICES
( X ) a.) Carefully regulate an intravenous solution of normal saline and lente insulin at 12:30 PM.
( X ) b.) Encourage the child to drink at least 500 mL of a sugar-free clear liquid by 11:30 AM.
( X ) c.) Begin intravenous administration of 5% dextrose in water at 11:00 AM.
( O ) d.) Assess the child beginning at 12:30 PM for shakiness, feelings of anxiety, or decreased level of consciousness.
RATIONALE: The onset of the action of insulin is 1/2 to 1 hour. The peak action occurs in 2 to 4 hours. The child needs to be checked for a hypoglycemic reaction (shaking, feelings of anxiety, and decreased level of consciousness) 2 hours after the insulin is given. Lente insulin is not given in an intravenous solution. Only regular insulin is given through the intravenous route. It is not necessary to force fluids on the child. Because there is no information that indicates the child is unable to take fluids and foods by mouth, it is not necessary to give a dextrose solution at this time. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 713 _ about (MC)
QUESTION: "A mother asks the nurse if the lesions around her child's mouth could be impetigo. To verify the mother's suspicions, the nurse would look for:"
CHOICES
( O ) a.) Honey-colored crusts, vesicles, and reddish maculae on the skin.
( X ) b.) Erythema and formation of pus around hair follicles.
( X ) c.) Increased warmth, intense redness, swelling, and firmness of the skin.
( X ) d.) Macular erythema with a sandpaper-like texture of the skin.
RATIONALE: Impetigo presents as reddish macules which turn to vesicles then erupt and form honey-colored crusts. The lesions can be in any stage. Redness and formation of pus around a follicle describes folliculitis. Cellulitis is described as being warm, intensely red, edematous, and firm. Macular eruption with a sandpaper-like texture describes staphylococcal scalded skin syndrome. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 722 _ about (MC)
QUESTION: "A 4-year-old child is brought to the clinic for a checkup. It is determined that the family does not have fluoridated water. The nurse would advise which of the following when using fluoride supplements?"
CHOICES
( X ) a.) Give with meals.
( X ) b.) Be sure to take the supplement with milk.
( O ) c.) Do not eat or drink for 30 minutes after the supplement.
( X ) d.) Have the child swallow the tablet immediately after putting it in the mouth.
RATIONALE: Fluoride supplements should be administered on an empty stomach. No food or fluids should be ingested for 30 minutes after taking the supplement. Fluoride should be given on an empty stomach. They should not be given with calcium-rich foods. A 4-year-old child would probably not be able to take a tablet. If the child were able, she or he should chew the tablet and swished the pieces for 30 seconds before swallowing. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 723 _ about (MC)
QUESTION: "The nurse is suctioning the tracheostomy of a child in a pediatric intensive care unit. The nurse should:"
CHOICES
( X ) a.) Insert the catheter with the suction port of the catheter closed.
( X ) b.) Keep the catheter straight as it is removed from the tracheostomy tube.
( X ) c.) Use clean technique while suctioning.
( O ) d.) Insert the catheter slightly beyond the end of the tracheostomy tube.
RATIONALE: To prevent damage to the carina, the catheter should only be inserted just slightly beyond the end of the tracheostomy tube. The catheter should be inserted with the suction port open then removed while turning the catheter with the suction port closed. The catheter should be rotated as it is removed to better clear secretions from the airway. In acute care settings, tracheostomy suctioning in children is an aseptic procedure. In some circumstances, it can be a clean procedure in the home. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 726 _ about (MC)
QUESTION: "An adolescent with type 1 diabetes is monitoring her blood glucose level at home. Which of the following actions indicates that she understands appropriate care management strategies for a blood glucose level of 250 mg/dL? She will:"
CHOICES
( X ) a.) Skip the next dose of insulin and drink fruit juice.
( O ) b.) Take insulin and drink water.
( X ) c.) Eat a high-carbohydrate meal and exercise.
( X ) d.) Inject glucagon and rest.
RATIONALE: A blood glucose level of 250 mg/dL is indicative of diabetic ketoacidosis. The client should take insulin to lower glucose levels, drink water to prevent dehydration, and contact her health care provider. Skipping a dose of insulin is inappropriate without first contacting the physician. In this case skipping a dose would worsen the client's hyperglycemia. Drinking fruit juice is recommended for treatment of mild hypoglycemia. Hypoglycemic episodes are managed by ingesting foods or beverages with high sugar content. Glucagon is used when the client is unconscious. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 727 _ about (MC)
QUESTION: "A child newly diagnosed with rheumatic fever is to receive penicillin therapy. Which of the following statements by the parents would lead the nurse to judge that the parents understand the teaching about penicillin as part of the treatment plan for rheumatic fever?"
CHOICES
( O ) a.) "Our child should take the medication until the physician discontinues it."
( X ) b.) "How long will it take for the penicillin to help relieve the joint discomfort?"
( X ) c.) "We need to also give these pills to our other children to prevent them from getting rheumatic fever."
( X ) d.) "We should give our child the medication on a full stomach."
RATIONALE: Penicillin is given to children with rheumatic fever to eradicate the hemolytic streptococci that triggered the autoimmune response that causes the disease. It does not decrease joint pain. Prophylactic use of penicillin with siblings is not indicated. Penicillin should be given on an empty stomach. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 729 _ about (MC)
QUESTION: "A parent group is discussing different types of punishment. The parents ask the nurse to discuss corporal punishment. The nurse tells the group that corporal punishment:"
CHOICES
( X ) a.) Does not physically harm the child.
( O ) b.) Can result in children becoming accustomed to spanking.
( X ) c.) Reinforces the idea that violence is not acceptable.
( X ) d.) Can be beneficial in teaching children what they should do.
RATIONALE: Corporeal punishment is an aversion technique that teaches children what not to do. Children can often become accustomed to physical punishment, so the punishment must be more severe to get the same results. Often, parents use physical punishment when they are in a rage; injury to the child can result. Corporeal punishment, such as spanking, can reinforce the idea that violence is acceptable in certain circumstances. Corporal punishment is not beneficial. It causes children to be fearful and to direct their anger in other ways. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 732 _ about (MC)
QUESTION: "A 10-month-old child with bronchitis is taken out of the 30% oxygen tent for breakfast because he refuses to eat unless in a high chair. During the feeding, the nurse notes that the child's respiratory rate has increased, he is becoming more irritable, and he is using accessory muscles to breathe. The first action of the nurse should be to:"
CHOICES
( O ) a.) Discontinue the feeding and place the child back in the tent.
( X ) b.) Assess the pulse rate and respirations and notify the physician.
( X ) c.) Perform postural drainage then complete the feeding.
( X ) d.) Suction the child's nose with a bulb syringe.
RATIONALE: The child who has increasing respiratory difficulty after being removed from an increased oxygen environment should be placed back in the environment. The child's pulse rate will most likely be increased. The nurse does not need to notify the physician of the child's status unless no improvement occurs after the child is back in the oxygen tent. It is best to wait until a later time to feed the child because the act of eating takes energy and oxygen that the child does not have in sufficient supply at the moment. Unless the child has blocked nasal passages, there is no reason to suction the nares. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 733 _ about (MC)
QUESTION: "A mother brings her 2-year-old adopted Korean child to the clinic for an initial checkup. The child has been living with the adopted family for several weeks. The nurse notes an irregular area of deep blue pigment on the child's buttocks extending into the sacral area. The nurse should:"
CHOICES
( O ) a.) Do nothing concerning this finding.
( X ) b.) Ask the mother in private how the bruise occurred.
( X ) c.) Notify social services of a case of possible child abuse.
( X ) d.) Question the mother about the family's discipline style.
RATIONALE: This lesion is a mongolian spot, which is common in children of Asian or African American heritage. The key word in the description is pigment. A bruise results from bleeding into subcutaneous or muscle tissue; it is not a pigment change in the skin. Notifying social services is inappropriate as this is a normal finding. Asking about the family's discipline style suggests the nurse has interpreted this normal finding as a bruise and not as pigment variation. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 736 _ about (MC)
QUESTION: "A child admitted to the hospital with a serum sodium level of 160 mmol/L is receiving 5% dextrose with 0.45 normal saline solution. The mother asks the child's nurse why the child is receiving sodium. The nurse's best reply would be, "Your child's sodium is:"
CHOICES
( X ) a.) High; I'll stop the infusion and check with the physician."
( O ) b.) High; but if serum sodium level is decreased too rapidly, it may cause seizures."
( X ) c.) Low; we need to give some more sodium intravenously."
( X ) d.) Normal; the solution will maintain the level."
RATIONALE: The normal serum sodium level for a child is 138 to 146 mmol/L. The value given is high. A rapid decrease in serum sodium level, however, can cause fluid shifts that will result in a rapid increase in intracranial pressure, increasing the risk of seizures. Therefore, the child's sodium level is monitored carefully and decreased slowly. There is no need to stop the infusion or question the physician as this treatment is designed to slowly lower the sodium level. The sodium level is not low. A solution of 0.2% normal saline in 5% dextrose is most commonly used as a maintenance fluid. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 740 _ about (MC)
QUESTION: "A 10-year-old child is sent home for pediculosis after being at camp for 1 week. The mother thinks others at camp have it. The mother asks the camp nurse how her son could have gotten pediculosis. The nurse would reply:"
CHOICES
( X ) a.) "Children at camp usually get it from the animals here."
( O ) b.) "Children who sleep close to someone who has it get it more easily."
( X ) c.) "He probably got it in boxing class."
( X ) d.) "Usually the kids get it at camp by sharing towels in the shower."
RATIONALE: Children at camp are at higher risk for developing pediculosis because of the close contact with others. Pediculosis is spread person-to-person or on other objects that are shared, such as helmets and combs. Lice are not transmitted by animals or pets. The louse is transmitted from person to person on caps, scarves, or other personal items used near the hair. The louse is transmitted from person to person on caps, scarves, or other personal items used near the hair. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 747 _ about (CM)
QUESTION: "When developing a teaching plan for the parents of a 12-month-old infant, which toys would the nurse expect to include as appropriate suggestions? Select all that apply."
CHOICES
( X ) a.) Plastic containers
( X ) b.) Play dough
( O ) c.) Large balls
( X ) d.) Riding toys
( O ) number="5">Jack in the box
( O ) number="6">Cup and spoon
RATIONALE: Twelve-month-old infants still engage in hand-to-mouth activity. Therefore, they need toys that they can manipulate yet are safe to put in their mouths, such as a cup and spoon. A Jack in the box is appropriate because children like the colors and the sound when the figure jumps out of the box. Larger toys, such as balls, also are appropriate because the infant has not yet developed the manual dexterity for smaller objects. Plastic containers, play dough, and riding toys are more appropriate for toddlers. A toddler can be more independent on a riding toy because of his or her larger size and increased coordination. Play dough is dangerous for infants because of the increased risk of swallowing or aspirating the substance. Developmentally, toddlers like to put objects in containers and dump them out.
NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 748 _ about (CM)
QUESTION: "The nurse is teaching the parents of a 5-year-old child who has just received DTaP, IPV, and MMR vaccines about commonly expected adverse effects. Which of the following would be included? Select all that apply."
CHOICES
( X ) a.) Fever of 103% F (39.5% C)
( O ) b.) Redness at injection site
( O ) c.) Rash
( O ) d.) Anorexia
( X ) number="5">Prolonged crying
( X ) number="6">Diarrhea
RATIONALE: Common adverse effects associated with these vaccines include redness, swelling, soreness at the injection site, low-grade fever, anorexia, malaise, rash 7-10 days following the MMR, and fussiness. A fever of 103% F is a high-grade fever and not usually seen following immunization administration. Prolonged crying and diarrhea are not associated with these immunizations. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
CL: Application
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--> QUESTION NUMBER _ 749 _ about (FI)
QUESTION: "A 5-year-old child who weighs 44 pounds is given penicillin V suspension for a throat culture positive for streptococcus. The dose is 40 mg/kg/day, divided into 2 doses. The pharmacy supplies penicillin V in a concentration of 250 mg/5 mL. The nurse would administer how many milliliters for each dose? "
RATIONALE: First convert the child's weight to kilograms by dividing by 2.2. 44 pounds = 20 kg. Next determine the dosage for 1 day: 40 mg x 20 kg = 800 mg per day or 400 mg per dose Lastly determine the amount for the dose: 250 = 400 5x Cross-multiply and divide: 250x = 2000 x = 8 mL/dose NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiologic integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 750 _ about (CM)
QUESTION: "Which suggestions would the nurse include when teaching the parents of a child who has viral tonsillitis? Select all that apply."
CHOICES
( X ) a.) Administering aspirin for fever control
( O ) b.) Gargling with warm salt water
( X ) c.) Supplying a regular diet
( X ) d.) Offering cough medicine every 4 hours
( O ) number="5">Giving acetaminophen for sore throat
( O ) number="6">Offering lots of fluids
RATIONALE: Treatment for viral tonsillitis consists of supportive care, gargles, encouraging fluids, and administering acetaminophen for fever and sore throat. Aspirin is not used to control fever because of its associated risk of Reye's syndrome. The child's throat is sore, so a regular diet would probably irritate the child's throat. Cough medicine would not be indicated unless the child has a cough. Viral tonsillitis usually does not cause coughing.
NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiologic integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 751 _ about (CM)
QUESTION: "When teaching the parents of a child diagnosed with Tetralogy of Fallot about the cardiac defects involved with this condition, which defects would the nurse describe? Select all that apply. "
CHOICES
( O ) a.) Right ventricular hypertrophy
( X ) b.) Aortic valve stenosis
( O ) c.) Ventricular septal defect
( O ) d.) Overriding aorta
( X ) number="5">Atrial septal defect
( O ) number="6">Pulmonary stenosis
RATIONALE: Tetralogy of Fallot involves four defects: Ventricular septal defect, overriding aorta, right ventricular hypertrophy, and pulmonary stenosis. Aortic valve stenosis and atrial septal defect are not components associated with this condition. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 752 _ about (CM)
QUESTION: "Which of the following might the nurse expect when assessing a child diagnosed with rheumatic fever? Select all that apply."
CHOICES
( X ) a.) Vomiting
( O ) b.) Arthralgia
( O ) c.) Pericardial friction rub
( O ) d.) Arthritis
( X ) number="5">Diarrhea
( X ) number="6">Seizures
RATIONALE: Signs and symptoms of rheumatic fever include carditis, pericardial friction rub, polyarthritis, chorea, erythema marginatum, subcutaneous nodules, fever, and arthralgia. Vomiting, diarrhea, and seizures are not typically associated with rheumatic fever.
NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 753 _ about (FI)
QUESTION: "A child with dehydration is to receive 500 mL IV fluids over the next 6 hours. The nurse would set the infusion pump to run at how many milliliters per hour?"
RATIONALE: The nurse must determine the flow rate for one hour by dividing 500 mL by 6 hours; 500/6 = 83 mL/hr.
NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 754 _ about (CM)
QUESTION: "Which of the following strategies would the nurse use when counseling an adolescent to change eating habits for weight loss? Select all that apply."
CHOICES
( O ) a.) Write down all foods eaten.
( O ) b.) Eat only at certain times.
( O ) c.) Leave food on your plate.
( O ) d.) Eat the food at a slower pace.
( X ) number="5">Do something else while eating.
RATIONALE: Keeping a written record of when, how much, and with whom eating occurs is important to identify eating patterns. Eating also should be restricted to certain times and in certain places. Other activities should not be done during a meal. The pace of eating should be slowed and leaving food on the plate is also encouraged. Low-fat, low-calorie foods typically are included in the plan. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 755 _ about (CM)
QUESTION: "Parents are asking about the signs and symptoms of a lower urinary tract infection (UTI). Which of the following would the nurse include in the response? Select all that apply."
CHOICES
( O ) a.) Abdominal pain
( O ) b.) Vomiting
( O ) c.) Diarrhea
( X ) d.) Fever
( O ) number="5">Dysuria
RATIONALE: The classic signs of a lower UTI include enuresis, abdominal pain, strong smelling urine, dysuria, urgency, vomiting, and diarrhea. Fever is found more commonly in upper urinary tract infections.
NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 756 _ about (CM)
QUESTION: "The nurse teaches the parents of a 5-year-old child who has been given trimethoprim/sulfamethoxazole (Bactrim, Septra) for a UTI about appropriate care measures. Which of the following would be included? Select all that apply."
CHOICES
( O ) a.) Using a sunscreen
( X ) b.) Refrigerating medication
( X ) c.) Administering with milk or food
( O ) d.) Keeping the child well hydrated
( O ) number="5">Keeping medication out of the sunlight
RATIONALE: Trimethoprim/sulfamethoxazole (Bactrim, Septra) needs to be kept out of direct sunlight (it comes in a dark bottle) and sunscreen should be applied to the child daily until the medication is completed. Children with a UTI should drink lots of fluids to help flush the organisms from the bladder. The medication does not need to be refrigerated, nor does it need to be taken with milk or food. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 757 _ about (FI)
QUESTION: "A 5-year-old child has been placed on phenytoin (Dilantin) for tonic-clonic seizures. The child weighs 42 pounds and the maintenance dose ordered for this child is 7.5 mg/kg/day. How many milligrams should the child receive each day? "
RATIONALE: First determine the child's weight in kilograms: 42 pounds divided by 2.2 = 19.0 kg Then determine the dose by multiplying the child's weight by the dose ordered: 19 kg x 7.5 mg = 143 mg/day NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 758 _ about (CM)
QUESTION: "A parent asks the nurse about the major causes of brain injury in children. Which of the following would the nurse include in the response as the major causes? Select the three most common causes."
CHOICES
( O ) a.) Falls
( O ) b.) Motor vehicle accidents
( O ) c.) Bicycle accidents
( X ) d.) Child abuse
( X ) number="5">Tumors
RATIONALE: Children tend to be impulsive, which contributes to head injuries. Also, the larger size of the heads of infants and toddlers causes them to fall more easily than older children. Falls account for one third of all head injuries. Motor vehicle accidents account for approximately 80% of all severe head injuries in children. Children 5-15 years of age are most likely to be involved in bicycle accidents as a result of approximately 50% wearing helmets. Although child abuse and tumors can cause brain injury, these incidents involve a much smaller number of children. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 759 _ about (CM)
QUESTION: "A child diagnosed with osteomyelitis will be discharged on IV nafcillin. After teaching the parents about adverse effects that are important to report, which effects if stated by the parents indicate that they have understood the instructions? Select all that apply."
CHOICES
( O ) a.) Sore mouth
( X ) b.) Pain with urination
( X ) c.) Headache
( O ) d.) Stomach upset
( O ) number="5">Fever
RATIONALE: Common adverse effects from nafcillin include vomiting, diarrhea, sore mouth, fever, and gastritis. Pain with urination and headache are not associated with this drug.
NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 760 _ about (FI)
QUESTION: "All of the following children were admitted yesterday. In which order would the nurse assess these children? Fill in the blank.
1. A 3-month-old infant with respiratory syncytial virus (RSV) and stable vital signs.
2. A 10-month-old infant with pneumonia and respiratory rate of 50.
3. A 3-year-old child with acute pyelonephritis and temperature of 104.5% F.
4. A 6-year-old child with concussion and little change in vital signs.
5. A 12-year-old child with a fractured femur and lacerated liver."
RATIONALE: The child whose condition could change most quickly would be assessed first and the most stable client would be assessed last. The child with a lacerated liver is at the highest risk for a rapid change in condition. Therefore, this child would be assessed first because the child is at high risk for hemorrhage. The child with a recent concussion would be assessed next because the child is at high risk for increased intracranial pressure, which would indicate a change in neurological status. The third child to be assessed is the 3-year-old child with pyelonephritis and fever. The fever needs to be acted upon but this assessment is not as critical as that for the child with a lacerated liver and the child with a concussion. The normal respiratory rate for a 10-month-old infant is 30 breaths per minute. Although the infant is tachypneic, this is expected with pneumonia. Additionally, the infant is not in acute respiratory distress. However, the increased respiratory rate needs evaluation, so the 10-month old infant would be assessed before the 3-month-old infant with RSV who has stable vital signs and is not in acute distress. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 761 _ about (CM)
QUESTION: "After teaching the parent of a child newly diagnosed with type I diabetes about signs of hypoglycemia, which of the following if stated by the parent indicates the need for additional teaching? Select all that apply."
CHOICES
( O ) a.) Lethargy
( X ) b.) Headache
( X ) c.) Dizziness
( X ) d.) Sweating
( X ) number="5">Tremors
( O ) number="6">Thirst
RATIONALE: Signs of hypoglycemia include irritability, headache, dizziness, pallor, sweating, and tremors. Signs of hyperglycemia include lethargy, thirst, confusion, abdominal pain, nausea, and vomiting. It is important for parents to know the difference so correction of the problem can be initiated. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 146 _ about (MC)
QUESTION: "A female client is experiencing bladder control problems. Which of the following client outcomes would indicate the success of nursing interventions to promote urinary continence?"
CHOICES
( O ) a.) Continence for 24 hours a day.
( X ) b.) Improvement in bladder control.
( X ) c.) Self-monitoring for urine retention.
( X ) d.) Compliance with drinking and voiding schedule.
RATIONALE: The ultimate goal is to promote urinary continence. Thus, the client being continent for 24 hours a day demonstrates definitive evidence that this goal has been met. Self-monitoring for urine retention is an important aspect of achieving the outcome but it addresses only one area and does not reflect goal achievement. Complying with the drinking and voiding schedule is an important aspect of achieving the outcome but it addresses only one area and does not reflect goal achievement. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 152 _ about (MC)
QUESTION: "When assisting the physician in cardioversion of a client admitted with ventricular tachycardia, the nurse knows that cardioversion differs from defibrillation. Which of the following is associated with the delivery of the shock with cardioversion? "
CHOICES
( X ) a.) Asynchronous shock with the R wave.
( O ) b.) Synchronous shock with the QRS complex.
( X ) c.) Use of a higher wattage.
( X ) d.) Use of a different machine.
RATIONALE: In cardioversion, the shock is delivered synchronously with the QRS complex. Cardioversion synchronized during the QRS complex is used to prevent the shock from occurring during the T wave, thereby causing ventricular fibrillation. Defibrillation is used to treat ventricular fibrillation which does not produce recognizable waveforms. Typically cardioversion is done at a lower wattage than defibrillation is. The same machine is used for cardioversion and defibrillation; the caregiver sets the mode to synchronous or asynchronous. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 154 _ about (MC)
QUESTION: "When caring for a client with acute osteomyelitis in the right tibia, which of the following measures is most appropriate to implement when repositioning the client's leg?"
CHOICES
( X ) a.) Hold the leg by the ankle when repositioning to avoid touching the tibia.
( X ) b.) Have the client move the leg by himself to decrease pain.
( O ) c.) Support the leg above and below the affected area when positioning.
( X ) d.) Apply warm moist compresses to the leg before repositioning.
RATIONALE: The most appropriate action when moving an extremity with acute osteomyelitis is to ensure that the extremity is carefully supported above and below the affected area. A splint may be useful to decrease discomfort. Acute osteomyelitis can be very painful. Therefore, the extremity must be handled carefully and moved slowly. Holding the leg by the ankle is inappropriate because doing so does not provide adequate support to the affected area. Allowing the client to move the leg by himself will not provide adequate support to the affected area. Applying warm moist compresses does not decrease the need to adequately support the affected area. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 159 _ about (MC)
QUESTION: "After a mastectomy for breast cancer, the nurse teaches the client how to avoid the development of lymphedema. Which of the following instructions would be included?"
CHOICES
( X ) a.) Applying an elastic bandage to the affected extremity.
( X ) b.) Limiting range-of-motion exercises in the shoulder and elbow.
( O ) c.) Elevating the affected arm on a pillow.
( X ) d.) Taking diuretics as necessary to decrease swelling.
RATIONALE: The client should be taught to elevate the affected arm on a pillow to promote venous return and lymphatic drainage of the area. Applying an elastic bandage is inappropriate because constriction of the extremity should be avoided. Range-of-motion exercising is not limited. Rather, it is encouraged. Diuretics are not used to control lymphedema. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 162 _ about (MC)
QUESTION: "After teaching a client how to instill nose drops, the nurse evaluates that the client's technique is correct when the client does which of the following? "
CHOICES
( X ) a.) Uses sterile technique when handling the dropper.
( X ) b.) Blows the nose gently after instilling the medicine.
( O ) c.) Lies supine for several minutes after instilling the drops.
( X ) d.) Uses a new dropper for each medication instillation.
RATIONALE: The client should be instructed to lie supine with head tilted back for several minutes after instillation of the nose drops to ensure adequate absorption of the medication by the nasal mucosa. Because the nose is not sterile, sterile technique is not necessary. The client should blow the nose gently before, not after, the medication. The dropper should be cleaned after each use; a new dropper is not necessary for each instillation. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 164 _ about (MC)
QUESTION: "A client has been told to take ibuprofen (Motrin, Advil) to relieve the pain of her rheumatoid arthritis. Which of the following statements indicates the client understands how to take this drug safely and effectively?"
CHOICES
( O ) a.) "I should not take aspirin with this drug unless my physician says to."
( X ) b.) "I should not take this drug with antacids or food products."
( X ) c.) "I do not need to worry about this medicine irritating my stomach."
( X ) d.) "I should notice the effects of this medicine within the first few days."
RATIONALE: Ibuprofen can be irritating to the stomach and should not be taken with other drugs that are known gastric irritants such as aspirin. Antacids may be taken at the same time as the ibuprofen because they do not affect the drug's absorption. The drug also may be taken with food to minimize gastrointestinal upset if it occurs. Ibuprofen is a known gastric irritant. It may take several days to weeks for the drug to be effective in relieving the client's symptoms. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 167 _ about (MC)
QUESTION: "When a client demonstrates the technique for self-administering NPH insulin, which of the following would indicate to the nurse that the client needs additional teaching?"
CHOICES
( O ) a.) Shaking the insulin vial before withdrawing the insulin into the syringe.
( X ) b.) Introducing the needle into subcutaneous tissue using a quick dart-like action.
( X ) c.) Pulling back on the syringe plunger as soon as the needle is in subcutaneous tissue.
( X ) d.) Holding an antiseptic sponge against the needle when removing it from subcutaneous tissue.
RATIONALE: The client should be instructed to mix the sediment that accumulates in a vial of NPH insulin by rolling the vial gently between the palms or by turning the vial upside down several times. Shaking the vial is not recommended because it produces bubbles that make it difficult to withdraw accurate doses of insulin. Using a quick dart-like action is a proper technique for self-administering insulin. Pulling back on the syringe plunger as soon as the needle is in subcutaneous tissue determines whether the needle is in a blood vessel and is a proper technique for self-administering insulin. Holding an antiseptic sponge against the needle when removing it from tissue to prevent the discomfort of the needle pulling on the skin is appropriate technique. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 168 _ about (MC)
QUESTION: "Which of the following positions would permit the best assessment of a client's inguinal hernia?"
CHOICES
( O ) a.) Standing.
( X ) b.) Sitting.
( X ) c.) Left side-lying.
( X ) d.) Right side-lying.
RATIONALE: For the best assessment of an inguinal hernia, the client should be in a standing position to allow the examiner to palpate for the inguinal ring. After being examined in the standing position, the client may be asked to lie down to determine whether the hernia can be reduced and its sac contents returned to the abdominal cavity. The sitting position does not allow the examiner to palpate for the inguinal ring. The left side-lying position does not allow the examiner to palpate for the inguinal ring. The right side-lying position does not allow the examiner to palpate for the inguinal ring. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease
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--> QUESTION NUMBER _ 171 _ about (MC)
QUESTION: "Which of the following nursing diagnoses would be most appropriate for a client newly diagnosed with non-insulin-dependent diabetes mellitus?"
CHOICES
( X ) a.) Risk for Infection related to newly diagnosed diabetes.
( X ) b.) Altered Nutrition: More Than Body Requirements related to overproduction of insulin.
( X ) c.) Pain related to elevated blood glucose levels.
( O ) d.) Altered Health Maintenance related to lack of knowledge of proper foot care.
RATIONALE: Knowledge of foot care is essential for the client with diabetes mellitus, especially a newly diagnosed diabetic, because of the risk for complications secondary to the effects of diabetes on the vascular and neurologic systems. Improper care may lead to serious debilitating complications. Although Risk for Infection may be an appropriate nursing diagnosis, Ineffective Health Maintenance is the priority for the newly diagnosed diabetic. Knowledge of foot care is essential to minimize the risk of complications, including infection, secondary to the effects of diabetes on the vascular and neurologic systems. With insulin-dependent diabetes, insulin is lacking as opposed to being overproduced. Overproduction of insulin would cause hypoglycemia resulting in a decrease, not an increase, of needed nutrients. Pain typically is not a problem associated with diabetes. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 175 _ about (MC)
QUESTION: "After 2 weeks of radiotherapy, a client with Hodgkin's disease becomes discouraged, stating, "I'm so tired that I can barely keep up with my studies." The nurse bases the response on which of the following statements about fatigue?"
CHOICES
( O ) a.) One of the most common problems associated with radiotherapy, persisting throughout therapy.
( X ) b.) A transient problem that typically will resolve as radiotherapy continues.
( X ) c.) Further evaluation needed to determine another possible cause because of no relationship to radiotherapy.
( X ) d.) An indication that the disease has been eradicated, making additional radiotherapy unnecessary.
RATIONALE: Fatigue is one of the most common problems associated with radiotherapy. It persists during therapy and for varying periods after therapy ends. Extra rest and a reduction in normal activity are often necessary to maintain a reasonable energy level. Fatigue persists during therapy and for varying periods after therapy ends. It is not a transient problem that resolves with the continuation of treatment. Fatigue is one of the most common problems associated with radiotherapy. Fatigue is one of the most common problems associated with radiotherapy. It is unrelated to the extent of disease present. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 177 _ about (MC)
QUESTION: "After abdominal surgery, a client is reluctant to turn in bed. Which of the following interventions would be most appropriate?"
CHOICES
( X ) a.) Allow the client to turn when she wants.
( O ) b.) Explain the importance of turning to the client.
( X ) c.) Remind her that she must follow her doctor's orders.
( X ) d.) Tell her family to encourage her to turn.
RATIONALE: The most appropriate intervention for the nurse is to reinforce for the client that turning in bed will decrease the likelihood for developing postoperative complications. Allowing the client to turn when she wants is not appropriate because with her reluctance, she would most likely not turn frequently enough. Reminding the client to follow the doctor's orders is inappropriate because this appears as a threat to the client and does not address the underlying problem of lack of knowledge. If the client understands the reason for turning, she may be more inclined to participate in the activity despite the discomfort. Although family encouragement may help, the best action is to explain the need for turning. If the client understands the reason for turning, she may be more inclined to participate in the activity despite the discomfort. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 180 _ about (MC)
QUESTION: "Which of the following statements would the nurse identify as the best indication of a 50-year-old client's developmental concerns at this time in his life?"
CHOICES
( O ) a.) It is time to reevaluate life's goals.
( X ) b.) The selection of a career is important.
( X ) c.) Leisure-time activities are a center of focus.
( X ) d.) Stress associated with illness precipitates a need to "settle down."
RATIONALE: During middle adulthood (age 45 to 55 years), most people go through a process of taking stock of their lives, becoming very aware of the time left to live. This appears to be especially true of men. Death becomes more of a reality instead of something that happens only to others. Career selection is more commonly associated with younger adults. Leisure-time activities are more commonly associated with younger adults. Settling down is a more typical concern of younger adults. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation
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--> QUESTION NUMBER _ 183 _ about (MC)
QUESTION: "A client with Hodgkin's disease explains the monitoring that he will be doing at home between radiation treatments. Which of the following statements would indicate that he knows how to detect a major complication?"
CHOICES
( X ) a.) "I'll measure my neck circumference every day."
( O ) b.) "I'll take my temperature every day."
( X ) c.) "I'll monitor the loss of body hair every week."
( X ) d.) "I'll check the circulation in my arms every day."
RATIONALE: Clients with Hodgkin's disease are extremely vulnerable to infection because of the defective immune responses caused by the tumor as well as the bone-marrow depression and low white blood cell count that result from radiation therapy. Fever is the most sensitive indicator of infection and should be reported immediately so that treatment can be initiated. Measuring neck circumference is not related to any major complications associated with Hodgkin's disease and radiation therapy. Loss of hair is unusual with radiation therapy to the neck. Upper extremity circulation is not related to any major complication associated with Hodgkin's disease and radiation therapy. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 190 _ about (MC)
QUESTION: "Which of the following interventions would be most helpful in preventing pressure ulcer formation in at-risk client?"
CHOICES
( O ) a.) Repositioning every hour.
( X ) b.) Providing a low-protein diet.
( X ) c.) Ensuring a generous fluid intake.
( X ) d.) Massaging reddened areas on the sacrum.
RATIONALE: Because pressure ulcers (decubitus ulcers) are caused by pressure to the tissues, the most important measure in preventing them is to relieve the pressure by repositioning the client every 1 to 2 hours. Adequate caloric and protein intake, although important, will not prevent pressure ulcer formation. The underlying cause is pressure. A generous fluid intake will not prevent ulcer formation. The underlying cause is pressure. Massaging reddened areas and bony prominences, once thought to reduce risk of pressure ulcer formation, is now known to increase the risk of pressure ulcer formation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 195 _ about (MC)
QUESTION: "A 70-year-old woman recently admitted to a nursing home has developed urinary incontinence. The client's family is concerned and asks the nurse what can be done to help their mother. Which of the following would be the nurse's most appropriate response?"
CHOICES
( O ) a.) "We need to assess your mother and her environment further to determine an appropriate plan of care for her incontinence."
( X ) b.) "Usually these episodes are self-limiting. After she adjusts to her environment, she should have no further incontinence."
( X ) c.) "This happens frequently and is not a cause for concern. We can provide her with absorbent pads to keep her dry."
( X ) d.) "It is difficult to treat urinary incontinence, especially in the elderly. If it continues, a catheter can be used to make her more comfortable."
RATIONALE: Clients who develop incontinence need to be thoroughly evaluated for an underlying physical cause. The client's physical environment and emotional and social factors also need to be evaluated because these elements can contribute to the development of urinary incontinence. Urinary incontinence should not be accepted as a normal occurrence in the elderly or in the nursing home. Urinary incontinence should not be accepted as a normal occurrence in the elderly or in the nursing home. Further investigation is necessary to determine the cause. Although urinary incontinence may be a frequent occurrence, it is a concern. Telling the family that it is not ignores their feelings and concerns. Using absorbent pads can promote feelings of embarrassment in the client. Behavioral interventions can be effective in the treatment of incontinence. Indwelling catheters are not considered the first line of treatment and are to be avoided. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 197 _ about (MC)
QUESTION: "Which of the following nursing measures would be most appropriate when caring for a client in skeletal traction for a fractured femur?"
CHOICES
( X ) a.) Maintaining the client in a supine position.
( X ) b.) Removing the weights temporarily when repositioning the client.
( O ) c.) Inspecting the pin site at least every 8 hours.
( X ) d.) Maintaining the foot in a position of plantar flexion.
RATIONALE: When a client is in skeletal traction, the pin site should be inspected for redness, swelling, drainage, pain, and movement at least once a shift. Doing so allows for early identification and prompt intervention should an infection occur. The client may be placed in a semi-Fowler's position and does not have to be kept supine. Skeletal traction is never interrupted by removing the weights. Plantar flexion is to be avoided to prevent the development of foot drop. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 200 _ about (MC)
QUESTION: "Which of the following statements demonstrates that a client understands what to expect after an upper gastrointestinal (UGI) radiograph series?"
CHOICES
( X ) a.) "I can expect to have stomach pains for about 2 days after the test."
( X ) b.) "I should limit my diet to soft foods until after my first bowel movement."
( O ) c.) "My stools will appear white in color for about 24 hours after the test."
( X ) d.) "I should limit my activity for 24 hours after the test."
RATIONALE: A UGI series involves the use of radiopaque material, such as barium. Thus, the client will experience white stools about 24 to 48 hours after the upper gastrointestinal series due to the passage of barium. Abdominal pain would not be expected after this test. If it occurs, the physician is to be notified.
Typically after a UGI series, a mild laxative is given to promote the passage of barium. Limiting the diet to soft foods is not necessary. An increase in fiber intake may be helpful in promoting peristalsis and the passage of barium. Limiting activity is not necessary after this test. In fact, activity is encouraged to aid elimination. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 207 _ about (MC)
QUESTION: "When developing a teaching plan for a sexuality class at a community center about human immunodeficiency virus (HIV) transmission, the nurse would include which of the following behaviors as a measure to greatly reduce the risk of transmission? "
CHOICES
( X ) a.) Avoiding inhalant drugs.
( X ) b.) Avoiding prolonged sex.
( O ) c.) Using latex condoms with sexual intercourse.
( X ) d.) Douching before and after sexual intercourse.
RATIONALE: Using a latex condom in conjunction with a spermicide during sexual intercourse greatly reduces the risk of HIV transmission. Because HIV is most concentrated in blood and vaginal and seminal fluids, protective measures during intercourse are necessary to prevent transmission. The use of inhalant drugs is not considered a risk factor for transmitting HIV. Any unprotected sex, regardless of the length of contact, can place an individual at risk for HIV. Douching has not been associated with decreasing the risk of HIV transmission. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease
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--> QUESTION NUMBER _ 210 _ about (MC)
QUESTION: "While reviewing the arterial blood gas values of a client with emphysema, the nurse would identify which of the following PaCO 2 values as indicating the need for immediate intervention? "
CHOICES
( X ) a.) 35 mm Hg.
( X ) b.) 45 mm Hg.
( X ) c.) 60 mm Hg.
( O ) d.) 80 mm Hg.
RATIONALE: Although normal PaCO 2 values range from 35 to 45 mm Hg, the client with long-standing emphysema has chronic carbon dioxide retention, leading to elevated PaCO 2 levels. A PaCO 2 level of 80 mm Hg is life-threatening and always requires immediate intervention, possibly mechanical ventilation, to reduce the PaCO 2 level. Normal PaCO 2 values range from 35 to 45 mm Hg. A value of 35 mm Hg would be within normal limits and would not be a cause for concern. Normal PaCO 2 values range from 35 to 45 mm Hg. A value of 45 mm Hg would be within normal limits and would not be a cause for concern. The client with emphysema and a PaCO 2 level of 60 mm Hg may not be in immediate danger, but the nurse would want to further evaluate the client with this level. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 215 _ about (MC)
QUESTION: "A client who has been using crutches at home for 1 week reports that he is having trouble using the crutches because his armpits hurt and his fingers tingle. Which of the following would be the nurse's most appropriate response? "
CHOICES
( X ) a.) "You need to do more arm exercises. It sounds like your muscles need strengthening."
( X ) b.) "That's normal. As you adjust to the crutches, the discomfort will diminish."
( X ) c.) "Be sure to take your pain medication before ambulating. That will help your discomfort."
( O ) d.) "Let me watch you ambulate. Your crutches or technique may need some adjustment."
RATIONALE: The nurse should reevaluate the client's use of his crutches because pressure on the axillae from the crutches can lead to "crutch paralysis" secondary to pressure on the brachial plexus nerves. This pressure can result from crutches that are used inappropriately or sized incorrectly. There should be two to three finger widths between the axillae and the top of the crutches when the crutches are placed 6 to 8 inches in front of the feet. When the client is walking, weight should be on the palms of the hands not on the axillae. Although the client's muscles may need strengthening, the client is reporting signs and symptoms associated with pressure on the brachial plexus that require a readjustment in the crutches or the client's technique. Complaints of pain in the axillae and tingling fingers are not normal. Further investigation is necessary. Although analgesic use prior to ambulating may be appropriate, complaints of pain in the axillae and tingling fingers are not normal. Analgesics would not be used to treat these complaints. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 217 _ about (MC)
QUESTION: "For a client with a demand pacemaker, the nurse explains that this pacemaker functions by providing stimuli to the heart muscle at which of the following times? "
CHOICES
( X ) a.) When the heart begins to beat irregularly.
( X ) b.) Constantly, resulting in a predetermined heart rate.
( O ) c.) When the heart rate falls below a specified level.
( X ) d.) Whenever ventricular fibrillation occurs.
RATIONALE: In contrast to a fixed-rate pacemaker, a demand pacemaker functions only when the heart rate falls below a certain level. A pacemaker is not used to provide cardioversion or defibrillation for cardiac arrhythmias (ie, when the heart begins to beat irregularly). A fixed-rate pacemaker stimulates heart contractions at a constant rate independent of the client's heart rate. This type is much less common than the demand pacemaker. For a client with ventricular fibrillation, a potentially life-threatening arrhythmia, an implanted defibrillator is used. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 218 _ about (MC)
QUESTION: "The nurse determines that a client's abdominal wound has eviscerated. Which of the following would the nurse do first? "
CHOICES
( X ) a.) Notify the client's physician immediately.
( X ) b.) Reinsert the protruding viscera into the abdominal cavity.
( X ) c.) Place the client in reverse Trendelenburg's position.
( O ) d.) Cover the wound with sterile saline-moistened dressings.
RATIONALE: In the event of wound evisceration, the first action would be to cover the wound with a sterile towel or dressing moistened with sterile normal saline solution to prevent possible infection and keep the protruding viscera moist. Notifying the physician would be done once the area is covered with sterile saline-moistened dressings. Reinserting any protruding viscera is never attempted because of the possible risks for infection and perforation. Typically, the client is placed supine with knees flexed to reduce tension on the protruding viscera. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 223 _ about (MC)
QUESTION: "When collaborating with the physician in the development of a drug regimen for a client with cancer, the nurse would expect which of the following medications to be avoided in the treatment of cancer pain? "
CHOICES
( O ) a.) Meperidine (Demerol).
( X ) b.) Morphine.
( X ) c.) Acetaminophen (Tylenol).
( X ) d.) Hydromorphone (Dilaudid).
RATIONALE: Meperidine, useful for short-term treatment of acute pain, is inappropriate for use with clients experiencing chronic pain, such as that associated with cancer, because of the drug's short duration of action. Meperidine also can be toxic in clients with impaired renal function or the elderly. To treat cancer pain, the World Health Organization recommends a three-step analgesic ladder approach involving nonopiod (nonnarcotic) analgesics, opioid analgesics, and adjuvant drugs such as antidepressants and antiemetics. Opioid drugs of choice include morphine, the most commonly used opioid drug used for the treatment of cancer pain; hydromorphone (Dilaudid); and codeine. To treat cancer pain, the World Health Organization recommends a three-step analgesic ladder approach involving nonopiod (non-narcotic) analgesics, opioid analgesics, and adjuvant drugs such as antidepressants and antiemetics. Common nonopiod analgesics include acetaminophen (Tylenol), salicylates, and nonsteroidal anti-inflammatory drugs (NSAIDS). To treat cancer pain, the World Health Organization recommends a three-step analgesic ladder approach involving nonopiod (non-narcotic) analgesics, opioid analgesics, and adjuvant drugs such as antidepressants and antiemetics. Opioid drugs of choice include morphine, the most commonly used opioid drug used for the treatment of cancer pain; hydromorphone (Dilaudid); and codeine. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 226 _ about (MC)
QUESTION: "Which of the following would the nurse suggest to a family living in a rural area where the drinking water is not fluoridated as the most appropriate means for obtaining a significant amount of fluoride? "
CHOICES
( O ) a.) Tea.
( X ) b.) Yogurt.
( X ) c.) Citrus juices.
( X ) d.) Natural cheeses.
RATIONALE: Most foods contain limited amounts of fluoride. However, tea contains a significant amount of fluoride and would be the most appropriate suggestion. Yogurt contains limited amounts of fluoride. Citrus juices contain limited amounts of fluoride. Natural cheeses contain limited amounts of fluoride. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease
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--> QUESTION NUMBER _ 232 _ about (MC)
QUESTION: "When developing the plan of care for a client with aplastic anemia, which of the following goals would be most appropriate to include? "
CHOICES
( O ) a.) Perform activities of daily living without excessive fatigue or dyspnea.
( X ) b.) Learn how to administer weekly vitamin B 12 injections.
( X ) c.) Correctly demonstrate how to take prescribed anticoagulant drug therapy.
( X ) d.) Describe self-care behaviors to prevent the transmission to family members.
RATIONALE: With aplastic anemia, measures to conserve energy and reduce oxygen requirements are key. Therefore, an appropriate goal would be to strive to perform activities of daily living without excessive fatigue or dyspnea. The client needs adequate vitamin B 12 in the diet. However, vitamin B 12 injections usually are not required. Anticoagulants are contraindicated in clients with low platelet counts, which often occur in aplastic anemia. Aplastic anemia is not contagious. Thus, measures to prevent transmission are inappropriate. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 237 _ about (MC)
QUESTION: "Which of the following would be the priority for a client admitted to the emergency room with burns covering an estimated 27% of body surface area? "
CHOICES
( X ) a.) Inserting a large-caliber intravenous line.
( X ) b.) Administering an intramuscular morphine injection.
( O ) c.) Establishing a patent airway.
( X ) d.) Administering tetanus toxoid.
RATIONALE: Establishing a patent airway is the priority intervention in burn trauma cases. Prophylactic intubation is initiated if heat has been inhaled or if the neck, head, or face is involved. Swelling of the upper airways can progress to obstruction. After the airway has been established, circulatory support is the next priority. Once the client's airway is established, circulatory support including fluid replacement is the next priority. This is best accomplished using two large-caliber peripheral catheters. However, if the burn is large or complicated by inhalation injuries, one peripheral line and one central line are preferred. Although burns, such as partial thickness burns, are painful, morphine sulfate, the analgesic of choice, is not administered until the client is stable. When it is warranted, the intravenous route is used. Tetanus prophylaxis is begun in the emergency room but only after the providing a patent airway and circulatory support. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 244 _ about (MC)
QUESTION: "When preparing a client for a scheduled colonoscopy, which of the following would the nurse include? "
CHOICES
( X ) a.) Inserting a nasogastric tube 12 hours before the procedure.
( O ) b.) Cleansing the bowel with laxatives or enemas.
( X ) c.) Administering an antibiotic to decrease the risk of infection.
( X ) d.) Spraying a local anesthetic into the client's throat to calm the gag reflex.
RATIONALE: A colonoscopy is the visual examination of the large bowel using a fiberoptic endoscope inserted into the client's rectum. Typically the client will be placed on a liquid diet 24 hours before the procedure and kept NPO after midnight the night before the procedure. The bowel is cleansed through the use of laxatives and enemas. Inserting a nasogastric tube is not part of the preparation for a colonoscopy. It may be done prior to bowel surgery or for gastric decompression. The client does not usually receive antibiotics before the procedure. However, antibiotics may be used prior to bowel surgery to decrease the risk of infection. A local anesthetic used to calm the gag reflex would be used for an upper gastrointestinal endoscopic procedure, such as a gastroscopy, not a lower gastrointestinal endoscopic procedure, such as a colonoscopy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 245 _ about (MC)
QUESTION: "Which of the following nursing interventions is most appropriate when caring for a client who has an acute case of stomatitis? "
CHOICES
( O ) a.) Using a soft toothbrush to provide oral hygiene.
( X ) b.) Rinsing mouth with commercial mouthwash before and after each meal.
( X ) c.) Cleansing gums and oral mucosa with lemon-glycerin swabs every shift.
( X ) d.) Keeping dentures in place to decrease development of edema.
RATIONALE: A soft toothbrush, Toothette, or gauze pad should be used to provide oral hygiene at least every 2 hours to promote client comfort and prevent superinfection. Commercial mouthwash is contraindicated because of high alcohol content that is irritating to inflamed mucosa. Lemon-glycerine swabs are to be avoided because they are drying and also can promote bacterial growth. Leaving dentures in place will have no effect on the development of edema. Additionally, further irritation of the oral mucosa may occur if dentures are left in place. Dentures should be removed to aid in relieving the client's discomfort or pain. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 247 _ about (MC)
QUESTION: "Which one of the following clients would the nurse expect to be at highest risk for developing a urinary tract infection? "
CHOICES
( X ) a.) Woman who has delivered two children vaginally.
( O ) b.) Man with an indwelling urinary catheter for incontinence.
( X ) c.) Man with a past medical history of renal calculi.
( X ) d.) Woman with well-controlled diabetes mellitus.
RATIONALE: Indwelling catheters are considered to be a major contributor to nosocomial infections. Any client with an indwelling catheter is at high risk for developing a urinary tract infection. A history of previous childbirths does not necessarily predispose a client to urinary tract infections. Clients with a history of renal calculi are not necessarily at risk for developing urinary tract infections unless the renal calculi recur. Clients with diabetes mellitus are at a higher risk for developing urinary tract infections, but this risk can be decreased by maintaining good control over blood glucose levels. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 248 _ about (MC)
QUESTION: "When developing the plan of care for a client with full-thickness burns over 35% of his body, the nurse would anticipate which of the following?"
CHOICES
( X ) a.) Using oral analgesics because full-thickness burns are painless owing to nerve destruction.
( X ) b.) Relying on nonpharmacologic measures to avoid respiratory depression.
( X ) c.) Sedating the client to an unconscious state to decrease awareness of pain.
( O ) d.) Administering intravenous opioid analgesics such as morphine.
RATIONALE: The pain associated with burns can be excruciating. Pain control most commonly involves the use of intravenous opioid analgesics. The intramuscular or subcutaneous route is not used because tissue is often edematous and limits absorption of medications. It would be uncommon for a client to experience only full-thickness burns. More commonly, the client experiences a combination of partial-thickness and full-thickness burns resulting in severe pain. Therefore, oral analgesics would be inappropriate. Nonpharmacologic measures may be used in conjunction with analgesia but would not be relied on to provide pain relief. It is inappropriate to sedate the client to the point of unconsciousness because this may promote the development of other complications. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 467 _ about (MC)
QUESTION: "Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with COPD. Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?"
CHOICES
( X ) a.) The oxygen will be lost at the client's nostrils if given at a higher level with a nasal cannula.
( X ) b.) The client's long history of respiratory problems indicates that he would be unable to absorb oxygen given at a higher rate.
( X ) c.) The cells in the alveoli are so damaged by the client's long history of respiratory problems that increased oxygen levels and reduced carbon dioxide levels likely will cause the cells to burst.
( O ) d.) The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing.
RATIONALE: Relatively low concentrations of oxygen are administered to clients with COPD so as not to eliminate their respiratory drive. Carbon dioxide content in the blood normally regulates respirations. Clients with COPD, though, are often accustomed to high carbon dioxide levels; the low oxygen blood level is their stimulus to breathe. If they receive excessive oxygen and experience a drop in the blood carbon dioxide, they may stop breathing. Oxygen flow rate is not diminished at high levels when administered through a nasal cannula. The client's ability to absorb oxygen administered at a higher level is not affected. Increased oxygen levels and decreased carbon dioxide levels cannot cause cells to burst. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 468 _ about (MC)
QUESTION: "The nurse uses 30 mL of solution to irrigate a nasogastric tube and notes that 20 mL returns promptly into the drainage container. When the nurse records the results of the irrigation, how much solution should be recorded as intake?"
CHOICES
( X ) a.) 10 mL.
( X ) b.) 20 mL.
( O ) c.) 30 mL.
( X ) d.) 50 mL.
RATIONALE: The nurse records the total amount of solution used to irrigate a gastric tube as intake and the total amount of return in the drainage container as output. This answer is incorrect. The nurse records the total amount of solution used to irrigate a gastric tube as intake and the total amount of return in the drainage container as output. This answer is incorrect. The nurse records the total amount of solution used to irrigate a gastric tube as intake and the total amount of return in the drainage container as output. This answer is incorrect. The nurse records the total amount of solution used to irrigate a gastric tube as intake and the total amount of return in the drainage container as output. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 469 _ about (MC)
QUESTION: "A client indicates that he is ready to look at his colostomy. Which of the following nursing interventions would be most effective in preparing the client to look at the colostomy?"
CHOICES
( X ) a.) Telling the client how normal body functions will continue.
( X ) b.) Encouraging the client to ask questions about the colostomy.
( X ) c.) Asking a member of the local ostomy club to visit the client.
( O ) d.) Using illustrated material during teaching sessions with the client.
RATIONALE: When a client demonstrates readiness to learn about colostomy, it is usually best to start with simple techniques such as using illustrative material during teaching sessions. This will help the client visualize how the colostomy will appear. Telling the client that normal body functions will continue is recommended. Using illustrated material will better prepare him for the sight of his colostomy. Encouraging him to ask questions is also highly recommended, however, pictures will help him visualize how the stoma will look. Visits from members of an ostomy club are very helpful, but these visits usually are more beneficial when the client already has knowledge of the colostomy and how it looks and functions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 470 _ about (MC)
QUESTION: "Which of the following would be the best indication that the goals for total parenteral nutrition (TPN) are being achieved for the client?"
CHOICES
( X ) a.) Urine negative for glucose.
( X ) b.) Serum potassium level of 4 mEq/L.
( X ) c.) Serum glucose level of 96.
( O ) d.) Weight gain of 0.5 pounds/day.
RATIONALE: Steady and progressive weight gain is the best indication that the client's nutritional goals are being met by TPN. This laboratory value is within normal limits but does not indicate attainment of nutritional goals. Hyperglycemia may be a metabolic complication of TPN with concomitant glycosuria. This laboratory value is within normal limits but does not indicate attainment of nutritional goals. Electrolyte values are assessed daily to determine the client's response to TPN. This laboratory value is within normal limits but does not indicate attainment of nutritional goals. Hyperglycemia may be a metabolic complication of TPN. The client's blood glucose level is monitored and insulin is prescribed as needed. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 471 _ about (MC)
QUESTION: "The nurse notes the following assessment findings regarding the client's peripheral vascular status: cramping leg pain relieved by rest; cool, pale feet; and delayed capillary refilling. Based on these data, the nurse would make a nursing diagnosis of:"
CHOICES
( X ) a.) Impaired Skin Integrity.
( X ) b.) Impaired Gas Exchange.
( O ) c.) Ineffective Peripheral Tissue Perfusion.
( X ) d.) Impaired Physical Mobility.
RATIONALE: The data obtained by the nurse are major defining characteristics for the nursing diagnosis Ineffective Peripheral Tissue Perfusion. The data do not indicate that the client's skin has been impaired at this time. The diagnosis Impaired Gas Exchange is used to describe clients with respiratory insufficiency. The data do not indicate that the client's physical mobility has been impaired at this time. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 616 _ about (MC)
QUESTION: "A client has been taking prescribed aspirin in large doses. She complains of stomach irritation, sometimes with vomiting. Of the following foods and beverages, the one most likely contributing to her gastrointestinal irritation would be:"
CHOICES
( X ) a.) Dry toast several times a day.
( X ) b.) A hard-boiled egg at least once a day.
( O ) c.) Several ounces of wine before her evening meal.
( X ) d.) Sweetened tea with each meal.
RATIONALE: Gastrointestinal irritation is a common side effect of aspirin, especially when taken in large doses. Such signs and symptoms as anorexia, nausea, vomiting, diarrhea, and constipation are also common. The combination of aspirin and alcohol is especially likely to cause gastrointestinal irritation, sometimes to the point of doing direct damage to gastric mucosa. Dry toast is not a gastrointestinal irritant. Hard-boiled eggs do not irritate the gastrointestinal tract. Sweetened tea is not a gastrointestinal irritant. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 622 _ about (MC)
QUESTION: "The classic signs and symptoms of rheumatoid arthritis include which of the following?"
CHOICES
( X ) a.) Pain on weight-bearing, rash, and low-grade fever.
( O ) b.) Joint swelling, joint stiffness in the morning, and bilateral joint involvement.
( X ) c.) Crepitus, development of Heberden's nodes, and anemia.
( X ) d.) Fatigue, leukopenia, and joint pain.
RATIONALE: Classic signs and symptoms of rheumatoid arthritis include joint pain, swelling, and warmth. Symptoms are typically bilaterally symmetric. Joint stiffness in the morning lasting longer than 30 minutes is another classic symptom. Rheumatoid arthritis is a systemic disease. Other symptoms can include fatigue, low-grade fever, anemia, and weight loss. Pain on weight-bearing, rash, and low-grade fever are not signs and symptoms of rheumatoid arthritis. Heberden's nodes are present in osteoarthritis (degenerative joint disease). Fatigue and joint pain are signs and symptoms of rheumatoid arthritis, but leukopenia is not. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 624 _ about (MC)
QUESTION: "Which of the following statements indicates that the client needs further teaching about taking medication to control his cancer pain?"
CHOICES
( X ) a.) "I should take my medication around-the-clock to control my pain."
( O ) b.) "I should skip doses periodically so I don't get hooked on my drugs."
( X ) c.) "It is okay to take my pain medication even if I am not having any pain."
( X ) d.) "I should contact the oncology nurse if my pain is not effectively controlled."
RATIONALE: The client should not skip his dosages of pain medication to prevent addiction. Clients with cancer pain do not become psychologically dependent on the medication and should not fear becoming addicted. The nurse should allow the client and family members to verbalize their concerns about drug addiction. This statement indicates an appropriate understanding of pain therapy. This statement indicates an appropriate understanding of pain therapy. This statement indicates an appropriate understanding of pain therapy. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 627 _ about (MC)
QUESTION: "The nurse is conducting an initial nursing history of a client who is experiencing pain related to bone cancer. The most important information to gather in this initial assessment is the:"
CHOICES
( X ) a.) Nurse's physical assessment of the client.
( X ) b.) Amount of pain medication the client is taking.
( O ) c.) Client's self-reporting of her pain experience.
( X ) d.) Family's response to the client's illness.
RATIONALE: The most important component of pain assessment is the client's self-report of the pain. The nurse should have the client describe the quality, location, and intensity of the pain; the client's response to the pain; and any alleviating or aggravating factors affecting the pain. The physical assessment should follow the pain assessment and should be delayed if the client is uncomfortable. This is an important component of the pain assessment, but it is meaningless without the client's self-report of the pain and the effectiveness of the pain therapy. The family's response to the client's illness casts light on the amount of support the client has and alerts the nurse to potential problems. With care, however, these concerns are secondary to the issue of pain control. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 628 _ about (MC)
QUESTION: "A client has had a cast applied to his arm as an outpatient in the emergency room. Which of the following home care instructions would be appropriate for cast care? The client should:"
CHOICES
( X ) a.) Use powder on the skin around the cast.
( O ) b.) Smell the cast for foul odors.
( X ) c.) Use a ruler to reach inside and scratch under the cast.
( X ) d.) Apply a heating pad to the arm for 24 hours after the injury.
RATIONALE: The client should be instructed to smell the cast to note foul odors, a sign of potential infection. Powder should not be used around the cast because it can get under the cast and become a potential medium for infection. Nothing should be inserted into the cast because a break in skin integrity can lead to an infection. A heating pad is not applied to a fracture; rather, the application of cold may be used to decrease edema and help decrease pain. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 638 _ about (MC)
QUESTION: "A client is 6 hours postoperative an abdominal hysterectomy. She has a strong urge to void and voids 25 mL into the bedpan. Based on these data, the nurse determines that the client:"
CHOICES
( X ) a.) Is probably dehydrated and needs additional intravenous fluids.
( O ) b.) Is experiencing urinary retention and needs to be catheterized.
( X ) c.) Needs more time to try to void and tells the client to try again in 1 hour.
( X ) d.) Has developed a urinary tract infection and needs antibiotics.
RATIONALE: Urinary control may not return for 6 to 8 hours after surgery owing to the effects of anesthesia and bladder manipulation during surgery. Urinary retention is common; voiding a small amount of urine after surgery may be indicative of urinary retention. The nurse should further assess for bladder distention by palpating and percussing the bladder and should intervene with catheterization as appropriate. Fluid status is closely monitored in the operating room and it is unlikely that the client is dehydrated. An urge to void usually indicates a full bladder and the client should not be asked to wait and try later. Leaving the bladder distended can stretch the bladder muscle, thus making it more difficult to void. While voiding in small amounts is a symptom of urinary tract infection, it is much more likely that anesthesia, pain, and manipulation during surgery are preventing complete bladder emptying. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 640 _ about (MC)
QUESTION: "A middle-aged woman with a malignant growth on the larynx is admitted to the hospital for a laryngectomy. The client would most likely state that the earliest symptom of her health problem was: "
CHOICES
( X ) a.) A sore throat.
( O ) b.) Chronic hoarseness.
( X ) c.) Pain radiating to the ear.
( X ) d.) Difficulty swallowing.
RATIONALE: Hoarseness that fails to subside with conservative care is an early sign of cancer of the larynx. Sore throat is not an early symptom of laryngeal cancer. Pain radiating to the ear may indicate that the tumor has metastasized. Difficulty swallowing is a later symptom that occurs as the tumor enlarges to the point of obstructing swallowing. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 646 _ about (MC)
QUESTION: "A client with diabetes is explaining to the nurse how he cares for his feet at home. Which statement indicates the client needs further instruction on how to care for his feet properly?"
CHOICES
( O ) a.) "I inspect my feet once a week for cuts and redness."
( X ) b.) "I am not allowed to use a heating pad on my feet."
( X ) c.) "It is important to dry my feet carefully after my bath."
( X ) d.) "I should not go barefoot, even in my home."
RATIONALE: Clients with diabetes should be taught to visually inspect their feet on a daily basis. This represents an accurate understanding of diabetic foot care. This represents an accurate understanding of diabetic foot care. This represents an accurate understanding of diabetic foot care. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 649 _ about (MC)
QUESTION: "The nurse plans to administer an injection of heparin to a client. Which of the following techniques for heparin administration is appropriate? The nurse:"
CHOICES
( X ) a.) Selects a 1.5-inch, 21-gauge needle for the injection.
( X ) b.) Makes the injection into the deltoid muscle.
( O ) c.) Applies gentle pressure to the site for 5 to 10 seconds after the injection.
( X ) d.) Aspirates with the plunger to check for entry into the blood vessel before injecting the heparin.
RATIONALE: Gentle pressure should be applied after the injection, but the area must not be massaged. Heparin is administered subcutaneously, never intramuscularly. A 25- or 26-gauge, 1/2- to 5/8-inch needle is most appropriate for heparin administration. The fatty layer of the abdomen is the preferred injection site. The nurse should select a site 1 to 2 inches away from the umbilicus, scar tissue, or any bruises. To decrease the risk of hematoma formation and tissue damage, aspiration of the plunger should be avoided. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 655 _ about (MC)
QUESTION: "After teaching a client about myasthenia gravis, the nurse would judge that the client has formed a realistic concept of her condition when she says that by taking her medication and pacing her activities:"
CHOICES
( X ) a.) She will live longer, but ultimately the disease will cause her death.
( X ) b.) Her symptoms will be controlled and eventually the disease will be cured.
( O ) c.) She should be able to control the disease and enjoy a healthy lifestyle.
( X ) d.) Her fatigue will be relieved, but she should expect occasional periods of muscle weakness.
RATIONALE: With a well-managed regimen, a client with myasthenia gravis should be able to control symptoms, maintain a normal lifestyle, and achieve a normal life expectancy. Myasthenia gravis can be controlled and need not be a fatal disease. Myasthenia gravis can be controlled, not cured. Episodes of increased muscle weakness should not occur if treatment is well-managed. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 657 _ about (MC)
QUESTION: "Health promotion activities to reduce the incidence of osteoporosis include:"
CHOICES
( O ) a.) Teaching women to maintain adequate calcium intake.
( X ) b.) Teaching women how to administer pain medication safely.
( X ) c.) Teaching women to increase caffeine intake as a preventive measure.
( X ) d.) Avoiding estrogen replacement therapy when postmenopausal.
RATIONALE: To reduce the risk of osteoporosis, women should have an intake of 1000 to 1500 mg of calcium per day. Pain management by medication is not a health-promotion activity. Caffeine intake is considered a contributing factor to osteoporosis. Estrogen replacement therapy helps prevent bone loss and osteoporosis. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease
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--> QUESTION NUMBER _ 658 _ about (MC)
QUESTION: "The nurse is assessing the neurovascular status of a client's right arm, which is newly cast. Which of the following assessment findings should be reported to the physician?"
CHOICES
( O ) a.) Nail bed capillary refill time of 10 seconds.
( X ) b.) Localized pain in the right arm.
( X ) c.) Slight swelling of the fingers.
( X ) d.) No pain on passive movement of fingers.
RATIONALE: Normal capillary refill is 3 to 5 seconds. A capillary refill time of 10 seconds is prolonged and should be reported. Localized pain immediately after a fracture is to be expected. Slight swelling of the fingers is expected and can be relieved by elevating the extremity. The absence of pain on passive movement of the client's fingers is a normal, desirable finding. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 659 _ about (MC)
QUESTION: "The nurse in the coronary care unit obtains a pulse rate of 116 bpm before administering digoxin to the client with heart failure. The appropriate action by the nurse is to:"
CHOICES
( O ) a.) Evaluate the client's cardiac rhythm.
( X ) b.) Administer the digoxin.
( X ) c.) Withhold the digoxin and take the pulse again in 15 minutes.
( X ) d.) Obtain the client's respiratory rate.
RATIONALE: Before administering the medication, the nurse needs to evaluate the possibility of digitalis toxicity. A sign of digitalis toxicity is atrial fibrillation, sometimes with a heart rate of more than 100 bpm. The appropriate action by the nurse is to evaluate the cardiac rhythm of the client. Tachycardia can be a sign of digitalis toxicity. The nurse should evaluate further before administering digoxin. The nurse needs to further evaluate the client's cardiac rhythm before determining any intervention. The cardiac rhythm is a higher assessment priority than the client's respiratory rate. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 663 _ about (MC)
QUESTION: "How can the emergency room nurse quickly estimate the extent of an adult client's burns?"
CHOICES
( X ) a.) By correlating the percentage of the burned area with the client's admission weight.
( X ) b.) By calculating the circumference of the body, then measuring and subtracting unburned areas from the total.
( O ) c.) By dividing the body into areas equal to multiples of nine with the calculation based on areas affected.
( X ) d.) By measuring the burned area in square inches, then multiplying that total by a factor of 0.862.
RATIONALE: The rule of nines is used to determine the extent of burns quickly. A chart with the body areas divided into areas equal to multiples of nine is used. Affected areas are shaded, and the total shaded areas are calculated. Other more detailed charts can be used later for more specific calculation. Weight is not a reliable parameter to use when measuring the extent of burns. It is impractical to measure the body when critical care is indicated. This is an incorrect formula. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 666 _ about (MC)
QUESTION: "The nurse plans to teach a client who is receiving radiation therapy how to care for his skin at home. The nurse's instructions should include:"
CHOICES
( X ) a.) "Apply a heating pad to the area to relieve pain."
( X ) b.) "You may use deodorant soap if you wish to cleanse the area."
( X ) c.) "Put baby oil on the area after each treatment to keep it from getting dry."
( O ) d.) "Keep the area covered when you go outdoors."
RATIONALE: Radiated skin is sensitive to the sun and cold temperatures so it should be protected. Heat should not be applied; the irradiated area should be protected from temperature extremes. Only mild soaps should be used. No lotions, perfumes, or oils should be applied to the area without the consent of the radiologist. Such preparations can increase the skin irritation that results from radiation treatments. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 668 _ about (MC)
QUESTION: "Which of the following assessments would be important for the nurse to make to determine whether or not a client is recovering as expected from spinal anesthesia?"
CHOICES
( X ) a.) Level of consciousness.
( X ) b.) Rate and depth of respirations.
( X ) c.) Rate of capillary refill in the toes.
( O ) d.) Degree of response to pinpricks in the legs and toes.
RATIONALE: Return of sensation in the toes and legs marks recovery from spinal anesthesia. Because the client receiving spinal anesthesia is conscious, he will not ordinarily be disoriented. The client's respiratory status is not affected by spinal anesthesia. Capillary refill time is an indicator of circulatory status, not neurological status. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 688 _ about (MC)
QUESTION: "Radiation therapy is instituted for a client with Hodgkin's disease. After 1 week, the radiation site becomes red and irritated. Which of the following statements would indicate that the client treated the area appropriately at home? "
CHOICES
( X ) a.) "I applied Aloe Vera lotion to the area."
( O ) b.) "I applied nothing to the area; I just kept it dry."
( X ) c.) "I applied moist cool soaks to the area."
( X ) d.) "I applied a hot-water bottle to the area."
RATIONALE: The area should be kept dry and open to the air. Lotions, creams, and powders may increase skin irritation and should be avoided. The area should be kept dry and open to the air. The client should seek guidance from the nurse or the radiologist about specific treatment measures. Radiated skin is temperature-sensitive. A hot-water bottle could cause a burn. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 691 _ about (MC)
QUESTION: "The primary nursing goals for a client with myasthenia gravis are to conserve the client's energy and:"
CHOICES
( X ) a.) Ensure a safe environment.
( O ) b.) Maintain respiratory function.
( X ) c.) Provide psychological support and reassurance.
( X ) d.) Promote comfort and relieve pain.
RATIONALE: In myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure. Providing a safe environment is a secondary goal. Providing emotional support is a secondary goal. Pain is not a problem with myasthenia gravis. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 698 _ about (MC)
QUESTION: "The nurse is planning an educational program about the prevention of osteoporosis for a group of women at the local community center. Which of the following preventive measures would be appropriate for the nurse to include in the teaching plan?"
CHOICES
( X ) a.) Increasing daily intake of protein.
( X ) b.) Ingesting 2000 mg of calcium supplements daily.
( X ) c.) Sunbathing for 1 hour a day during the summer months.
( O ) d.) Encouraging weight-bearing exercise on a regular basis.
RATIONALE: Exercise, especially weight-bearing exercise such as walking or jogging, is recommended on a regular basis to maintain high-density bone mass. Diet should be high in calcium and vitamin D; increasing the daily intake of protein is not appropriate. It is recommended that premenopausal women consume about 1000 to 1200 mg of calcium daily. Sunbathing is not recommended. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease
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--> QUESTION NUMBER _ 700 _ about (MC)
QUESTION: "Outcome criteria for the client with osteoarthritis should include:"
CHOICES
( X ) a.) Joint degeneration arrested.
( X ) b.) Able to self-administer gold compound safely.
( X ) c.) Feels better than on hospital admission.
( O ) d.) Joint range of motion improved.
RATIONALE: One outcome criterion for the client with osteoarthritis is improved joint mobility. It is probably not possible to arrest the disease. Gold compound is administered to clients with rheumatoid arthritis, not osteoarthritis. Outcome criteria should be specific; feeling better is too general to be useful. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 708 _ about (MC)
QUESTION: "Which of the following is an early symptom of glaucoma?"
CHOICES
( X ) a.) Hazy vision.
( X ) b.) Loss of central vision.
( X ) c.) Blurred or "sooty" vision.
( O ) d.) Impaired peripheral vision.
RATIONALE: In glaucoma, peripheral vision is impaired long before central vision is impaired. Hazy, blurred, or distorted vision is consistent with a diagnosis of cataracts. Loss of central vision is consistent with senile macular degeneration but it occurs late in glaucoma. Blurred or "sooty" vision is consistent with a diagnosis of detached retina. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease
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--> QUESTION NUMBER _ 711 _ about (MC)
QUESTION: "For a client with a sucking stab wound in the chest wall, the nurse should first:"
CHOICES
( X ) a.) Start administering oxygen.
( O ) b.) Cover the wound with a petroleum-impregnated dressing.
( X ) c.) Prepare to do a tracheostomy.
( X ) d.) Prepare for endotracheal intubation.
RATIONALE: The first course of action for a client with a sucking chest wound is to stop air from entering the chest cavity. Air entry will cause the lung to collapse. Stopping air entry is best done in an emergency situation by applying an air-occlusive dressing over the wound. Starting oxygen therapy may be necessary later but does not have the same priority on admission as closing the wound. The data provided do not support the need for a tracheostomy. Preparing for endotracheal intubation may be necessary later but does not have the same priority on admission as closing the wound. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 714 _ about (MC)
QUESTION: "A client who is receiving chemotherapy expresses concern at the thought of losing her hair. The nurse's best response would be:"
CHOICES
( X ) a.) "Don't worry about your hair loss. A good wig can disguise that."
( X ) b.) "No one knows how long it will take your hair to grow back. You will have to learn to cope with its loss."
( X ) c.) "A little hair loss shouldn't concern you. You have more serious things to worry about."
( O ) d.) "Your hair loss will be temporary. Would you like to tell me about your concerns?"
RATIONALE: Alopecia, which can occur with the administration of some chemotherapeutic agents, is psychologically disturbing for many clients even though the loss is temporary. Clients should be reassured that their hair will grow back. The nurse should encourage the client to discuss any concerns and should explore the various options available to the client (eg, wigs, scarves, turbans). This comment trivializes the client's concerns. This answer conveys negativity and harsh judgment and is likely to demoralize the client. This response ignores the client's concerns. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: Coping and adaptation
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--> QUESTION NUMBER _ 716 _ about (MC)
QUESTION: "The occupational health nurse is screening employees for symptoms of carpal tunnel syndrome. Symptoms indicative of carpal tunnel syndrome most commonly include:"
CHOICES
( O ) a.) Paresthesia in the thumb and first and second fingers.
( X ) b.) Difficulty flexing fingers.
( X ) c.) Decreased capillary refilling.
( X ) d.) Numbness in the forearm.
RATIONALE: Symptoms of carpal tunnel syndrome include pain, numbness, paresthesia, and weakness in the thumb and first and second fingers of the affected extremity (along the median nerve). Symptoms may be more severe at night owing to pressure or flexion of the wrist. Frequently the dominant hand is affected, although carpal tunnel syndrome can occur bilaterally. Carpal tunnel syndrome does not result in difficulty flexing the finger. Carpal tunnel syndrome is a neurological disorder, not a circulatory disorder. Numbness in the forearm is not a symptom of median nerve compression. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease
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--> QUESTION NUMBER _ 717 _ about (MC)
QUESTION: "A client has a total serum cholesterol level of 326 mg/dL. The nurse explains to the client that this level:"
CHOICES
( X ) a.) Is normal and requires no further treatment.
( O ) b.) Is high and will require dietary modification.
( X ) c.) Is low and requires no further treatment.
( X ) d.) Is borderline normal and may require dietary modification.
RATIONALE: A total serum cholesterol level of 326 mg/dL is high. A client with a cholesterol level of 326 will require dietary modifications and may be placed on lipid-lowering medication. Normal serum cholesterol is from 140 to 200 mg/dL. A low cholesterol level would be a level under 140 mg/dL. Borderline normal would be 200 to 210 mg/dL. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************
--> QUESTION NUMBER _ 718 _ about (MC)
QUESTION: "A client calls the physician's office 2 days after a herniorrhaphy to report that his scrotum is swollen and painful. To promote comfort, the nurse should instruct the client to:"
CHOICES
( X ) a.) Apply a snug binder on his abdomen.
( X ) b.) Have him wear a truss to support the scrotum.
( O ) c.) Elevate the scrotum and place ice bags on the area intermittently.
( X ) d.) Have him lie on his side and place a pillow between his legs.
RATIONALE: A swollen, painful scrotum after herniorrhaphy is relatively common. Elevating the scrotum, as on a rolled towel, and intermittently placing ice bags on the area are helpful. Applying an abdominal binder will have no effect on the scrotal swelling. Applying a truss is unlikely to promote comfort when the scrotum is swollen. Having the client lie on his side with a pillow between his legs will not elevate the scrotum; therefore, this will not help reduce swelling and discomfort. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
******************************
--> QUESTION NUMBER _ 724 _ about (MC)
QUESTION: "The nurse should plan care for the client with cancer based on the fact that an important principle of using medication to manage cancer pain is to:"
CHOICES
( X ) a.) Avoid giving the client addictive medications.
( X ) b.) Provide the medications as soon as the client requests them.
( X ) c.) Discontinue the medications periodically to discourage the development of drug tolerance.
( O ) d.) Individualize the medication therapy to the client.
RATIONALE: The most important principle related to the management of cancer pain is to individualize the therapy to the client. Fear of client addiction to pain medication is unfounded. Medications should not be given on an as-needed basis. They should be given on a regular, around-the-clock schedule to maintain a therapeutic blood level and analgesic effect. Medications should not be discontinued. They should be given in increasing dosages as drug tolerance develops. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 731 _ about (MC)
QUESTION: "Which one of the following would the nurse evaluate as an expected outcome for a client who has undergone surgical repair of an inguinal hernia?"
CHOICES
( X ) a.) The client's voiding patterns will return to normal within 6 months after surgery.
( O ) b.) The client will verbalize understanding of instructions to avoid lifting for 2 to 6 weeks after surgery.
( X ) c.) The client will use a cane for assistance with ambulation for 2 to 6 weeks after surgery.
( X ) d.) The client will remain on a soft diet until the wound is healed.
RATIONALE: The client should be instructed to avoid straining and lifting for 2 to 6 weeks after surgery. The client should be able to void without difficulty after the immediate postoperative phase. The client typically can ambulate without assistance and should not require assistive devices, unless such devices were used before surgery. The client returns to a regular diet as tolerated after surgery. Increased dietary fiber intake is suggested to avoid constipation, but the client does not need to remain on a soft diet until the wound heals. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
******************************
--> QUESTION NUMBER _ 734 _ about (MC)
QUESTION: "Which of the following nursing diagnoses would receive the greatest priority in the care of an unconscious client with a head injury?"
CHOICES
( X ) a.) Impaired Gas Exchange related to shallow irregular breathing.
( X ) b.) Risk for Injury related to disorientation and decreased level of consciousness.
( X ) c.) Disturbed Sensory Perception related to decreased level of consciousness.
( O ) d.) Ineffective Airway Clearance related to inability to remove respiratory secretions.
RATIONALE: A major goal of nursing care of the unconscious client with a head injury is to establish and maintain an open airway. An obstructed airway can lead to hypoxia and carbon dioxide retention which will further increase intracranial pressure. This nursing diagnosis is appropriate for this client but is not the highest priority. This nursing diagnosis is appropriate for this client but is not the highest priority. This nursing diagnosis is appropriate for this client but is not the highest priority. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 735 _ about (MC)
QUESTION: "The nurse is taking a nursing history on a preoperative client. Which of the following pieces of information would most likely have a significant impact on the client's recovery postoperatively? The client:"
CHOICES
( O ) a.) Has smoked 1 pack of cigarettes a day for 12 years.
( X ) b.) Had a cold 6 weeks ago.
( X ) c.) Drinks about two beers a week on a regular basis.
( X ) d.) Is 10 pounds overweight.
RATIONALE: A client who smokes is at increased risk for atelectasis postoperatively; thus, smoking is the most significant risk factor listed in this item. If the client has completely recovered from the cold he had 6 weeks ago, it would be irrelevant to his postoperative recovery. This amount of alcohol intake is minimal and will have no bearing on his postoperative recovery. Although an obese client faces increased surgical risks, an excess of 10 pounds is not significant to pose a greater risk than the smoking. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
******************************
--> QUESTION NUMBER _ 744 _ about (MC)
QUESTION: "A client with insulin-dependent diabetes mellitus is being considered for the tight-control program. In determining if the client is a candidate for this program, the nurse and health care team evaluate the:"
CHOICES
( X ) a.) Client's daily dietary requirements.
( X ) b.) Client's family support system.
( O ) c.) Client's previous compliance history.
( X ) d.) Length of time the client has had diabetes mellitus.
RATIONALE: The tight-control program for clients with diabetes mellitus involves frequent testing of serum glucose and insulin administration (every 2 to 4 hours in some cases). The tight-control program has been found to be effective in reducing vascular complications associated with diabetes mellitus. For a client to be placed on this program, it would be essential to evaluate the client's previous ability to be compliant with the diabetic regimen. The client's dietary requirements do not influence whether or not he is a candidate for a tight-control program. Although family support is important, the client's personal history of compliance with the therapeutic regimen is more important. Duration of illness is not a factor in the decision to pursue a tight-control program. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 748 _ about (MC)
QUESTION: "Which of the following would be an appropriate nursing diagnosis for a hospitalized client with bacterial pneumonia and shortness of breath?"
CHOICES
( X ) a.) Ineffective Cardiopulmonary Tissue Perfusion related to myocardial damage.
( O ) b.) Risk for Self-Care Deficit related to fatigue.
( X ) c.) Deficient Fluid Volume related to nausea and vomiting.
( X ) d.) Disturbed Thought Processes related to inadequate relief of chest pain.
RATIONALE: Fatigue is a major problem for the client with pneumonia, making it difficult to perform self-care activities. Fatigue is due to reduced oxygenation and inability to sleep and rest because of coughing. The hospital environment further contributes to interrupted sleep patterns. Myocardial damage is not typically associated with pneumonia. Deficient Fluid Volume might occur with the client with pneumonia; however, it would most likely be related to fever and increased insensible fluid loss from respiratory secretions, not nausea and vomiting. Disturbed Thought Processes, which is characterized by cognitive dissonance, memory problems, and inappropriate non:reality-based thinking, is not typically related to inadequate pain relief. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
******************************
--> QUESTION NUMBER _ 749 _ about (MC)
QUESTION: "A client with bacterial pneumonia is coughing up tenacious, purulent sputum. Which of the following measures would most likely help liquefy these viscous secretions?"
CHOICES
( X ) a.) Performing postural drainage.
( O ) b.) Breathing humidified air.
( X ) c.) Clapping and percussing over the affected lung.
( X ) d.) Performing coughing and deep-breathing exercises.
RATIONALE: Humidified air helps to liquefy respiratory secretions, making them easier to raise and expectorate. Postural drainage may be helpful for respiratory hygiene but will not affect the nature of secretions. Vibration and percussion of the chest wall may be helpful for respiratory hygiene but will not affect the nature of secretions. Coughing and deep-breathing exercises may be helpful for respiratory hygiene but will not affect the nature of secretions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 750 _ about (MC)
QUESTION: "A client has been diagnosed with bacterial pneumonia. After 1 day of antibiotic therapy, the client's white blood cell count is still 14,000/mm 3. In response to this report, the nurse should:"
CHOICES
( O ) a.) Notify the physician.
( X ) b.) Increase the next dose of the antibiotic.
( X ) c.) Initiate reverse isolation precautions.
( X ) d.) Administer the next scheduled antibiotic dose early.
RATIONALE: If the white blood cell count does not begin decreasing, it may indicate that the antibiotic is not effective against the organism causing the pneumonia. The physician should be notified as he or she may want to consider changing antibiotics. Altering prescribed medication doses is not a nursing responsibility. Reverse isolation is used for clients with a very low white blood cell count. The antibiotic dosing schedule should be strictly maintained. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 751 _ about (MC)
QUESTION: "Which of the following would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia?"
CHOICES
( X ) a.) Change current diet habits.
( X ) b.) Seek prompt antibiotic therapy for viral infections.
( X ) c.) Receive prophylactic antibiotic therapy.
( O ) d.) Obtain annual influenza and pneumococcal vaccines.
RATIONALE: Annual influenza and pneumococcal vaccines are effective in reducing the recurrence of pneumonia. Dietary changes are not indicated in the prevention of pneumonia. Antibiotics are ineffective against viral infections. Prophylactic antibiotic therapy is not typically prescribed because of the increasing prevalence of resistant bacterial strains. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease
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--> QUESTION NUMBER _ 752 _ about (MC)
QUESTION: "In teaching a client with tuberculosis about self-care at home, the nurse will include all of the following measures. Which of the measures would have the highest priority?"
CHOICES
( X ) a.) Getting adequate rest.
( X ) b.) Eating a nourishing diet.
( O ) c.) Taking medications as prescribed.
( X ) d.) Quitting smoking.
RATIONALE: It is essential that a client with tuberculosis take medications exactly as prescribed. Sufficient rest is important for the healing process but not as important as taking medications as prescribed. Eating a nourishing diet is important for the healing process but not as important as taking medications as prescribed. Smoking cessation is a priority for all clients, especially those with respiratory problems. However, taking antitubercular medication as prescribed has the highest priority. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 753 _ about (MC)
QUESTION: "The single most effective way to decrease the spread of microorganisms is:"
CHOICES
( O ) a.) Frequent handwashing.
( X ) b.) Having separate personal care items for each person.
( X ) c.) Using disposable equipment whenever possible.
( X ) d.) Isolating people known to be harboring disease-causing microorganisms.
RATIONALE: The hands spread disease-causing organisms. The hands spread disease-causing organisms. When practical, using disposable equipment is preferable to sterilization, but it does not override frequent, thorough handwashing for control of infection. Isolating people known to be harboring disease-causing organisms is a cornerstone of infection control, but practitioners must still wash their hands to avoid spreading disease. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 754 _ about (MC)
QUESTION: "Medical therapy for a client with a newly positive Mantoux skin test who does not have active tuberculosis would involve which of the following?"
CHOICES
( X ) a.) Reevaluating the client's condition every 6 months.
( X ) b.) Performing a repeat skin test every 6 months.
( O ) c.) Administering isoniazid for about 9 months.
( X ) d.) Administering isoniazid until the skin test reverts to negative.
RATIONALE: Clients with newly positive skin tests are aggressively treated with isoniazid for about 9 months. The client needs with a newly positive Mantoux test requires prophylactic drug treatment. Repeat skin testing should not be performed as it will always be positive. Skin tests do not convert to negative once a positive response has been obtained. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 755 _ about (MC)
QUESTION: "Theophylline ethylenediamide is administered to a client with COPD to:"
CHOICES
( X ) a.) Reduce bronchial secretions.
( O ) b.) Relax bronchial smooth muscle.
( X ) c.) Strengthen myocardial contractions.
( X ) d.) Decrease alveolar elasticity.
RATIONALE: Theophylline ethylenediamide is a xanthine derivative that acts directly on bronchial smooth muscle to relax and dilate the bronchi and relieve bronchial constriction and spasms. When the drug exerts its primary desired effect, dyspnea and shortness of breath decrease. Theophylline ethylenediamide does not reduce bronchial secretions. Theophylline ethylenediamide does increase strength of myocardial contractility, but this is not the action for which it is used. Theophylline ethylenediamide does not decrease alveolar elasticity. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 756 _ about (MC)
QUESTION: "A client's lab report reveals the following set of arterial blood gas (ABG) values: pH, 7.52; PaO 2, 50 mm Hg; PaCO 2, 28 mm Hg; HCO 3-, 24 mEq/L. The nurse would interpret these ABG values as indicating:"
CHOICES
( X ) a.) Metabolic acidosis.
( X ) b.) Metabolic alkalosis.
( X ) c.) Respiratory acidosis.
( O ) d.) Respiratory alkalosis.
RATIONALE: The client's pH is alkalotic and the PaCO 2 is decreased, indicating respiratory alkalosis. The HCO 3- is normal. The PaO 2 level has little direct bearing on acid-base status but is important in evaluating the client's overall condition. In this client, the low PaO 2 level could be contributing to an increased respiratory rate and the respiratory alkalosis. Metabolic acidosis occurs when a base bicarbonate deficit occurs. Metabolic alkalosis occurs when there is a loss of acid or increase in bicarbonate. Respiratory acidosis occurs when there is an increase in carbon dioxide. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 757 _ about (MC)
QUESTION: "For a client with COPD who has trouble raising respiratory secretions, which of the following nursing measures would help reduce the tenacity of secretions?"
CHOICES
( X ) a.) Ensuring that the client's diet is low in salt.
( X ) b.) Ensuring that the client's oxygen therapy is continuous.
( O ) c.) Helping the client maintain a high fluid intake.
( X ) d.) Keeping the client in a semi-sitting position as much as possible.
RATIONALE: A fluid intake of 2 to 3 L/day, providing that the client does not have cardiovascular or renal disease, helps liquefy bronchial secretions. A low-salt diet does not help reduce the viscosity of mucus. Continuous oxygen therapy does not help reduce the viscosity of mucus. Maintaining a semi-sitting position does not help reduce the viscosity of mucus. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 758 _ about (MC)
QUESTION: "As part of the client's diagnostic work-up, she is to have a bronchoscopy under local anesthesia. Her preoperative medication will be atropine sulfate, 0.4 mg, and meperidine hydrochloride (Demerol), 100 mg intramuscularly. Which of the following interventions should the nurse perform after the test?"
CHOICES
( X ) a.) Irrigate the nasogastric tube with 30 mL of normal saline every 2 hours.
( X ) b.) Offer 200 mL of oral fluids every hour to liquefy lung secretions.
( X ) c.) Observe the abdomen for signs of distention and board-like rigidity.
( O ) d.) Position the client on her side and keep her NPO for several hours.
RATIONALE: Positioning on the side allows any vomitus to roll out by gravity, thereby reducing the risk of aspiration. A nasogastric tube is not placed after a bronchoscopy because the gastrointestinal tract is not entered. Oral fluids are withheld until the gag-and-swallow reflexes return. Preoperative sedation and local anesthesia impair swallowing and the laryngeal reflex, which is protective in nature. The trachea, not the bowel, can be perforated inadvertently; abdominal distention and rigidity would indicate bowel perforation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 759 _ about (MC)
QUESTION: "To help control pain during coughing for a client who has had a lobectomy, the nurse should:"
CHOICES
( X ) a.) Place the bed in slight Trendelenburg's position and help the client turn onto her operative side to splint the incision.
( O ) b.) Raise the bed to semi-Fowler's position and place one hand on the client's back, on the left side, and one hand under the incision.
( X ) c.) Keep the bed flat and tell the client to place her hands over the incision before taking a deep breath.
( X ) d.) Raise the bed to complete Fowler's position and help the client turn onto her operative side to splint the incision.
RATIONALE: Semi-Fowler's position allows for downward displacement of the diaphragm and relaxation of the abdominal muscles, which are needed for good ventilatory excursion. The hand placement supports the operative area and splints it without causing pain from pressure. Trendelenburg's position is contraindicated because abdominal contents pushing against the diaphragm will decrease effective lung volume. Keeping the bed flat does not allow the diaphragm to descend. Positioning the client on the operative side prevents maximum inflation of the left lung. Placing the hands on the operative area before inhalation can restrict thoracic movement. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 760 _ about (MC)
QUESTION: "Which of the following signs and symptoms would alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy?"
CHOICES
( X ) a.) Increased blood pressure and decreased pulse and respiratory rates.
( X ) b.) Sanguineous drainage from the chest tube at a rate of 50 mL per hour during the past 3 hours.
( O ) c.) Restlessness and shortness of breath.
( X ) d.) Urine output of 180 mL during the past 3 hours.
RATIONALE: Restlessness indicates cerebral hypoxia due to decreased circulating volume. Shortness of breath occurs because blood collecting in the pleural space faster than suction can remove it prevents the lung from reexpanding. Increased blood pressure and decreased pulse and respiratory rates are classic late signs of increased intracranial pressure. Decreasing blood pressure and increasing pulse and respiratory rates occur with hypovolemic shock. Sanguineous drainage that changes to serosanguineous drainage at a rate less than 100 mL/hour is normal in the early postoperative period. Urine output of 180 mL over the past 3 hours indicates normal kidney perfusion. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 761 _ about (MC)
QUESTION: "With a diagnosis of right rib fracture and closed pneumothorax, the client should be placed in:"
CHOICES
( X ) a.) Modified Trendelenburg's position with the lower extremities elevated.
( X ) b.) Reverse Trendelenburg's position with the head down.
( X ) c.) Left side-lying position with the head elevated 15 to 30 degrees.
( O ) d.) Semi- to high-Fowler's position, tilted toward the right side.
RATIONALE: Pneumothorax will cause a client to feel extremely short of breath. Semi- or high- Fowler's position will facilitate ventilation by the unaffected lung. Likewise, positioning the client on the unaffected side compromises the remaining functional lung. A flat Trendelenburg's position places additional pressure on the chest and inhibits ventilation. Reverse Trendelenburg places additional pressure on the chest and inhibits ventilation. Pneumothorax will cause a client to feel extremely short of breath. Semi- or high- Fowler's position will facilitate ventilation by the unaffected lung. Likewise, positioning the client on the unaffected side compromises the remaining functional lung. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 762 _ about (MC)
QUESTION: "On admission, the client's arterial blood gas (ABG) values were: pH, 7.20; PaO 2, 64 mm Hg; PaCO 2, 60 mm Hg; and HCO 3-, 22 mEq/L. A chest tube is inserted, and oxygen at 4 L/minute is started. Thirty minutes later, his repeat blood gas values are: pH, 7.30; PaO 2, 76 mm Hg; PaCO 2, 50 mm Hg; and HCO 3-, 22 mEq/L. This change would indicate:"
CHOICES
( X ) a.) Impending respiratory failure.
( O ) b.) Improving respiratory status.
( X ) c.) Developing respiratory alkalosis.
( X ) d.) Obstruction in the chest tubes.
RATIONALE: The ABG values after chest tube insertion are returning to normal, indicating that treatment is effective. Impending respiratory failure would be indicated by a decreasing PaO 2 or an increasing PaCO 2. The client is not alkalotic because the pH values are below 7.35. If the chest tubes were obstructed, the client's respiratory status would deteriorate. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 763 _ about (MC)
QUESTION: "A client has had thoracic surgery for removal of a benign mediastinal tumor. He has a left chest tube to water seal drainage. The nurse auscultates scattered crackles bilaterally. Which of the following interventions would be most appropriate?"
CHOICES
( X ) a.) Check the water-seal system.
( O ) b.) Encourage deep breathing and ambulation as soon as the client is able.
( X ) c.) Perform suctioning once per shift and ask the physician to order an expectorant.
( X ) d.) Reduce the frequency of pain medication and increase the suction in the water-seal bottle.
RATIONALE: Crackles occur because of retained secretions and shallow breathing. Shallow breathing is a common problem after thoracic surgery owing to the pain associated with deep inspiration. Assisting the client to deep breathe and ambulate will help expand the lung tissue, clear secretions and improve oxygenation. Scattered crackles are indicative of fluid in the airways, not a malfunctioning drainage system. The alert, nonintubated client should not be suctioned when coughing and deep breathing can clear the airways. Reducing pain medication would make effective deep breathing and ambulating more difficult. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 764 _ about (MC)
QUESTION: "A client says to the nurse, "My father died of a heart attack when he was 60, and I suppose I will too." Which of the following responses by the nurse would be the most appropriate?"
CHOICES
( O ) a.) "Tell me more about what you are feeling."
( X ) b.) "Are you thinking that you won't recover from this illness?"
( X ) c.) "You have a fine doctor. Everything will be all right soon, I'm sure."
( X ) d.) "Would you agree that this would be very unlikely?"
RATIONALE: When a client makes a comment about death, it is best for the nurse to help the client express his or her feelings. Asking a question that requires no more than a yes or no answer is unlikely to elicit how the client really feels and offers no support. Trying to explain away the client's feelings will be of no help to the client and ignores the way the client feels. Cliches such as "everything will be all right soon" are not helpful because they ignore the client's feelings. Because the client has just stated that he assumes he will die at 60, it is unlikely that he will agree to the nurse's version of what is likely or unlikely. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 765 _ about (MC)
QUESTION: "A priority nursing diagnosis during the first 24 hours following an MI is:"
CHOICES
( O ) a.) Ineffective Cardiac Tissue Perfusion.
( X ) b.) Risk for Infection.
( X ) c.) Deficient Fluid Volume.
( X ) d.) Constipation.
RATIONALE: Ineffective Cardiac Tissue Perfusion related to myocardial damage and inadequate cardiac output is a major problem immediately after a heart attack. Therapy is directed toward improving cardiac output and decreasing myocardial workload. Risk for Infection is not a priority diagnosis in this case. Deficient Fluid Volume is not indicated. Constipation is not a priority problem during the first 24 hours. NURSING PROCESS STEP: Analysis, nursing diagnosis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 766 _ about (MC)
QUESTION: "Which of the following findings is suggestive of myocardial infarction (MI)?"
CHOICES
( X ) a.) Elevated serum cholesterol value.
( O ) b.) Elevated creatine phosphokinase (CPK) value.
( X ) c.) Below-normal erythrocyte sedimentation rate.
( X ) d.) Elevated white blood cell count.
RATIONALE: Common laboratory findings in the client who has suffered a MI include elevated CPK level. CPK is also released during muscle injury and brain injury. The CPK isoenzyme CPK-MB elevates only in response to myocardial damage. Elevated serum cholesterol level is a risk factor for coronary artery disease (CAD). It is not a diagnostic tool for MI. The erythrocyte sedimentation rate may be elevated with an MI but it is not diagnostic. The white blood cell count is typically elevated but not diagnostic for MI. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 767 _ about (MC)
QUESTION: "Nursing measures for the client who has had an MI include helping the client to avoid activity that results in Valsalva's maneuver. Valsalva's maneuver may cause cardiac dysrhythmias, increased venous pressure, increased intrathoracic pressure, and thrombi dislodgment. Which of the following actions would help prevent Valsalva's maneuver? Have the client:"
CHOICES
( X ) a.) Assume a side-lying position.
( X ) b.) Clench her teeth while moving in bed.
( X ) c.) Drink fluids through a straw.
( O ) d.) Avoid holding her breath during activity.
RATIONALE: Valsalva's maneuver, or bearing down against a closed glottis, can best be prevented by instructing the client to exhale during activities such as having a bowel movement or moving around in bed. Valsalva's maneuver is not prevented by having the client assume a side-lying position. Clenching the teeth will likely contribute to Valsalva's maneuver, not inhibit it. Drinking fluids through a straw has no effect on preventing or causing Valsalva's maneuver. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 768 _ about (MC)
QUESTION: "A client with heart failure loses 3.2 kg while hospitalized. Approximately how many pounds has the client lost?"
CHOICES
( X ) a.) 1 pound.
( X ) b.) 3 pounds.
( X ) c.) 5 pounds.
( O ) d.) 7 pounds.
RATIONALE: 1 kg = 2.2 pounds; therefore, 3.2 x 2.2 = 7.04 pounds. This answer is incorrect. 1 kg = 2.2 pounds; therefore, 3.2 x 2.2 = 7.04 pounds. This answer is incorrect. 1 kg = 2.2 pounds; therefore, 3.2 x 2.2 = 7.04 pounds. This answer is incorrect. 1 kg = 2.2 pounds; therefore, 3.2 x 2.2 = 7.04 pounds. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 769 _ about (MC)
QUESTION: "The nurse is preparing the client with heart failure to go home. The nurse should instruct the client to:"
CHOICES
( X ) a.) Monitor urine output daily.
( X ) b.) Maintain bed rest for at least 1 week.
( X ) c.) Monitor daily potassium intake.
( O ) d.) Weigh daily.
RATIONALE: People with heart failure are taught to maintain a target weight and to weigh themselves daily to monitor increasing fluid retention. Fluid retention can lead to decompensation and hospitalization. Monitoring daily urine output is not required of these clients. A week of bed rest is not indicated for most people with heart failure. Clients on potassium-wasting diuretics will be taught to include dietary sources of potassium or to take a potassium supplement. However, all clients with heart failure should weigh themselves daily to monitor fluid status. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 770 _ about (MC)
QUESTION: "The client asks the nurse about the reason for taking enalapril maleate. Enalapril is prescribed for people with heart failure to:"
CHOICES
( X ) a.) Lower the blood pressure by increasing peripheral vasoconstriction.
( X ) b.) Lower the heart rate by slowing the conduction system.
( O ) c.) Block the conversion of angiotensin I to angiotensin II.
( X ) d.) Increase myocardial contractility, thereby improving cardiac output.
RATIONALE: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor that prevents conversion of angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor and also contributes to aldosterone secretion. Thus, enalapril decreases blood pressure through systemic vasodilation. Enalapril does not cause increased vasoconstriction, which would raise blood pressure. Enalapril does not affect the heart's conduction system. Enalapril does not affect myocardial contractility. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 771 _ about (MC)
QUESTION: "A client with heart failure will take oral furosemide (Lasix) at home. To help the client evaluate the effectiveness of furosemide therapy, the nurse should teach the client to:"
CHOICES
( O ) a.) Weigh himself daily.
( X ) b.) Take his blood pressure daily.
( X ) c.) Keep a daily record of his urinary output.
( X ) d.) Have a serum potassium level drawn weekly.
RATIONALE: Monitoring daily weights will help determine the effectiveness of diuretic therapy. A client who gains weight without diet changes most probably is retaining fluids, so the diuretic therapy should be adjusted. Blood pressure monitoring is useful when diuretics are prescribed to control blood pressure. However, in heart failure clients the primary indication is to promote sodium and water excretion of sodium and water by the kidneys. While it may be useful to monitor urinary intake and output in the hospital, daily weights are a sensitive indicator of fluid status and more practical for home management. The client may be told to eat a potassium-rich diet; however, serum potassium levels are not used to determine the effectiveness of diuretic therapy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 772 _ about (MC)
QUESTION: "A client's chest tube accidentally disconnects from the drainage tube when she turns onto her side. Which of the following actions should the nurse take first?"
CHOICES
( X ) a.) Notify the physician.
( O ) b.) Clamp the chest tube.
( X ) c.) Raise the level of the drainage system.
( X ) d.) Reconnect the tube.
RATIONALE: When a chest tube becomes disconnected, the nurse should take immediate steps to prevent air from entering the chest cavity which may cause the lung to collapse. Therefore, when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double-clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. Then the physician should be notified. First priority must be given to clamping the chest tube. To prevent backward flow of drainage, the drainage system should never be raised above chest level. To prevent backward flow of drainage, the drainage system should never be raised above chest level. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 773 _ about (MC)
QUESTION: "While a client with hypertension is being assessed, he says to the nurse, "I really don't know why I'm here. I feel fine and haven't had any symptoms." The nurse would explain to the client that symptoms of hypertension:"
CHOICES
( O ) a.) Are often not present.
( X ) b.) Signify a high risk of stroke.
( X ) c.) Occur only with malignant hypertension.
( X ) d.) Appear after irreversible kidney damage has occurred.
RATIONALE: Most people with hypertension, even those with dangerous elevations in blood pressure, have no symptoms. Therefore, the presence or absence of symptoms is not an accurate reflection of a person's status. The severity of the hypertension, rather than the presence of absence of symptoms, determines the risk of some complications such as stroke. The presence of symptoms does not necessarily indicate that the client has malignant hypertension. Symptoms are not directly related to the status of the kidney. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 774 _ about (MC)
QUESTION: "The plan of care for a client with hypertension taking propranolol hydrochloride would include:"
CHOICES
( X ) a.) Instructing the client to discontinue the drug if nausea occurs and to monitor blood pressure.
( X ) b.) Monitoring blood pressure every week and adjusting the medication dose accordingly.
( X ) c.) Measuring partial thromboplastin time weekly to evaluate blood clotting status.
( O ) d.) Instructing the client to notify the physician of irregular or slowed pulse rate.
RATIONALE: Propranolol hydrochloride is a B-adrenergic blocking agent used to treat hypertension. In addition to lowering blood pressure by blocking sympathetic nervous system stimulation, the drug lowers the heart rate. Therefore, the client should be assessed for bradycardia and other dysrhythmias. The client needs to be instructed not to discontinue medication because sudden withdrawal of propranolol hydrochloride may cause rebound hypertension. Propranolol dosage is not typically adjusted based on weekly blood pressure readings. Measurement of partial thromboplastin time values is not a factor in treatment of hypertension. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 775 _ about (MC)
QUESTION: "Nonpharmacologic approaches to hypertension control that the nurse may be involved in teaching the client with hypertension include:"
CHOICES
( X ) a.) Proper administration of antihypertensive agents.
( X ) b.) Activity restrictions.
( X ) c.) Low potassium diet therapy.
( O ) d.) A regular exercise program.
RATIONALE: A regular exercise program is a nonpharmacologic approach that aids weight management, an essential component of hypertension control. Proper administration of antihypertensive agents is a pharmacologic approach. Activity restrictions are not commonly part of therapy for clients with hypertension. A low-sodium rather than low-potassium diet may be adjunct therapy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 776 _ about (MC)
QUESTION: "A 54-year-old woman comes to the emergency department complaining of chest pain on exertion. The pain subsides with rest. A myocardial infarction (MI) is ruled out and the client is diagnosed with unstable angina. The woman says, "I really thought I was having a heart attack. How can you tell the difference?" Which response by the nurse would provide the client with the most accurate information about the difference between the pain of angina and that of MI?"
CHOICES
( X ) a.) "The pain associated with a heart attack is much more severe."
( X ) b.) "The pain associated with a heart attack radiates into the jaw and down the left arm."
( X ) c.) "It is impossible to differentiate anginal pain from that of a heart attack without an ECG."
( O ) d.) "The pain of angina is usually relieved by resting or lying down."
RATIONALE: The characteristic of anginal pain that helps differentiate it from the pain of a heart attack is that anginal pain is transient and usually alleviated by resting or lying down. In unstable angina, however, there is increasing frequency, intensity, or duration of pain. Anginal pain is not always less severe than that of an MI. Anginal pain may radiate down the arm or into the jaw. Anginal pain may be relieved with rest, while the pain related to an MI is not. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 777 _ about (MC)
QUESTION: "Which of the following points should the nurse include about sublingual nitroglycerin when instructing the client with angina?"
CHOICES
( X ) a.) The drug will cause increased urine output.
( O ) b.) Store the tablets in a tight, light-resistant container.
( X ) c.) Use the tablets only when the pain is severe.
( X ) d.) The shelf life of nitroglycerin is long; it keeps for up to 2 years.
RATIONALE: Clients should be instructed to keep nitroglycerin in a tightly closed, dark container and to replenish it frequently because it deteriorates rather rapidly. Nitroglycerin does not cause increased urine output. Clients should be instructed to use nitroglycerin at the first indication of chest pain, not to wait before using the drug. Nitroglycerin deteriorates rapidly. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 778 _ about (MC)
QUESTION: "Nitroglycerin is also available in ointment or paste form. Before applying nitroglycerin ointment, the nurse should:"
CHOICES
( X ) a.) cleanse the skin with alcohol where the ointment will be placed.
( X ) b.) obtain the client's pulse rate and rhythm.
( O ) c.) remove the ointment previously applied.
( X ) d.) instruct the client to expect pain relief in the next 15 minutes.
RATIONALE: When applying nitroglycerin ointment to a client's skin, the nurse should first remove the ointment applied during previous administration. Otherwise the client will be receiving too much medication. It is not necessary to clean the skin with alcohol before applying ointment. The blood pressure should be assessed before administration because the ointment may decrease blood pressure. Nitroglycerin ointment is not used for relief of acute cardiac pain. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 779 _ about (MC)
QUESTION: "A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which statement by the nurse best explains the procedure to the client?"
CHOICES
( O ) a.) "PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter."
( X ) b.) "PTCA involves cutting away blockages with a special catheter."
( X ) c.) "PTCA involves passing a catheter through the coronary arteries to find blocked arteries."
( X ) d.) "PTCA involves inserting grafts to divert blood from blocked coronary arteries."
RATIONALE: PTCA is best described as insertion of a balloon-tipped catheter into the coronary artery to compress a plaque, thereby opening a stenosed or blocked artery. This is a description of an atherectomy. This only describes a cardiac catheterization. Inserting grafts to divert blood from blocked arteries describes coronary artery bypass graft surgery. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 780 _ about (MC)
QUESTION: "A priority nursing diagnosis for a client receiving chemotherapy would be:"
CHOICES
( X ) a.) Excess Fluid Volume.
( X ) b.) Impaired Physical Mobility.
( O ) c.) Risk for Infection.
( X ) d.) Disturbed Body Image.
RATIONALE: A common priority problem for clients receiving chemotherapy is infection because chemotherapeutic agents may suppress formation of white blood cells and their components, leading to increased risk of infection. Careful monitoring of white blood cell levels is warranted in clients receiving immunosuppressive drugs. Deficient Fluid Volume is more typical than Excess Fluid Volume . Impaired Physical Mobility is not necessarily a problem encountered during chemotherapy. Disturbed Body Image is a possible diagnosis; however, the risk for infection and its physiologic consequences (overwhelming infection) are of greater importance. NURSING PROCESS STEP: Analysis, nursing diagnosis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 781 _ about (MC)
QUESTION: "A client receiving chemotherapy experiences episodes of severe nausea and has vomited more than 1000 mL of clear fluid in the past 4 hours. The nurse's most appropriate action would be to:"
CHOICES
( O ) a.) Notify the physician.
( X ) b.) Maintain the client on a liquid diet.
( X ) c.) Continue to monitor the client for another 4 hours.
( X ) d.) Administer antiemetic medication as ordered.
RATIONALE: The nurse should notify the physician of extreme amounts of emesis because further treatment may be warranted. Placing the client on a liquid diet is the physician's decision. The client needs intervention now to provide basic comfort (relief of nausea) and to prevent problems associated with excessive fluid loss through emesis (electrolyte imbalance, dehydration). Administering antiemetic medication is important but the severity of the client's nausea and amount of vomiting are important information to share with the physician for additional intervention. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 782 _ about (MC)
QUESTION: "The nurse understands that Hodgkin's disease is suspected when a client presents with a painless, swollen lymph node. Hodgkin's disease typically affects people in which age group? "
CHOICES
( X ) a.) Children (ages 6 to 12 years).
( X ) b.) Teenagers (ages 13 to 20 years).
( O ) c.) Young adults (ages 21 to 40 years).
( X ) d.) Older adults (ages 41 to 50 years).
RATIONALE: Hodgkin's disease most often strikes young adults usually between ages 21 and 40 years. Hodgkin's disease most often strikes young adults usually between ages 21 and 40 years. Hodgkin's disease most often strikes young adults usually between ages 21 and 40 years. Hodgkin's disease most often strikes young adults usually between ages 21 and 40 years. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 783 _ about (MC)
QUESTION: "Which of the following criteria are acceptable for a rescuer to discontinue CPR?"
CHOICES
( X ) a.) When it is obvious that the victim will not survive.
( O ) b.) When the rescuer is exhausted.
( X ) c.) After 30 minutes of CPR without a pulse rate.
( X ) d.) When the family requests discontinuation.
RATIONALE: According to the American Heart Association, CPR, once initiated, may be discontinued only when the rescuer is exhausted or when a physician is present to determine client status. A physician, not the rescuer, must determine the client's status. There is not an established time limit for discontinuing CPR. Family members' request to discontinue CPR cannot be honored. It is the physician's responsibility to determine when CPR can be discontinued. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 784 _ about (MC)
QUESTION: "In the early stage of shock, the nurse would expect the results of arterial blood gas (ABG) analysis to indicate:"
CHOICES
( O ) a.) Respiratory alkalosis.
( X ) b.) Respiratory acidosis.
( X ) c.) Metabolic alkalosis.
( X ) d.) Metabolic acidosis.
RATIONALE: As a compensatory measure in the early stage of shock, the client hyperventilates in response to hypoxemia. Hyperventilation is an attempt to provide more oxygen to the tissues to compensate for decreased circulating volume. It increases minute volume and results in decreased PaCO 2, while PaO 2 remains normal. This is the classic picture of respiratory alkalosis. Respiratory acidosis occurs in the advanced stage of shock. Metabolic alkalosis does not develop in shock unless overcorrection of acidosis is a result of administering sodium bicarbonate. Metabolic acidosis occurs in the advanced stage of shock. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 785 _ about (MC)
QUESTION: "If none of the following bed positions is contraindicated, which position would be preferred for the client with hypovolemic shock?"
CHOICES
( X ) a.) Supine.
( X ) b.) Semi-Fowler's.
( O ) c.) Supine with the legs elevated 15 degrees.
( X ) d.) Trendelenburg's.
RATIONALE: A client in hypovolemic shock is best positioned supine in bed with the feet elevated 15 degrees to bring peripheral blood into the central circulation. The supine position does not promote venous return. Semi-Fowler's position would not facilitate venous return. Trendelenburg's position was formerly recommended but has been found to inhibit respiratory expansion and possibly to cause increased intracranial pressure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 786 _ about (MC)
QUESTION: "Which of the following would be an appropriate nursing diagnosis for a client with iron-deficiency anemia?"
CHOICES
( X ) a.) Excess Fluid Volume related to anemia.
( X ) b.) Imbalanced Nutrition related to Nausea.
( O ) c.) Activity Intolerance related to Fatigue.
( X ) d.) Impaired Home Maintenance related to neurological impairment.
RATIONALE: Fatigue is commonly experienced by clients with iron-deficiency anemia due to reduced oxygen-carrying capacity from low hemoglobin. The fatigue may lead to the client's inability to participate in activity. Excess Fluid Volume is not a problem of iron-deficiency anemia. Nausea is not typically related to iron-deficiency anemia, although anorexia may be a problem. Neurologic impairment is not related to iron-deficiency anemia; pernicious anemia may cause neurologic impairment. NURSING PROCESS STEP: Analysis, nursing diagnosis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 787 _ about (MC)
QUESTION: "Which of the following statements best explains the common observation that health care personnel avoid terminally ill people?"
CHOICES
( X ) a.) The family members who are present can provide essential care.
( O ) b.) Health care personnel do not understand their own feelings about death and dying.
( X ) c.) The dying person requires minimal physical care to be comfortable.
( X ) d.) To protect a person's right to die with dignity, it is best to avoid interrupting the client.
RATIONALE: Health care personnel may avoid the terminally ill client because they are uncomfortable about death and do not understand their own feelings about dying. Family members should not be expected to assume responsibility for the client's care, but they should be involved in the client's care to the extent they desire. Skilled and knowledgeable nursing care is required to make a dying person comfortable. Interrupting the client does not necessarily interfere with the right to die with dignity. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 788 _ about (MC)
QUESTION: "A client is brought to the hospital after vomiting bright red blood and is admitted through the emergency department with a bleeding duodenal ulcer. While the client is bleeding, it will be essential for the nurse to assess frequently for signs of early shock. Which one of the following is an important indicator of early shock?"
CHOICES
( O ) a.) Tachycardia.
( X ) b.) Dry, flushed skin.
( X ) c.) Increased urine output.
( X ) d.) Loss of consciousness.
RATIONALE: In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation. The skin becomes cool and clammy. Urine output in early shock may be normal or slightly decreased. The client may experience increased restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 789 _ about (MC)
QUESTION: "Which of the following expected outcomes would be most appropriate for a client with peptic ulcer disease? The client will:"
CHOICES
( O ) a.) verbalize absence of epigastric pain.
( X ) b.) accept the need to inject himself with vitamin B 12 for the rest of his life.
( X ) c.) understand the need to increase his exercise activity.
( X ) d.) eliminate stress from his life.
RATIONALE: A realistic goal for this client would be to gain relief from epigastric pain. There is no need for vitamin B 12 injections because this client has not had any gastric surgery that would lead to vitamin B 12 deficiency. Exercise should be modified, not increased, because it can stimulate further production of gastric acid. It is not possible to eliminate stress from a client's life. Instead, the client should be assisted to develop effective coping and problem-solving strategies as necessary. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 790 _ about (MC)
QUESTION: "A client diagnosed with a peptic ulcer undergoes an upper gastrointestinal endoscopy to help the physician visualize the ulcer's location and severity. Immediately after the endoscopy, what would be a priority for the nurse to assess?"
CHOICES
( O ) a.) Return of the gag reflex.
( X ) b.) Bowel sounds.
( X ) c.) Peripheral pulses.
( X ) d.) Intake and output.
RATIONALE: Prior to an upper gastrointestinal endoscopy, a local anesthetic is applied to the posterior pharynx. This results in temporary loss of the gag reflex which facilitates passage of the endoscope. The client is at risk for aspiration until the gag reflex returns. Therefore, monitoring the client for return of the gag reflex is a priority nursing assessment. An upper gastrointestinal endoscopy does not affect bowel sounds. Peripheral pulses are not affected by an upper gastrointestinal endoscopy. It is useful to monitor the client's intake and output until he has completely recovered from sedation, however, monitoring the airway is always the highest priority. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 791 _ about (MC)
QUESTION: "The client with a peptic ulcer is prescribed antibiotics and bismuth salts. The nurse explains that this combination of medications will:"
CHOICES
( X ) a.) Prepare his bowel for surgery.
( O ) b.) Eradicate the Helicobacter pylori bacteria.
( X ) c.) Prevent future ulcers from forming.
( X ) d.) Prevent bleeding from the ulcer.
RATIONALE: H. pylori is present in 70% of patients with peptic ulcers. Bacteriostatic or bacteriocidal antibiotics are given to eradicate the bacteria from the gastric mucosa. Bismuth salts suppress the H. pylori bacteria and help to heal the mucosa. Although sometimes indicated, surgery for peptic ulcer is much less common now that the role of H. pylori in the development of gastric ulcers is understood. The bowel preparation for gastric surgery does not include bismuth salts. While treatment for H. pylori drastically reduces the recurrence rate, 10% of clients treated for H. pylori will have a recurrence of peptic ulcer disease. While effective treatment will eliminate the possibility of complications, antibiotics and bismuth salts will not directly prevent bleeding. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 792 _ about (MC)
QUESTION: "Which of the following statements would indicate that the client with peptic ulcer disease understands how to effectively adjust his response to work-related stress?"
CHOICES
( X ) a.) "My job is too stressful. I will have to find a different career."
( X ) b.) "I don't have any control over my stressors at work. My coworkers are difficult to work with."
( X ) c.) "Well, I guess this ulcer means I won't be able to work toward a promotion."
( O ) d.) "I will have to improve my ability to cope with stress."
RATIONALE: Although clients cannot eliminate stress, they can improve their ability to cope with it. Considering a job change may help a client deal with stress, but improving the ability to cope with stress is most effective. Identifying stressors at work may help a client deal with stress, but improving the ability to cope with stress is most effective. Setting professional goals a little lower may help a client deal with stress, but improving the ability to cope with stress is most effective. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 793 _ about (MC)
QUESTION: "Which of the following activities should the nurse encourage the client with a peptic ulcer to avoid?"
CHOICES
( X ) a.) Chewing gum.
( O ) b.) Smoking cigarettes.
( X ) c.) Eating chocolate.
( X ) d.) Taking acetaminophen (Tylenol).
RATIONALE: Cigarette smoking should be avoided because of its stimulatory effect on gastric secretions. Nicotine also increases the release of epinephrine, which leads to vasoconstriction. The client may chew gum if desired. The client may eat chocolate if desired. A client with a peptic ulcer should check with the physician before taking any over-the-counter drug, but acetaminophen does not typically cause gastric irritation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 794 _ about (MC)
QUESTION: "Which of the following symptoms would the nurse most likely observe in a client with cholecystitis from cholelithiasis?"
CHOICES
( X ) a.) Black stools.
( O ) b.) Nausea after ingestion of high-fat foods.
( X ) c.) Elevated temperature of 103%F (39.4%C).
( X ) d.) Decreased white blood cell count.
RATIONALE: A client with cholecystitis from cholelithiasis may experience nausea, vomiting, abdominal discomfort, and other gastrointestinal symptoms after eating high-fat foods. This is due to decreased fat absorption related to lack of normal bile flow from the gall bladder. Black stools are indicative of gastrointestinal bleeding, not gall bladder disease. Clients are more likely to have a low-grade fever. Clients are more likely to an elevated white blood cell count due to inflammation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 795 _ about (MC)
QUESTION: "Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?"
CHOICES
( O ) a.) Administering pain medication.
( X ) b.) Completing the admission history.
( X ) c.) Maintaining hydration.
( X ) d.) Teaching about planned diagnostic tests.
RATIONALE: Administering pain medication would have the highest priority during the first hour after the client's admission. Completing the admission history can be done after the client's pain is controlled. Maintaining hydration is important but will be accomplished over time. In the first hour after admission, the highest priority is pain relief. It is not appropriate to try to teach while a client is in pain. Teaching about planned diagnostic tests can occur after the client is comfortable. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 796 _ about (MC)
QUESTION: "A client is scheduled for oral cholecystography. Which one of the following actions would the nurse plan to implement before the test?"
CHOICES
( X ) a.) Have the client drink 1000 mL of water.
( O ) b.) Ask the client about possible allergies to iodine or shellfish.
( X ) c.) Administer an intravenous contrast agent the evening before the test.
( X ) d.) Administer tap-water enemas until clear.
RATIONALE: Iodine compounds used as radiographic contrast agents, such as iopanoic acid (Telepaque), should not be administered to the client with iodine and seafood allergies because anaphylaxis may occur. Drinking large amounts of water is indicated for certain kidney or urinary bladder studies, not gall bladder studies. The contrast agent is administered orally 10 to 12 hours before the test. The client is NPO after administration of the contrast agent. Enemas are not required for cholecystography. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 797 _ about (MC)
QUESTION: "The nurse should understand that the primary reason for withholding food and fluids from a client who will receive general anesthesia is to help prevent:"
CHOICES
( X ) a.) Constipation during the immediate postoperative period.
( O ) b.) Vomiting and possible aspiration of vomitus during surgery.
( X ) c.) Pressure on the diaphragm with poor lung expansion during surgery.
( X ) d.) Gas pains and distention during the immediate postoperative period.
RATIONALE: Oral food and fluids are withheld before surgery when a client receives general anesthesia primarily to help prevent vomiting and possible aspiration of stomach contents. Constipation after surgery is influenced by multiple factors such as the nature of the surgery, the postoperative diet, and use of opioid analgesics. Food and fluids are not withheld prior to surgery to relieve pressure on the diaphragm and increase lung expansion. Withholding food and fluids before surgery does not eliminate gas pains or abdominal distention in the postoperative period. General anesthesia and manipulation of abdominal contents can cause peristaltic action to cease temporarily. This leads to abdominal distention and gas pain. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 798 _ about (MC)
QUESTION: "The nurse administers a preoperative intramuscular medication at the ventrogluteal site. The nurse will inject the medication into which muscle?"
CHOICES
( X ) a.) Rectus femoris.
( O ) b.) Gluteus minimus.
( X ) c.) Vastus lateralis.
( X ) d.) Gluteus maximus.
RATIONALE: When using the ventrogluteal site, the nurse injects the medication into the gluteus minimus muscle. The rectus femoris muscle, which is located on the anterior aspect of the thigh, can be used for intramuscular injections. The vastus lateralis muscle is used for the vastus lateralis injection site. The gluteus maximus muscle is used for the dorsogluteal injection site. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 799 _ about (MC)
QUESTION: "The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?"
CHOICES
( O ) a.) Inspect skin around the T tube daily for irritation.
( X ) b.) Irrigate the T tube every 4 hours to maintain patency.
( X ) c.) Maintain client in a supine position while T tube is in place.
( X ) d.) Keep T tube clamped except for during mealtimes.
RATIONALE: Bile is erosive and extremely irritating to the skin. Therefore, it is essential that skin around the T tube be kept clean and dry. T tubes are not routinely irrigated; they are irrigated only on order of the physician. There is no need to maintain the client in a supine position; assist the client into a position of comfort. T tubes are never clamped without a physician's order. If ordered to be clamped, however, this typically is done 1 to 2 hours before and after meals. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 800 _ about (MC)
QUESTION: "Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?"
CHOICES
( X ) a.) Having the client take rapid, shallow breaths to decrease pain.
( X ) b.) Having the client lay on the left side while coughing and deep breathing.
( O ) c.) Teaching the client to use a folded blanket or pillow to splint the incision.
( X ) d.) Withholding pain medication so the client can be alert enough to follow the nurse's instructions.
RATIONALE: A folded bath blanket or pillow placed over the incision will be most effective in helping the client cough and deep breathe after a cholecystectomy. Taking rapid, shallow breaths would not be effective in decreasing pain. Lying on the left side would cause decreased lung expansion. When possible, the client should be positioned in semi-Fowler's or Fowler's position to promote maximum lung expansion.. Withholding pain medication will make the client less likely to cough and deep breathe owing to the discomfort. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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