South Texas University MEDSURG Nclex practive 100 Prepu

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Question 1: (see full question) A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? Impaired oral mucou... s membranes Impaired gas exchange Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airw ... (more) Pneumocystis jiroveci (carinii) pneumonia Pneumocystis carinii pneumonia You selected: Incorrect Correct response: Explanation: Remediation: Question 2: (see full question) Adolescents and adults who were sexually abused as children commonly mutilate themselves. The nurse interprets this behavior as: You selected: use of physical pain to avoid dealing with emotional pain. Correct Explanation: Dealing with the physical pain associated with mutilation is viewed as easier than dealing with the intense anger and emotional pain. The client fears an aggressive outburst when a ... (more) Remediation: Self-mutilation Question 3: (see full question) A client with diabetes mellitus asks the nurse to recommend something to remove corns from his toes. The nurse should advise the client to: You selected: consult a health care provider (HCP) about removing the corns. Correct Explanation: A client with diabetes should be advised to consult a HCP or podiatrist for corn removal because of the danger of traumatizing the foot tissue and potential development of ulcers (more) Remediation: Foot care Diabetes Question 4: (see full question) You selected: A nurse is developing a care plan for a client recovering from a serious thermal burn. What does the nurse determine is the priority goal of therapy? Maintaining the client's fluid and electrolyte balance Correct Explanation: Remediation: After maintaining respirations, the most important and immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance t ... (more) Fluid assessment Burn wound care Question 5: (see full question) You selected: Correct Explanation: Remediation: A distraught father is waiting for his son to come out of surgery. He accidentally backed the car into his son, causing multiple fractures and a serious head injury. Which statement by the father would most alert the nurse to the need for a psychiatric consultation? "If he dies, there will be nothing for me to do but join him." The statement about joining the son if he dies indicates potential for self-harm and subsequent suicide, always a risk during crisis. Although the father may be charged with reckle ... (more) Suicide precautions Question 6: (see full question) You selected: Correct Explanation: Remediation: A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis? Risk for injury Because of decreased physical mobility, a client with recent left-sided hemiparesis is at risk for falls in the home setting. His ability to cope with the stroke is important, but ... (more) Stroke Question 7: (see full question) You selected: Correct Explanation: Remediation: At which time should the nurse instruct the client to take ibuprofen, prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation? immediately after a meal Drugs that cause gastric irritation, such as ibuprofen, are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an e ... (more) Ibuprofen Question 8: (see full question) Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy? Teach the client to use a folded blanket or pillow to splint the incision. 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 ... (more) Cholecystectomy Teaching Coughing and Splinting You selected: Correct Explanation: Remediation: Question 9: (see full question) A child requires IV fluids to infuse at 27 ml/hr. The tubing delivers 60 gtts/ml. How many gtts/min should the nurse count to ensure that the fluid is safely infusing? 27 gtts/min The nurse should count 27 gtts/min. 27 ml/h x 60 gtts/ml ÷ 60 min/h = 27 gtts/min IV infusion, dose and flow rate calculations You selected: Correct Explanation: Remediation: Question 10: (see full question) You selected: Correct Explanation: Remediation: Before administering the evening dose of an ordered medication, a nurse on the evening shift finds an unlabeled, filled syringe in a client's medication drawer. What should the nurse do? Discard the syringe to avoid a medication error. As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe practices because they promote error. Safe medication administration practices Question 11: (see full question) You selected: A 13-year-old child has seen the school nurse several times with headache, vomiting, and difficulty walking. When calling the adolescent's mother about these symptoms, what should the nurse suggest the mother do first? Make an appointment with the adolescent's health care provider (HCP). Correct Explanation: Remediation: A child who has symptoms of vomiting, headaches, and problems walking needs to be evaluated by a health care provider (HCP) to determine the cause. Unexplained headaches and vomiti ... (more) Physical assessment, pediatric Question 12: (see full question) You selected: A newly-admitted client has told the nurse, "I always take a thyroid pill each morning but I do not think I have been prescribed it here in the hospital." The nurse confirms that the client's medication orders do not include this. What is the nurse's best action? Contact the client's provider, and discuss the fact that the client normally takes thyroid supplements. Correct Explanation: The nurse's priority action is to make the provider aware of this potential oversight. Family members should not bring medications that have not been prescribed in the hospital. Th ... (more) Question 13: (see full question) You selected: Correct Explanation: Remediation: While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next? Continue to monitor the suture line, and document findings. During the fibrinoplastic stage of healing, granulation tissue, which has a characteristic pink shiny appearance, fills in the wound. This normal occurrence requires the nurse to c ... (more) Wound Healing Question 14: (see full question) The health care provider (HCP) prescribes a serum lithium level tomorrow for a client with bipolar disorder, manic phase, who has been receiving lithium 300 mg PO three times daily for the past 5 days. At what time should the nurse plan to have the blood specimen obtained?g times should the nurse plan to have the blood specimen obtained? You selected: before breakfast Correct Explanation: Because lithium reaches peak blood levels in 1 to 3 hours, blood specimens for serum lithium concentration determinations are usually drawn before the first dose of lithium in the ... (more) Remediation: Lithium carbonate Question 15: (see full question) You selected: Correct Explanation: Remediation: While making a home visit to a multigravida 2 weeks after the birth of viable twins at 38 weeks’ gestation, the nurse observes that the client looks pale, has dark circles around her eyes, and is breastfeeding one of the twins. The client’s apartment is clean, and nothing appears out of place. The client tells the nurse that she completed three loads of laundry this morning. A priority need for this client is: fatigue related to home maintenance and caring for twins. Most postpartum clients have excessive fatigue after childbirth. This multigravida has dark circles around her eyes and is pale, which can indicate anemia or excessive sleep depriv ... (more) Sleep deprivation Question 16: (see full question) You selected: Correct Explanation: Remediation: A nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which feature as the main advantage of this method? The implants provide effective, continuous contraception that isn't user dependent. Although all of the options accurately describe features of subdermal contraceptive implants, the main advantage of this contraceptive method is effective, continuous contraception ... (more) Subdermal contraceptive implants Question 17: (see full question) You selected: Correct Explanation: Remediation: A client diagnosed with antisocial personality disorder asks the nurse if he can have an additional smoke break because he's anxious. Which response by the nurse is best? "Clients are permitted to smoke at designated times. You have to follow the rules." Consistency is essential when dealing with antisocial clients. They disregard social norms and don't believe the rules apply to them. Agreeing to give the client a smoke break woul ... (more) Antisocial personality disorder Question 18: Which statement indicates that a client with esophageal reflux You selected: “I can have lemonade after meals.” Incorrect Correct response: “I won’t drink any carbonated drinks.” Explanation: Carbonated drinks should be avoided when a client has esophageal reflux disorder, because the carbonation causes increased esophageal pressure, which leads to increased reflux. Caf ... (more) Remediation: Hernia (hiatal) Question 19: A client comes to the emergency department reporting pain in (see full question) the right leg. When obtaining the history, the nurse learns that the client has a history of obesity and hypertension. Based on this information the nurse anticipates the client having which musculoskeletal disorder? You selected: Degenerative joint disease Correct Explanation: Obesity predisposes the client to degenerative joint disease. Obesity isn't a predisposing factor for muscular dystrophy, scoliosis, or Paget's disease (more) Question 20: The nurse is caring for a client being discharged following (see full question) kidney transplantation. The client is ordered mofetil to prevent organ rejection. Which nursing instruction is essential regarding medication use? You selected: Contact the health care provider at first signs of an infection. Correct Explanation: Mofetil is an organ rejection medication that diminishes the body’s ability to identify and eliminate pathogens (immunosuppressant). Identifying symptoms of infection at an early ... (more) Remediation: mycophenolate mofetil Question 21: The nurse is planning care for an infant with bronchiolitis. (see full question) What is the nurse’s priority intervention for this child? You selected: Assess respiratory status frequently Correct Explanation: Infants with bronchiolitis will have impaired gas exchange related to bronchiolar obstruction, atelectasis, and hyperinflation. Changes in respiratory status may occur quickly as e ... (more) Remediation: Respiratory assessment, neonatal, respiratory therapy Question 22: Which of the following behaviors would indicate to the nurse (see full question) that follow-up is needed for a client having difficulty attaching to her newborn? You selected: Holds the baby in the en face position Incorrect Correct response: Lets the baby cry to get to sleep Explanation: Not responding to the needs of the newborn (e.g., crying) may indicate that the mother is not attaching to her infant. It is normal behavior for the mother to talk to the baby in a ... (more) Remediation: Parent-infant bonding Question 23: A 20-year-old female client says, “I feel that my vaginal (see full question) opening constricts whenever I am about to have intercourse. I seem to have no control over it.” Which of the following terms should the nurse use to document the client’s condition? You selected: Orgasmic dysfunction. Incorrect Correct response: Vaginismus. Explanation: The client is experiencing an involuntary contraction of the muscles surrounding the vaginal orifice; this should be documented as vaginismus. Dyspareunia is painful intercourse. D ... (more) Question 24: After lobectomy for lung cancer, a client receives a chest tube (see full question) connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? You selected: Water-seal chamber Correct Explanation: Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respiration ... (more) Remediation: Chest tubes Question 25: The client has sore nares while a nasogastric (NG) tube is in (see full question) place. Which nursing measure would be most appropriate to help alleviate the client's discomfort? You selected: Apply a water-soluble lubricant to the nares. Correct Explanation: Applying a water-soluble lubricant to the nares helps alleviate sore nares when an NG tube is in place. Repositioning the tube does not eliminate the possibility of irritating the ... (more) Remediation: Nasogastric tube insertion Nasogastric tube monitoring Question 26: A charge nurse is developing the client care assignments for (see full question) the shift. Which client is most appropriately assigned to a licensed practical nurse (LPN)? You selected: A client who underwent craniotomy three days ago and has just been transferred from the intensive care unit (ICU) Incorrect Correct response: A client who experienced a cerebral vascular accident and has a do-not-resuscitate (DNR) status Explanation: The most appropriate client to assign to the LPN is the newly- admitted client with DNR status. Typically, a newly admitted client is assigned to a registered nurse (RN) because the ... (more) Remediation: Delegating care Question 27: (see full question) A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of: You selected: respiratory alkalosis Correct Explanation: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation, which does not cause metabolic acidosis ... (more) Remediation: Arterial blood gas analysis Question 28: A nurse assesses arterial blood gas results for a client in acute (see full question) respiratory failure (ARF). Which of the following results are consistent with this disorder? You selected: pH 7.46, PaO2 80 mm Hg Incorrect Correct response: pH 7.28, PaO2 50 mm Hg Explanation: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 m ... (more) Remediation: Acute respiratory failure Arterial blood gas analysis Question 29: Which of the following actions performed by a nurse will (see full question) increase the risk of liability? Select all that apply. You selected: • Asking unlicensed assistive personnel to assess a client’s wound • Providing information to a caller about a client’s diagnosis and treatment • Assisting a client on ordered bed rest to walk to the toilet Correct Explanation: Nursing standards of practice are stated within the nurse practice act of each state, territory, or province. These standards include scope of practice, delegation, professional et ... (more) Question 30: The nurse is caring for a client in the medical unit. The nurse (see full question) receives a health care provider’s order for Hydrocortisone 100 mg intravenously at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse is most correct to understand that this treatment is common in clients with which disease process? You selected: Hyperthyroidism Incorrect Correct response: Addison’s disease Explanation: Intravenous hydrocortisone for clients in acute adrenal crisis is the proper treatment for individuals with Addison’s disease. Cushing’s syndrome is associated with excessive a ... (more) Remediation: Adrenal hypofunction Question 31: A nurse on a night shift entered an elderly client’s room during (see full question) a scheduled check and discovered the client on the floor beside her bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? You selected: Following up the incident with other members of the care team. Incorrect Correct response: Identifying risks and ensuring future safety for clients. Explanation: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the ... (more) Remediation: Fall management Question 32: A nurse is teaching a client with multiple sclerosis (MS). (see full question) When teaching the client how to reduce fatigue, the nurse should tell the client to: You selected: take a hot bath. Incorrect Correct response: rest in an air-conditioned room. Explanation: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A ... (more) Remediation: Multiple sclerosis Question 33: Which instruction should the nurse include in the teaching (see full question) plan for a client with seizures who is going home with a prescription for gabapentin? You selected: Notify the health care provider (HCP) if vision changes occur. Correct Explanation: Gabapentin may impair vision. Changes in vision, concentration, or coordination should be reported to the HCP. Gabapentin should not be stopped abruptly because of the potential fo ... (more) Remediation: Gabapentin Question 34: An adolescent client, diagnosed with depression and a suicide (see full question) attempt, is admitted to an inpatient adolescent psychiatric unit. The nurse documents that “the client describes a recent breakup of a dating relationship with an emotionless tone and a flat facial expression.” Which nursing diagnosis would be a priority in the client’s plan of care? You selected: Low self esteem related to feelings of abandonment Incorrect Correct response: Risk for suicide related to depressed mood Explanation: The priority for this client is his/her risk for suicide related to depressed mood. The client’s anger has turned inward, and the nurse must be alert for another suicide attempt (more) Remediation: Suicide precautions Question 35: A client at term arrives in the labor unit experiencing (see full question) contractions every 4 minutes. After a brief assessment, she's admitted and an electric fetal monitor is applied. Which finding alerts the nurse to an increased risk for fetal distress? You selected: Blood pressure of 146/90 mm Hg Correct Explanation: A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth rest ... (more) Remediation: Chronic hypertension in pregnancy patient care Contraction stress test Question 36: A nurse explains to a client with thyroid disease that the (see full question) thyroid gland normally produces: You selected: thyrotropin-releasing hormone (TRH) and TSH. Incorrect Correct response: T3, thyroxine (T4), and calcitonin. Explanation: The thyroid gland normally produces thyroid hormone (T3 and T4) and calcitonin. The pituitary gland produces TSH to regulate the thyroid gland. The hypothalamus gland produces TRH ... (more) Remediation: Thyroxine level Question 37: Which guidelines define and regulate what the nurse may and (see full question) may not do as a professional? You selected: Nurse practice act Correct Explanation: Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the s ... (more) Question 38: What advice should a nurse give to the parents of a 2-year-old (see full question) child who frequently throws temper tantrums? You selected: Ignore the behavior when it happens. Correct Explanation: Ignoring tantrums is the best advice because paying attention to the undesirable behavior can reinforce it. Changing settings can actually increase the tantrum behavior. Allowing t ... (more) Question 39: The mother of a 10-year-old girl with diabetes asks the nurse’s (see full question) advice about whether or not her child, who has always been compliant with treatment, should be allowed to go trick-or- treating on Halloween with several friends. The nurse should tell the mother: You selected: "Yes, she needs to be with friends and do the things other children do." Correct Explanation: The nurse should advise the mother to allow the child to go trick-or-treating. Children need to be treated like their peers. Sheltering them from all temptation does not allow them ... (more) Remediation: Risk for impaired parenting Diabetes mellitus, pediatric Question 40: The family of a laboring client is distressed to discover that the (see full question) on-call physician is a male. The client’s husband forbids the physician from providing care for his wife. What is the nurse’s best strategy in which to provide care in labor and birth when confronted with a cultural conflict? You selected: “I will make every effort to work with your cultural beliefs.” Correct Explanation: The nurse knows he/she must make every effort to respect and work within the cultural limitations in each client situation. Telling the family they are compromising the health of th ... (more) Remediation: Cultural needs assessment during pregnancy Question 41: A client received burns to his entire back and left arm. Using (see full question) the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? You selected: 27% Correct Explanation: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body sur ... (more) Remediation: Burn care Burns Question 42: A nurse is assisting a client with a chronic respiratory disease (see full question) to walk in the hallway. The nurse observes as the client’s SpO2 drops from 94% to 88% during ambulation. Which of the following is the appropriate action of the nurse? You selected: Administer low flow supplemental O2 Correct Explanation: The drop in SpO2 to 88% indicates that the client is hypoxemic and needs supplemental oxygen when exercising. The appropriate action would be to administer low flow oxygen to impro ... (more) Question 43: A client with a history of Addison’s disease is experiencing (see full question) weakness and headache. The vital signs are blood pressure of 100/60 and heart rate of 80. Laboratory values are Na 130, potassium 4.8, and blood glucose 70. Which of the following would the nurse expect to administer? You selected: IV total parenteral nutrition and insulin coverage Incorrect Correct response: IV normal saline and glucocorticoids Explanation: The client with Addison’s is expected to have hypotension and inadequate corticosteroids. There is no evidence that the client would be anemic. Although the blood pressure may be ... (more) Remediation: Adrenal hypofunction Question 44: A nurse is caring for a client with acute pyelonephritis. Which (see full question) nursing intervention is the most important? You selected: Increasing fluid intake to 3 L/day Correct Explanation: Acute pyelonephritis is a sudden inflammation of the interstitial tissue and renal pelvis of one or both kidneys. Infecting bacteria are normal intestinal and fecal flora that grow ... (more) Remediation: Acute pyelonephritis Question 45: The nurse is teaching a client with type I diabetes self- (see full question) administration of insulin. Which statement by the client would be an expected outcome of the teaching session? Select all that apply. You selected: • “I need to make sure that I eat my meals and snacks on time after I take my insulin.” • “If I monitor and control my blood glucose levels carefully, there is less likelihood of suffering long-term complications.” • “If I lose weight and control my carbohydrate intake, I can progress to diabetic pills.” Incorrect Correct response: • “I need to make sure that I eat my meals and snacks on time after I take my insulin.” • “If I monitor and control my blood glucose levels carefully, there is less likelihood of suffering long-term complications.” • “If I exercise more than is normal, there is a risk that I might become hypoglycemic.” Explanation: The client demonstrates understanding of type 1 diabetes by stating the importance of regularly scheduled meals and snacks as well as the importance of maintaining good control of ... (more) Remediation: Diabetes mellitus, type 1 Diabetes Question 46: The nurse is caring for a child with hemophilia who is actively (see full question) bleeding from the leg. The nurse should apply: You selected: direct pressure to the injured area continuously for 10 minutes. Correct Explanation: For the child with hemophilia who is actively bleeding, the nurse should apply direct pressure to the injured area for 10 minutes continuously along with elevating the leg. The con ... (more) Remediation: Hemophilia, pediatric Hemostasis Question 47: The nurse is caring for a client following a motor vehicle (see full question) incident with head trauma suspected of diabetes insipidus. Which nursing intervention is appropriate? You selected: Assess pupils for constriction. Incorrect Correct response: Measure and record urinary output. Explanation: Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an unusually high oral intake of fluids. Treatment with the appropriate drug should decrease bo ... (more) Remediation: Diabetes insipidus Question 48: The nurse is ambulating a client. The client experiences chest (see full question) pain after ambulating 50 feet. What is the nurse’s priority intervention? You selected: Administer the ordered sublingual nitroglycerin Incorrect Correct response: Sit the client down Explanation: The priority is to decrease oxygen consumption by sitting this client down. When the client’s condition is stabilized, he can be returned to bed. An ECG can be obtained after the ... (more) Remediation: Ambulation, progressive Question 49: Which is an expected outcome of pursed-lip breathing for (see full question) clients with emphysema? You selected: to promote carbon dioxide elimination Correct Explanation: Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client rel ... (more) Remediation: Emphysema Respiratory: Gas Exchange in Alveoli Question 50: A client with suspected inhalation anthrax is admitted to the (see full question) emergency department. Which action by the nurse takes the highest priority? You selected: Suction the client as needed to obtain a sputum specimen for culture and sensitivity. Incorrect Correct response: Monitor vital signs and oxygen saturation every 15 to 30 minutes. Explanation: Monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. Suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the ... (more) Remediation: Levofloxacin Question 51: A registered nurse (RN) is supervising an unlicensed assistive (see full question) personnel (UAP). Which principle would the nurse follow when delegating tasks? You selected: The RN must directly supervise all delegated tasks Incorrect Correct response: The RN delegates a task based on the UAP’s skill set Explanation: The RN must delegate tasks that are within the scope of practice of the unlicensed personnel. The RN need not directly supervise all delegated tasks, as this would negate the benef ... (more) Remediation: Delegating care Question 52: Which outcome criterion would be most appropriate for a (see full question) client with a nursing diagnosis of Ineffective airway clearance? You selected: Breath sounds clear on auscultation Correct Explanation: The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. Congestion on X-ray, continued use o ... (more) Remediation: Respiration assessment Question 53: A client with bipolar disorder, manic phase, shows little (see full question) interest in eating. To help the client meet recommended daily allowances of nutrients, the nurse should: You selected: teach the client about proper nutrition. Incorrect Correct response: give the client half of a meat and cheese sandwich to carry with him. Explanation: The best nursing intervention is giving the client finger foods high in protein and calories that he can eat while he paces or walks. Informing the client that snacks are available ... (more) Remediation: Bipolar disorder Question 54: A client with chronic renal failure who receives hemodialysis (see full question) three times weekly has a hemoglobin (Hb) level of 7 g/dl (70mmol/L). The most therapeutic pharmacologic intervention would be to administer: You selected: epoetin alfa. Correct Explanation: Chronic renal failure diminishes the production of erythropoietin by the kidneys and leads to a subnormal Hb level. (Normal Hb level is 13 to 18 g/dl in men and 12 to 16 g/dl in wome ... (more) Remediation: Epoetin alfa Question 55: A client is admitted to the hospital with a diagnosis of renal (see full question) calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6° F (38.1° C). Which outcome would be a priority for this client? You selected: maintenance of fluid and electrolyte balance Incorrect Correct response: alleviation of pain Explanation: The priority nursing goal for this client is to alleviate the pain, which can be excruciating. Prevention of urinary tract complications and alleviation of nausea are appropriate t ... (more) Remediation: Renal calculi Question 56: A client with emphysema is at a greater risk for developing (see full question) what acid–base imbalance? You selected: Respiratory alkalosis Incorrect Correct response: Chronic respiratory acidosis Explanation: Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associa ... (more) Remediation: Emphysema Question 57: Two days after the client donated the right lobe of the liver to (see full question) his father, he tells the nurse, “I was pressured by my family to donate a piece of my liver.” What is the nurse’s priority intervention in this situation? You selected: Explore the client’s statement obtaining additional, detailed information. Correct Explanation: This powerful statement by the client needs to be explored and the client requires support. This is the first step in an ethical analysis. The donor’s advocate teams needs to be ... (more) Reference: Hinkle, J. L., & Cheever, K. H. Brunner & Suddarth’s textbook of medical-surgical nursing, 13th ed. Philadelphia: Wolters Kluwer, 2014, Chapter 54, Management of Patients with Kidney Disorders, pages 32, 1383. Question 58: After administering the prescribed medications, which of the (see full question) following clients requires immediate intervention? You selected: A client taking digoxin who has a morning potassium level of 3.0 mEq/L. Correct Explanation: The client’s low potassium level increases the risk for digoxin toxicity and potential dysrhythmias. Digoxin inhibits the action of the sodium-potassium pump that moves sodium an ... (more) Remediation: Digoxin toxicity Neurological: Equilibrium Potential Neurological: Flipping the Membrane Potential Question 59: The nurse has taught the wife of a client who experienced (see full question) traumatic vision loss strategies for effectively interacting with her spouse. Which statement by the wife indicates that the health teaching was successful? You selected: “Today I used the clock suggestion to state where things were located in the room.” Correct Explanation: If the wife is giving directions by using clock cues, then the teaching has been effective. When the wife unilaterally makes decisions like deciding to obtain a service dog, determ ... (more) Reference: Hinkle, J. L., & Cheever, K. H. Brunner & Suddarth’s textbook of medical-surgical nursing, 13th ed. Philadelphia: Wolters Kluwer, 2014, Chapter 9, Chronic Illness and Disability, page 145. Question 60: How should a nurse prepare a suspension before (see full question) administration? You selected: By shaking it so that all the drug particles are dispersed uniformly Correct Explanation: The nurse should shake a suspension before administration to disperse drug particles uniformly. Diluting the suspension and crushing particles aren't recommended for this drug form ... (more) Remediation: Oral drug administration Question 61: Parents tell a nurse that they have not met their goal of home (see full question) management of their son with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make? You selected: Evaluate the client for voluntary admission to a mental health facility. Correct Explanation: A voluntary admission is the preferred approach because it involves having the client recognize existing problems and facilitates the client's involvement in treatment. Chemical re ... (more) Remediation: Psychiatric nursing assessment Voluntary admission to a psychiatric unit Question 62: A client is admitted at 30 weeks' gestation with contractions (see full question) every 3 minutes. Her cervix is 1 to 2 cm dilated and 75% effaced. Following a 4-g bolus dose, IV magnesium sulfate is infusing at 2 g/h. How will the nurse know the medication is having the intended effect? You selected: Contractions will increase in frequency, leading to birth. Incorrect Correct response: Contractions will decrease in frequency, intensity, and duration. Explanation: The expected outcome of magnesium sulfate administration is suppression of the contractions because the client is in preterm labor. Magnesium sulfate is a smooth muscle relaxant us ... (more) Remediation: Magnesium sulfate administration Tocolytic therapy Question 63: During labor, a client's cervix fails to dilate progressively, (see full question) despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate? You selected: Contractions will be stronger and more uncomfortable and will peak more abruptly. Correct Explanation: Oxytocin administration causes stronger, more uncomfortable contractions, which peak more abruptly than spontaneous contractions. Remediation: Oxytocin administration during labor and delivery Prolonged labor patient care Question 64: The nurse is preparing a community education program about (see full question) preventing hepatitis B infection. Which information should be incorporated into the teaching plan? You selected: Good personal hygiene habits are most effective at preventing the spread of hepatitis B. Incorrect Correct response: The use of a condom is advised for sexual intercourse. Explanation: Hepatitis B is spread through exposure to blood or blood products and through high-risk sexual activity. Hepatitis B is considered to be a sexually transmitted disease. High-risk s ... (more) Remediation: Hepatitis, viral Question 65: Which concept is most important for a nurse to communicate (see full question) to a client preparing to sign an informed consent for electroconvulsive therapy (ECT)? You selected: "You may experience a time of confusion after the treatment." Correct Explanation: The nurse should explain to the client that he may experience a time of confusion following ECT as a result of electricity passing through the cerebral cortex and disrupting nerve ... (more) Remediation: Electroconvulsive therapy Electroconvulsive therapy Question 66: A client is admitted to an acute care facility after an episode of (see full question) status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? You selected: Recent stress level Incorrect Correct response: Compliance with the prescribed medication regimen Explanation: The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't cont ... (more) Remediation: Seizures, generalized tonic-clonic Question 67: A client insists on leaving against medical advice (AMA). (see full question) Which of the following would be the best action by the nurse? You selected: Ask the provider to inform the client of potential complications. Correct Explanation: A client has the right to refuse care including the right to leave an agency against medical advice. The nurse does not encourage the client to leave and cannot hold the client aga ... (more) Remediation: General Discharge Instructions Question 68: A nurse is caring for a female client who is receiving (see full question) antibiotics to treat a gram-negative bacterial infection. The client experiences an adverse effect related to the destruction of the normal flora in the GI tract. What finding does the nurse expect to assess? You selected: Oral candidiasis Incorrect Correct response: Diarrhea Explanation: Broad-spectrum antibiotics that destroy aerobic and anaerobic bacteria also destroy the normal flora of the GI tract, which are responsible for absorbing water and certain nutrient ... (more) Question 69: An obese client has returned to the unit after receiving (see full question) electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help? You selected: "Obtain the sliding board or two other people to assist us." Correct Explanation: To successfully move an obese client from the stretcher to the bed without incurring injury, at least four staff members must perform the transfer. If only two people are available ... (more) Remediation: Sliding board transfer Question 70: The nurse is reviewing the electrocardiogram of a client who (see full question) has elevated ST segments visible in leads II, III, and aVf. Which is the nurse’s best action? You selected: Notify the healthcare provider Correct Explanation: Leads II, III, and aVF record electrical events on the inferior surface of the left ventricle; elevated ST sements indicate that the client is experiencing a myocardial infarction. (more) Remediation: Electrocardiography Myocardial infarction Question 71: The nurse is caring for a client on a second course of (see full question) antibiotics to eliminate osteomyelitis. It is most essential for the nurse to instruct on which aspect of daily care? You selected: A diet high in protein and nutrients Correct Explanation: It is essential for the nurse to instruct on a diet that is high in protein and nutrients to increase healing and strengthen the immune system. This, in addition to the second cour ... (more) Question 72: Which findings best correlate with a diagnosis of (see full question) osteoarthritis? You selected: Joint stiffness that decreases with activity Correct Explanation: A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that decreases with activity and movement. Erythema and edema over the affected joint, an ... (more) Remediation: Osteoarthritis Question 73: A client with Alzheimer's disease mumbles incoherently and (see full question) rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to: You selected: fold towels and pillowcases. Correct Explanation: Folding towels and pillowcases is a simple activity that redirects the client's attention. Also, because this activity is familiar, the client is likely to perform it successfully. ... (more) Remediation: Alzheimer Question 74: A hospitalized client fell on the floor and sustained a small (see full question) laceration on the hand that required stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine with epinephrine and a suture kit in order to suture the laceration. The nurse should question: You selected: bupivacaine with epinephrine as the local anesthetic. Correct Explanation: The nurse should question the use of a local anesthetic agent with epinephrine on the hands or feet because the epinephrine is a vasoconstrictor and can cause ischemia and gangrene ... (more) Remediation: Bupivacaine injection solution Question 75: A daughter is concerned that her mother is in denial because (see full question) when they discuss the diagnosis of breast cancer, the mother says that breast cancer is not that serious and then changes the subject. The nurse can tell the daughter that denial can be a healthy defense mechanism if it is used: You selected: to allow her mother to continue in her role as a mother. Correct Explanation: Denial is a defense mechanism used to shut out a situation that is too frightening or threatening to tolerate. In this case, denial allows the client to vacillate between acceptanc ... (more) Question 76: A client is being admitted to the hospital with abdominal pain, (see full question) anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him: You selected: onto the bedpan. Correct Explanation: A client who's dizzy and anemic is at risk for injury because of his weakened state. Assisting him with the bedpan would best meet his needs at this time without risking his safety ... (more) Remediation: Bedpan and urinal use Question 77: A nurse’s initial client assessment indicates probable opioid (see full question) overdose complicated by alcohol ingestion. What intervention should the nurse perform first? You selected: Administer IV naloxone Correct Explanation: If a client has ingested opioids, naloxone would reverse the effects and rouse the client. Intravenous fluids would most likely be administered, and this client would be closely mo ... (more) Remediation: naloxone hydrochloride Question 78: The nurse is reviewing the following physician’s order written (see full question) for a postmenopausal woman: “calcitonin salmon nasal spray 200 IU, one spray every day.” What is the appropriate action to be taken by the nurse regarding this order? You selected: Clarify with the physician that the spray should be given in only one nostril per day. Correct Explanation: Calcitonin salmon nasal spray should be administered in only one nostril per day. Many preprinted order sheets automatically print “administer in both nostrils” when a nasal sp ... (more) Remediation: calcitonin salmon Safe medication administration practices, general Question 79: The parents of a school-age child with a brain tumor have (see full question) elected to have only comfort measures instituted for their dying child. The child has been experiencing significant discomfort and has been receiving pain medication. A nurse knows that the pain-management principle most effective in controlling the child's pain is: You selected: using an age-appropriate tool for effectively assessing pain. Incorrect Correct response: striving to prevent pain by routine administration of pain medication. Explanation: When providing comfort measures for a child, the nurse should strive to prevent pain by providing routine pain medication. Although the nurse should administer pain medication prom ... (more) Remediation: Care of the Hospitalized Child: Pain Management Question 80: A client is being discharged with nasal packing in place. The (see full question) nurse should instruct the client to: You selected: gargle every 4 hours with salt water. Incorrect Correct response: perform frequent mouth care. Explanation: Frequent mouth care is important to provide comfort and encourage eating. Mouth care promotes moist mucous membranes. Nose drops cannot be used with nasal packing in place. When sn ... (more) Remediation: Nasal packing, posterior insertion, assisting Question 81: A mother calls the health clinic and tells the nurse that she (see full question) found her toddler with an open and empty bottle of acetaminophen. The mother asks the nurse what she should do. What is the nurse’s priority intervention? You selected: Give the mother instructions on how to call poison control Correct Explanation: The mother should call poison control and ask what immediate steps she should take to treat this ingestion. Home administration of syrup of ipecac is no longer recommended. Milk is ... (more) Remediation: acetaminophen Poisoning management, pediatric Question 82: The nurse-manager of a 20-bed coronary care unit is not on (see full question) duty when a staff nurse makes a serious medication error that results in a client’s overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse- manager? You selected: The nurse-manager would receive a call at home from the on- duty nursing supervisor, apprising him/her of the problem as soon as possible. Correct Explanation: The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possib ... (more) Question 83: Which instruction should be included in the discharge teaching (see full question) plan for a client after thyroidectomy for Graves' disease? You selected: Keep an accurate record of intake and output. Incorrect Correct response: Have regular follow-up care. Explanation: The nurse should instruct the client with Graves' disease to have regular follow-up care because most cases of Graves' disease eventually result in hypothyroidism. Annual thyroid- s ... (more) Remediation: Thyroidectomy Question 84: When developing the teaching plan for a client who uses a (see full question) walker, which principle should a nurse consider? You selected: If one leg is weaker than the other, the walker and the stronger leg should move, together, approximately 6″ ahead of the body. The client's weight is supported by his weaker leg. Incorrect Correct response: When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. Explanation: To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the ... (more) Remediation: Walkers Question 85: The nurse has received change-of-shift report on the following (see full question) clients. Who should the nurse plan to assess first? You selected: A client with first-degree heart block and a heart rate of 62 who is dizzy when ambulating. Incorrect Correct response: A client newly admitted after their implantable cardioverter- defibrillator (ICD) fired twice who has a dose of amiodarone due. Explanation: The firing of the ICD suggests that the client’s ventricles are irritable. The nurse’s priority is to assess the client and administer the amiodarone to prevent further dysrhyt ... (more) Question 86: A 7-year-old client is admitted to the hospital for a (see full question) tonsillectomy. After the surgery, the physician orders a clear liquid diet. The nurse is correct in giving the child which items? Select all that apply. You selected: • Chicken broth • Apple juice • Lime gelatin • Ice cream Incorrect Correct response: • Apple juice • Lime gelatin • Chicken broth Explanation: Clear liquids include clear broth, gelatin, clear juices, water, and ice chips. Cream of chicken soup, orange juice, and ice cream are included in a full liquid diet. Remediation: Tonsillectomy and adenoidectomy Question 87: A client is taking fluphenazine. The nurse understands that (see full question) teaching and discharge instructions are understood when the client states: You selected: “I need to stay out of the sun.” Correct Explanation: Fluphenazine is an antipsychotic drug that can cause photosensitivity and sunburn. Clients taking this drug don’t need to increase fluid intake, avoid cheese or eggs, or plan res ... (more) Remediation: fluphenazine decanoate Question 88: A nurse is preparing to administer the first dose of tobramycin (see full question) to an adolescent with cystic fibrosis. The order is for 3 mg/kg I.V. daily in three divided doses. The client weighs 95 lb (43.2 kg). How many milligrams should the nurse administer per dose? Record your answer using one decimal place. You selected: 43.2 Correct Explanation: To perform this dosage calculation, the nurse should calculate the client's daily dose using this formula: 43.2 kg × 3 mg/kg = 129.6 mg Lastly, the nurse should calculate the div (more) Question 89: A client admitted to the alcohol detoxification program asks (see full question) the nurse if there's anything he can take to "stop me from wanting a drink so badly." The nurse should teach the client about: You selected: haloperidol. Incorrect Correct response: naltrexone. Explanation: Naltrexone is a drug that can decrease alcoholic cravings. Chlordiazepoxide and other sedatives help reduce the symptoms of alcohol withdrawal but don't decrease cravings. Haloperi ... (more) Remediation: Naltrexone Question 90: After teaching a client about lorazepam, which client (see full question) statement indicates the need for further teaching? Select all that apply. You selected: • “I can take lorazepam with food if I get nauseous.” • “I can chew sugarless gum if my mouth feels dry.” • “I should not drink alcohol.” Incorrect Correct response: • ”I can adjust the dosage when I feel more anxious.” • ”I can stop taking lorazepam immediately if I need to.” Explanation: Lorazepam, a benzodiazepine, is used as an antianxiety agent and depresses the central nervous system (CNS). Benzodiazepines cause physical dependence and tolerance and sho ... (more) Remediation: lorazepam Question 91: The nurse assists the client to the operating room table and (see full question) supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? You selected: Wetness in the sterile cloth on top of the nonsterile table has been noted. Correct Explanation: Moisture outside the sterile package contaminates the sterile field because fluid can be wicked into the sterile field. Bacteria tend to settle, so there is less contamination abov ... (more) Remediation: Sterile field management, OR Question 92: The client who has undergone a bilateral adrenalectomy is (see full question) concerned about persistent body changes and unpredictable moods. The nurse should tell the client that: You selected: the physical changes are temporary, but the mood swings are permanent. Incorrect Correct response: the body and mood will gradually return to normal. Explanation: As the body readjusts to normal cortisol levels, mood and physical changes will gradually return to a normal state. The body changes are not permanent, and the mood swings should l ... (more) Remediation: Adrenalectomy Question 93: A mother tells the nurse that her 4 1/2-year-old child “does not (see full question) seem to know the difference between right and wrong.” This behavior is typical of which levels as described by Kohlberg’s theory of levels of moral development? You selected: preconventional Correct Explanation: The preconventional level of Kohlberg’s stages of moral development is typical of the preschool-aged child. Stage 1 behaviors of this preconventional level have a punishment- obed ... (more) Question 94: When a nurse attempts to make sure the physician obtained (see full question) informed consent for a thyroidectomy, she realizes the client doesn't fully understand the surgery. She approaches the physician, who curtly says, "I've told him all about it. Just get the consent." The nurse should: You selected: tell the physician the client isn't comfortable consenting to surgery at this point. Correct Explanation: The nurse has evaluated the client's knowledge concerning the surgery and determined that he doesn't have enough information to give informed consent. Even though the physician mig ... (more) Remediation: Informed consent Question 95: A nurse is frustrated by her inability to make much progress (see full question) establishing a therapeutic relationship with a client with bipolar disorder. Her most professional response would be to: You selected: ask the physician to reevaluate the client's medication. Incorrect Correct response: discuss the situation with a more experienced peer. Explanation: A collaborative approach is always a better way to address challenging situations; additional input may provide insight to help the nurse provide more effective client care. Asking ... (more) Question 96: A client is receiving captopril for heart failure. The nurse (see full question) should notify the physician that the medication therapy is ineffective if an assessment reveals: You selected: dry cough. Incorrect Correct response: peripheral edema. Explanation: Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't i ... (more) Remediation: Captopril Heart failure Question 97: The pediatric nurse is caring for a 10-month-old infant. The (see full question) health care provider orders an IV infusion of dextrose 5% in 0.45% NaCl solution to be infused at 7 mg/kg/hr. The infant weighs 22 lb (10 kg). How many ml/hr of the ordered solution should the nurse infuse? Record your answer using a whole number. You selected: 70 Correct Explanation: To perform this dosage calculation, the nurse should first convert the infant’s weight to kilograms: (1 kg/2.2 lb) x 22 lb = 10 kg Next, the nurse should multiply the infant’ (more) Question 98: The nurse has been instructing the client about how to prepare (see full question) meals that are low in fat. Which of thThe nurse has been instructing the client about how to prepare meals that are low in fat. Which of these comments would indicate the client needs additional teaching?ese comments would indicate the client needs additional teaching? You selected: ”I will eat more liver with onions.” Correct Explanation: Liver and organ meats are high in cholesterol and saturated fat and should be limited. Water-packed tuna is one of the leanest fish available. Using a nonstick pan when cooking red ... (more) Question 99: When assessing a client who is receiving tricyclic (see full question) antidepressant therapy, which finding should alert the nurse to the possibility that the client is experiencing anticholinergic effects? You selected: tremors and cardiac arrhythmias Incorrect Correct response: urine retention and blurred vision Explanation: Anticholinergic effects, which result from blockage of the parasympathetic nervous system, include urine retention, blurred vision, dry mouth, and constipation. Tremors, cardiac ar ... (more) Remediation: Amitriptyline hydrochloride Question 100: A nurse meets frequently with a depressed client. The client (see full question) stays mostly in his room and speaks only when addressed, answering briefly and abruptly while keeping his eyes on the floor. Initially, the nurse should focus on the client's ability to do which function? You selected: Function independently. Incorrect Correct response: Express himself verbally. Explanation: When working with a client who is withdrawn and speaks little, answers briefly, and looks at the floor, the nurse should focus on interacting with the client to decrease withdrawal ... (more) Remediation: Severe depression patient care [Show More]

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