Safe and Effective Care Environment
A client admitted to the hospital with obsessive compulsive disorder repeatedly cleans the bathroom fixtures. The client becomes enraged and starts to bite and kick the roommate for occupying the bathroom. Which of the following actions should the nurse take?
a. provide a safe environment for both clients
b. place the client in seclusion
c. physically restrain the client
d. administer a medication to provide chemical restraint
a. provide a safe environment for both clients
A client's laboratory test results reveal a decreased serum transferrin and total iron-binding capacity. The nurse expects to note which disorder documented in the client's record as the most likely cause of the client's anemia?
a. infection
b. malnutrition
c. iron deficiency
d. sickle cell disease
b. malnutrition
Malnutrition can cause reductions in the serum transferrin and total iron-binding capacity.
A nurse palpates the anterior fontanelle of a neonate and notes that it feels soft. This nurse understands that this finding indicates which of the following?
a. increased intracranial pressure
b. dehydration
c. decreased intracranial pressure
d. a normal finding
d. a normal finding
The anterior fontanelle is normally 2/5-5 cm in width and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could be indicative of increased intracranial pressure. Conversely, a depressed fontanelle could mean that the neonate is dehydrated.
Which emotional response related to chronic respiratory disease requires immediate nursing intervention?
a. anxiety
b. depression
c. suicidal ideation
d. ineffective coping
c. suicidal ideation
a. drinks plenty of water
b. eats foods that are high in potassium
c. consumes sufficient amounts of high-fiber foods
d. moves from a sitting to a standing position slowly
d. moves from a sitting to a standing position slowly
Captopril is an angiotensin-converting enzyme (ACE) inhibitor. Orthostatic hypotension is a concern for clients taking antihypertensive medications. Clients are advised to avoid standing in one position for lengthy amounts of time, to change positions slowly, and to avoid extreme warmth (showers, baths, and weather).
A nurse plans to change the dressing of a client who has had arterial bypass surgery. Which of the following techniques is most important for the nurse to follow?
a. standard technique
b. aseptic technique
c. clean technique
d. reverse isolation technique
b. aseptic technique
A nurse is monitoring the results of periodic serum laboratory studies drawn on a client with diabetic ketoacidosis who is receiving an intravenous insulin infusion. The nurse alerts the physician for which of the following values?
a. Potassium 3.1 mEq/dl
b. calcium 9.2 mg/dl
c. sodium 137 mEq/L
d. serum osmolality 288mOsm/kg H2O
a. Potassium 3.1 mEq/dl
The client with diabetic keto acidosis intially becomes hyperkalemic as potassium leaves the cells in response to a lowered pH level. Once fluid replacement and insulin therapy are started, the potassium level drops quickly. This occurs because potassium is excreted in the urine once rehydration has occurred. Thus, the nurse must plan to monitor the results of serum potassium levels carefully, and report hypokalemia promptly. The other lab values are within normal range.
A client complaining of chronic dry skin and pruritus may benefit from which of the following interventions?
a. taking baths twice daily using a diluted solution of vinegar and water
b. using astringents on the skin
c. using emollients on the skin
d. purchasing a dehumidifier for the home
c. using emollients on the skin
A client will be receiving parenteral nutrition at home for long-term nutritional therapy, and the infusion will run continuously at 100ml per hour. The nurse would be concerned about which of the following potential problems?
a. fluid volume deficit
b. lack of hope
c. social isolation
d. low self-esteem
c. social isolation
A client's medication is available for injection in an ampule. Which of the following should the nurse do when preparing this medication?
a. shake the ampule gently to mix the contents before snapping it
b. place an alcohol wipe around the neck of the ampule before snapping it open
c. snap the tøp of the ampule so that it opens toward the nurse
d. wipe the neck of the ampule with gauze after snapping it open.
b. place an alcohol wipe around the neck of the ampule before snapping it open
A clinic nurse is caring for a child who was diagnosed with erythema infection (fifth disease), and the mother asks the nurse how this disease is transmitted. The nurse informs the mother that fifth disease is transmitted by which of the following routes?
a. airborne particles
b. fecal-oral route
c. saliva
d. contact with sweat
a. airborne particles
The nurse develops a discharge plan for a client who had a total hysterectomy. The nurse should include which activity instructions in the plan? Select all that apply
a. avoid heavy lifting
b. sit as much as possible
c. take baths rather than showers
d. limit stair climbing to five times a day
e. gradually increase walking as exercise but stop before becoming fatigued.
f. avoid jogging, aerobic exercises, sports, or strenuous exercise for 6 weeks.
a. avoid heavy lifting
d. limit stair climbing to five times a day
e. gradually increase walking as exercise but stop before becoming fatigued.
f. avoid jogging, aerobic exercises, sports, or strenuous exercise for 6 weeks.
A nurse has conducted dietary teaching with a client diagnosed with iron deiciency anemia. The nurse determines that the client understands the information if the client states that he or she should increase intake of which of the following foods?
a. refined white bread
b. egg whites
c. pineapple
d. kidney beans
d. kidney beans
A client is being admitted to the inpatient mental health unit with a diagnosis of a cluster A personality disorder. The nurse assesses this client for which of the following behaviors that are characteristic of this type of personality disorder?
a. suspicious and eccentric
b. manipulative and dramatic
c. characterized by anger
d. anxious and fearful
a. suspicious and eccentric
Clients with cluster A personality disorders often behave in a manner that is odd and eccentric. Suspicion of others is particularly typical in clients with paranoid personality disorder, cluster A disorder.
A nurse is teaching a hypertensive client about strategies to prevent episodes of lightheadedness after taking anithypertensive medication. The nurse should include with of the following points in the discussion?
a. standing motionless during the first hour after taking the dose
b. moving quickly when rising from a sitting to a standing position
c. taking warm baths to enhance medication effects
d. avoiding alcohol intake
d. avoiding alcohol intake
The client taking antihypertensive medications should be taught to avoid situations that promote lightheadedness and dizziness.
What equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anthesthesia?
a. oxygen via nasal cannula
b. suction equipment
c. cardiac monitor
d. a straw and Styrofoam cup
b. suction equipment
A nurse is performing an admission assessment on a newborn infant admitted to the nursery with the diagnosis of subdural hematoma following a difficult vaginal delivery. The nurse should do which of the following to assess for major symptoms associated with subdural hematoma?
a. monitors for urine in the blood
b. monitors the urinary output pattern
c. tests for contractures of the extremities
d. tests for equality of extremities when simulating reflexes
d. tests for equality of extremities when simulating reflexes
A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can cause changes in the stimuli responses in the extremities on the opposite side of the body, especially if the infant is actively bleeding.
A nurse has given dietary instructions to a client diagnosed with acute glomerulonephritis. The nurse determines that the client understands the information presented if the client states to do which of the following?
a. increase intake of high-fiber foods
b. increase intake of potassium-rich foods
c. limit intake of magnesium-rich foods
d. limit protein intake
d. limit protein intake
In acute glomerulonephritis, protecting the kidneys is important while they are recovering their function. The diet for this client is generally high in calories and low in protein. This diet inhibits protein catabolism and allows the kidneys to rest.
The nurse is caring for a client in whom anorexia nervosa has been diagnosed. The nurse assesses the client, knowing that which of the following is a characteristic of this disorder?
a. the client is not concerned about control and autonomy
b. the client has a realistic view of the body
c. the disorder is characterized by eating binges followed by maladaptive or inappropriate reparative behavior
d. the client is determined to lose weight mainly by restricting food intake, even when emaciated.
d. the client is determined to lose weight mainly by restricting food intake, even when emaciated.
A nurse is caring for a client who is receiving an intermittent feeding via a nasogastric tube. Before feeding the client via the nasogastric tube, the nurse should take which of the following actions?
a. check the placement of the tube
b. check the last time that medications were given
c. check the client's temperature
d. warm the feeding to 103 degrees F
a. check the placement of the tube
To prevent aspiration while administering a tube feeding, the nurse should place the client in an upright sitting position or place the head of the bed elevated at least 30 degrees. Before the feeding, the nurse checks the placement of the tube by aspirating gastric contents and measuring the pH.
A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and should take which of the following actions?
a. allow the visitor to spend time alone with the client
b. tell the client what a beautiful package this is
c. suggest that the client open the gift
d. reinforce the safety policies with the client
c. suggest that the client open the gift
The nurse provides information about the signs of hypoglycemia to a client with diabetes mellitus who is taking insulin. Which of the following signs should the nurse include in the information? Select all that apply
a. hunger
b. sweating
c. weakness
d. nervousness
e. cool, clammy skin
f. increased urine output
a. hunger
b. sweating
c. weakness
d. nervousness
e. cool, clammy skin
A client is newly diagnosed with COPD and returns home after a short hospitalization. The home care nurse understands that the most important teaching strategies are designed to:
a. promote membership in support groups
b. Encourage the client to become a more active person
c. identify irritants in the home that interfere with breathing
d. improve oxygenation and minimize carbon dioxide retention
d. improve oxygenation and minimize carbon dioxide retention
Improving oxygenation and minimizing carbon dioxide retention is the primary goal. The other options are interventions that will help achieve this primary goal.
A client who has received a diagnosis of cancer asks the question, "Why did this have to happen to me?" What stage of coping with the possibility of death does this nurse assess that the client is experiencing?
a. denial and isolation
b. anger
c. bargaining
d. depression
b. anger
A nurse is preparing to institute intravenous heparin therapy for the client. The nurse should question the physician's prescription because of which of the following active problems listed on the client's medical record?
a. deep vein thrombosis
b. degenerative arthritis
c. cerebral aneurysm
d. chronic obstructive pulmonary disease
c. cerebral aneurysm