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NCLEX SATA 1 4.

Acetone breath
1. A patient is admitted to the same day surgery unit 5. Elevated serum bicarbonate
for liver biopsy. Which of the following laboratory tests 9. When planning care for a client with ulcerative colitis
assesses coagulation? Select all that apply. who is experiencing symptoms, which client care
1. Partial thromboplastin time. activities can the nurse appropriately delegate to a
2. Prothrombin time. unlicensed assistant? Select all that apply.
3. Platelet count. 1. Assessing the client’s bowel sounds
4. Hemoglobin 2. Providing skin care following bowel movements
5. Complete Blood Count 3. Evaluating the client’s response to antidiarrheal
6. White Blood Cell Count medications
2. A patient is admitted to the hospital with suspected 4. Maintaining intake and output records
polycythemia vera. Which of the following symptoms is 5. Obtaining the client’s weight.
consistent with the diagnosis? Select all that apply. 10. Which of the following nursing diagnoses would be
1. Weight loss. appropriate for a client with heart failure? Select all
2. Increased clotting time. that apply.
3. Hypertension. 1. Ineffective tissue perfusion related to decreased peripheral
4. Headaches. blood flow secondary to decreased cardiac output.
3. The nurse is teaching the client how to use a 2. Activity intolerance related to increased cardiac output.
metered dose inhaler (MDI) to administer a 3. Decreased cardiac output related to structural and
Corticosteroid drug. Which of the following client functional changes.
actions indicates that he is using the MDI correctly? 4. Impaired gas exchange related to decreased sympathetic
Select all that apply. nervous system activity.
1. The inhaler is held upright. 11. When caring for a client with a central venous line,
2. Head is tilted down while inhaling the medication which of the following nursing actions should be
3. Client waits 5 minutes between puffs. implemented in the plan of care for chemotherapy
4. Mouth is rinsed with water following administration administration? Select all that apply.
5. Client lies supine for 15 minutes following administration. 1. Verify patency of the line by the presence of a blood return
4. The nurse is teaching a client with polycythemia vera at regular intervals.
about potential complications from this disease. Which 2. Inspect the insertion site for swelling, erythema, or
manifestations would the nurse include in the client’s drainage.
teaching plan? Select all that apply. 3. Administer a cytotoxic agent to keep the regimen on
1. Hearing loss schedule even if blood return is not present.
2. Visual disturbance 4. If unable to aspirate blood, reposition the client and
3. Headache encourage the client to cough.
4. Orthopnea 5. Contact the health care provider about verifying placement
5. Gout if the status is questionable.
6. Weight loss 12. A 20-year old college student has been brought to
5. Which of the following would be priority assessment the psychiatric hospital by her parents. Her admitting
data to gather from a client who has been diagnosed diagnosis is borderline personality disorder. When
with pneumonia? Select all that apply. talking with the parents, which information would the
1. Auscultation of breath sounds nurse expect to be included in the client’s history?
2. Auscultation of bowel sounds Select all that apply.
3. Presence of chest pain. 1. Impulsiveness
4. Presence of peripheral edema 2. Lability of mood
5. Color of nail beds 3. Ritualistic behavior
6. The nurse is teaching a client who has been 4. psychomotor retardation
diagnosed with TB how to avoid spreading the disease 5. Self-destructive behavior
to family members. Which statement(s) by the client 13. When assessing a client diagnosed with impulse
indicate(s) that he has understood the nurses control disorder, the nurse observes violent,
instructions? Select all that apply. aggressive, and assaultive behavior. Which of the
1. “I will need to dispose of my old clothing when I return following assessment data is the nurse also likely to
home.” find? Select all that apply.
2. “I should always cover my mouth and nose when 1. The client functions well in other areas of his life.
sneezing.” 2. The degree of aggressiveness is out of proportion to the
3. “It is important that I isolate myself from family when stressor.
possible.” 3. The violent behavior is most often justified by the stressor.
4. “I should use paper tissues to cough in and dispose of 4. The client has a history of parental alcoholism and chaotic,
them properly.” abusive family life.
5. “I can use regular plate and utensils whenever I eat.” 5. The client has no remorse about the inability to control his
7. The nurse is admitting a client with hypoglycemia. anger.
Identify the signs and symptoms the nurse should 14. Which of the following nursing interventions are
expect. Select all that apply. written correctly? (Select all that apply.)
1. Thirst 1. Apply continuous passive motion machine during day.
2. Palpitations 2. Perform neurovascular checks.
3. Diaphoresis 3. Elevate head of bed 30 degrees before meals.
4. Slurred speech 4. Change dressing once a shift.
5. Hyperventilation 15. The nurse is monitoring a client receiving
8. Which adaptations should the nurse caring for a peritoneal dialysis and nurse notes that a client’s
client with diabetic ketoacidosis expect the client to outflow is less than the inflow. Select actions that the
exhibit? Select all that apply: nurse should take.
1. Sweating 1. Place the client in good body alignment
2. Low PCO2 2. Check the level of the drainage bag
3. Retinopathy 3. Contact the physician
4. Check the peritoneal dialysis system for kinks 5. Monitor deep tendon reflexes hourly
5. Reposition the client to his or her side. 6. Monitor I and O’s hourly
16. The nurse is caring for a hospitalized client who has 7. Notify the physician if urinary output is less than 30 ml per
chronic renal failure. Which of the following nursing hour.
diagnoses are most appropriate for this client? Select 23. When interpreting an ECG, the nurse would keep in
all that apply. mind which of the following about the P wave? Select
1. Excess Fluid Volume all that apply.
2. Imbalanced Nutrition; Less than Body Requirements 1. Reflects electrical impulse beginning at the SA node
3. Activity Intolerance 2. Indicated electrical impulse beginning at the AV node
4. Impaired Gas Exchange 3. Reflects atrial muscle depolarization
5. Pain. 4. Identifies ventricular muscle depolarization
17. The nurse is assessing a child diagnosed with a 5. Has duration of normally 0.11 seconds or less.
brain tumor. Which of the following signs and 24. When caring for a client with a central venous line,
symptoms would the nurse expect the child to which of the following nursing actions should be
demonstrate? Select all that apply. implemented in the plan of care for chemotherapy
1. Head tilt administration? Select all that apply.
2. Vomiting 1. Verify patency of the line by the presence of a blood return
3. Polydipsia at regular intervals.
4. Lethargy 2. Inspect the insertion site for swelling, erythema, or
5. Increased appetite drainage.
6. Increased pulse 3. Administer a cytotoxic agent to keep the regimen on
18. The nurse is caring for a client with a T5 complete schedule even if blood return is not present.
spinal cord injury. Upon assessment, the nurse notes 4. If unable to aspirate blood, reposition the client and
flushed skin, diaphoresis above the T5, and a blood encourage the client to cough.
pressure of 162/96. The client reports a severe, 5. Contact the health care provider about verifying placement
pounding headache. Which of the following nursing if the status is questionable.
interventions would be appropriate for this client? 25. To assist an adult client to sleep better the nurse
Select all that apply. recommends which of the following? (Select all that
1. Elevate the HOB to 90 degrees apply.)
2. Loosen constrictive clothing 1. Drinking a glass of wine just before retiring to bed
3. Use a fan to reduce diaphoresis 2. Eating a large meal 1 hour before bedtime
4. Assess for bladder distention and bowel impaction 3. Consuming a small glass of warm milk at bedtime
5. Administer antihypertensive medication 4. Performing mild exercises 30 minutes before going to bed
6. Place the client in a supine position with legs elevated 26. The nurse recognizes that a client is experiencing
19. The nurse is evaluating the discharge teaching for a insomnia when the client reports (select all that apply):
client who has an ileal conduit. Which of the following 1. Extended time to fall asleep
statements indicates that the client has correctly 2. Falling asleep at inappropriate times
understood the teaching? Select all that apply. 3. Difficulty staying asleep
1. “If I limit my fluid intake I will not have to empty my 4. Feeling tired after a night’s sleep
ostomy pouch as often.” 27. The nurse teaches the mother of a newborn that in
2. “I can place an aspirin tablet in my pouch to decrease order to prevent sudden infant death syndrome (SIDS)
odor.” the best position to place the baby after nursing is
3. “I can usually keep my ostomy pouch on for 3 to 7 days (select all that apply):
before changing it.” 1. Prone
4. “I must use a skin barrier to protect my skin from urine.” 2. Side-lying
5. “I should empty my ostomy pouch of urine when it is full.” 3. Supine
20. A nurse is assisting in performing an assessment on 4. Fowler’s
a client who suspects that she is pregnant and is 28. A client has a diagnosis of primary insomnia. Before
checking the client for probable signs of assessing this client, the nurse recalls the numerous
pregnancy. Select all probable signs of pregnancy. causes of this disorder. Select all that apply:
1. Uterine enlargement 1. Chronic stress
2. Fetal heart rate detected by nonelectric device 2. Severe anxiety
3. Outline of the fetus via radiography or ultrasound 3. Generalized pain
4. Chadwick’s sign 4. Excessive caffeine
5. Braxton Hicks contractions 5. Chronic depression
6. Ballottement 6. Environmental noise
21. A nurse is monitoring a pregnant client with 29. Select all that apply to the use of barbiturates in
pregnancy induced hypertension who is at risk for treating insomnia:
Preeclampsia. The nurse checks the client for which 1. Barbiturates deprive people of NREM sleep
specific signs of Preeclampsia (select all that apply)? 2. Barbiturates deprive people of REM sleep
1. Elevated blood pressure 3. When the barbiturates are discontinued, the NREM sleep
2. Negative urinary protein increases.
3. Facial edema 4. When the barbiturates are discontinued, the REM sleep
4. Increased respirations increases.
22. A nurse is caring for a pregnant client with severe 5. Nightmares are often an adverse effect when discontinuing
preeclampsia who is receiving IV magnesium sulfate. barbiturates.
Select all nursing interventions that apply in the care 30. Select all that apply that is appropriate when there
for the client. is a benzodiazepine overdose:
1. Monitor maternal vital signs every 2 hours 1. Administration of syrup of ipecac
2. Notify the physician if respirations are less than 18 per 2. Gastric lavage
minute. 3. Activated charcoal and a saline cathartic
3. Monitor renal function and cardiac function closely 4. Hemodialysis
4. Keep calcium gluconate on hand in case of a magnesium 5. Administration of Flumazenil
sulfate overdose
Answers and Rationale cardiac output triggers compensatory mechanisms, such as
1. Answer: 1, 2, and 3 an increase in sympathetic nervous system activity.
Prothrombin time, partial thromboplastin time, and platelet 11. Answer: 1, 2, 4, 5.
count are all included in coagulation studies. The hemoglobin A major concern with intravenous administration of cytotoxic
level, though important information prior to an invasive agents is vessel irritation or extravasation. The Oncology
procedure like liver biopsy, does not assess coagulation. Nursing Society and hospital guidelines require frequent
2. Answer: 2, 3, and 4 evaluation of blood return when administering vesicant or non
Polycythemia vera is a condition in which the bone marrow vesicant chemotherapy due to the risk of extravasation.
produces too many red blood cells. This causes an increase in These guidelines apply to peripheral and central venous lines.
hematocrit and viscosity of the blood. Patients can experience In addition, central venous lines may be long-term venous
headaches, dizziness, and visual disturbances. Cardiovascular access devices. Thus, difficulty drawing or aspirating blood
effects include increased blood pressure and delayed clotting may indicate the line is against the vessel wall or may
time. Weight loss is not a manifestation of polycythemia vera. indicate the line has occlusion. Having the client cough or
3. Answer: 1 and 4. move position may change the status of the line if it is
4. Answers: 2, 3, 4 and 5. temporarily against a vessel wall. Occlusion warrants more
Polycythemia vera, a condition in which too many RBCs are thorough evaluation via x-ray study to verify placement if the
produced in the blood serum, can lead to an increase in the status is questionable and may require a declotting regimen.
hematocrit and hypervolemia, hyperviscosity, and 12. Answer: 1, 2, 5.
hypertension. Subsequently, the client can experience 13. Answer: 1, 2, 4.
dizziness, tinnitus, visual disturbances, headaches, or a A client with an impulse control disorder who displays violent,
feeling of fullness in the head. The client may also experience aggressive, and assaultive behavior generally functions well in
cardiovascular symptoms such as heart failure (shortness of other areas of his life. The degree of aggressiveness is
breath and orthopnea) and increased clotting time or typically out of proportion with the stressor. Such a client
symptoms of an increased uric acid level such as painful commonly has a history of parental alcoholism and a chaotic
swollen joints (usually the big toe). Hearing loss and weight family life, and often verbalizes sincere remorse and guilt for
loss are not manifestations associated with polycythemia the aggressive behavior.
vera. 14. Answer: 3.
5. Answer: 1, 3, 5. It is specific in what to do and when.
A respiratory assessment, which includes auscultation of 15. Answer: 1, 2, 4, 5.
breath sounds and assessing the color of the nail beds, is a If outflow drainage is inadequate, the nurse attempts to
priority for clients with pneumonia. Assessing for the presence stimulate outflow by changing the client’s position. Turning
of chest pain is also an important respiratory assessment as the client to the other side or making sure that the client is in
chest pain can interfere with the client’s ability to breathe good body alignment may assist with outflow drainage. The
deeply. Auscultating bowel sounds and assessing for drainage bag needs to be lower than the client’s abdomen to
peripheral edema may be appropriate assessments, but these enhance gravity drainage. The connecting tubing and the
are not priority assessments for the patient with pneumonia. peritoneal dialysis system is also checked for kinks or twisting
6. Answer: 2, 4, 5. and the clamps on the system are checked to ensure that
7. Answer: 2, 3, 4. they are open. There is no reason to contact the physician.
Palpitations, an adrenergic symptom, occur as the glucose 16. Answer: 1, 2, 3.
levels fall; the sympathetic nervous system is activated and Appropriate nursing diagnoses for clients with chronic renal
epinephrine and norepinephrine are secreted causing this failure include excess fluid volume related to fluid and sodium
response. Diaphoresis is a sympathetic nervous system retention; imbalanced nutrition, less than body requirements
response that occurs as epinephrine and norepinephrine are related to anorexia, nausea, and vomiting; and activity
released. Slurred speech is a neuroglycopenic symptom; as intolerance related to fatigue. The nursing diagnoses of
the brain receives insufficient glucose, the activity of the CNS impaired gas exchange and pain are not commonly related to
becomes depressed. chronic renal failure.
8. Answer: 2, 4. 17. Answer: 1, 2, 4.
Metabolic acidosis initiates respiratory compensation in the Head tilt, vomiting, and lethargy are classic signs assessed in
form of Kussmaul respirations to counteract the effects of a child with a brain tumor. Clinical manifestations are the
ketone buildup, resulting in a lowered PCO2. A fruity odor to result of location and size of the tumor.
the breath (acetone breath) occurs when the ketone level is 18. Answer: 1, 2, 4, 5.
elevated in ketoacidosis. The client has signs and symptoms of autonomic dysreflexia.
9. Answer: 2, 4, and 5. The potentially life-threatening condition is caused by an
The nurse can delegate the following basic care activities to uninhibited response from the sympathetic nervous system
the unlicensed assistant: providing skin care following bowel resulting from a lack of control over the autonomic nervous
movements, maintaining intake and output records, and system. The nurse should immediately elevate the HOB to 90
obtaining the client’s weight. Assessing the client’s bowel degrees and place extremities dependently to decrease
sounds and evaluating the client’s response to medication are venous return to the heart and increase venous return from
registered nurse activities that cannot be delegated. the brain. Because tactile stimuli can trigger autonomic
10. Answer: 1 and 3. dysreflexia, any constrictive clothing should be loosened. The
HF is a result of structural and functional abnormalities of the nurse should also assess for distended bladder and bowel
heart tissue muscle. The heart muscle becomes weak and impaction, which may trigger autonomic dysreflexia, and
does not adequately pump the blood out of the chambers. As correct any problems. Elevated blood pressure is the most
a result, blood pools in the left ventricle and backs up into the life-threatening complication of autonomic dysreflexia
left atrium, and eventually into the lungs. Therefore, greater because it can cause stroke, MI, or seizures. If removing the
amounts of blood remain in the ventricle after contraction triggering event doesn’t reduce the client’s blood pressure, IV
thereby decreasing cardiac output. In addition, this pooling antihypertensives should be administered. A fan shouldn’t be
leads to thrombus formation and ineffective tissue perfusion used because cold drafts may trigger autonomic dysreflexia.
because of the decrease in blood flow to the other organs and 19. Answer: 3, 4.
tissues of the body. Typically, these clients have an ejection The client with an ileal conduit must learn self-care activities
fraction of less than 50% and poorly tolerate activity. Activity related to care of the stoma and ostomy appliances. The
intolerance is related to a decrease, not increase, in cardiac client should be taught to increase fluid intake to about 3,000
output. Gas exchange is impaired. However, the decrease in ml per day and should not limit intake. Adequate fluid intake
helps to flush mucus from the ileal conduit. The ostomy
appliance should be changed approximately every 3 to 7 days Research demonstrate that the occurrence of SIDS is reduced
and whenever a leak develops. A skin barrier is essential to with these two positions.
protecting the skin from the irritation of the urine. An aspirin 28. Answer: 1, 4, and 6.
should not be used as a method of odor control because it can Acute or primary insomnia is caused by emotional or physical
be an irritant to the stoma and lead to ulceration. The ostomy discomfort not caused by the direct physiologic effects of a
pouch should be emptied when it is one-third to one-half full substance or a medical condition. Excessive caffeine intake is
to prevent the weight from pulling the appliance away from an example of disruptive sleep hygiene; caffeine is a
the skin. stimulant that inhibits sleep. Environmental noise causes
20. Answers: 1, 4, 5, and 6. physical and/or emotional and therefore is related to primary
The probable signs of pregnancy include: insomnia.
Uterine Enlargement 29. Answer: 2, 4, and 5.
Hegar’s sign or softening and thinning of the uterine segment Barbiturates deprive people of REM sleep. When the
that occurs at week 6. barbiturate is stopped and REM sleep once again occurs, a
Goodell’s sign or softening of the cervix that occurs at the rebound phenomenon occurs. During this phenomenon, the
beginning of the 2nd month persons dream time constitutes a larger percentage of the
Chadwick’s sign or bluish coloration of the mucous total sleep pattern, and the dreams are often nightmares.
membranes of the cervix, vagina and vulva. Occurs at week 30. Answer: 2, 3, and 5.
6. If ingestion is recent, decontamination of the GI system is
Ballottement or rebounding of the fetus against the indicated. The administration of syrup of ipecac is
examiner’s fingers of palpation contraindicated because of aspiration risks related to
Braxton-Hicks contractions sedation. Gastric lavage is generally the best and most
Positive pregnancy test measuring for hCG. effective means of gastric decontamination. Activated
Positive signs of pregnancy include: charcoal and a saline cathartic may be administered to
Fetal Heart Rate detected by electronic device (doppler) at remove any remaining drug. Hemodialysis is not useful in the
10-12 weeks treatment of benzodiazepine overdose. Flumazenil can be
Fetal Heart rate detected by nonelectronic device (fetoscope) used to acutely reverse the sedative effects of
at 20 weeks AOG benzodiazepines, though this is normally done only in cases of
Active fetal movement palpable by the examiners extreme overdose or sedation.
Outline of the fetus via radiography or ultrasound
21. Answer: 1 and 3. NCLEX SATA 2
The three classic signs of preeclampsia are hypertension, 1. A 6-year-old child with leukemia is hospitalized and
generalized edema, and proteinuria. Increased respirations is receiving combination chemotherapy. Laboratory
are not a sign of preeclampsia. results indicate that the child is neutropenic, and the
22. Answers: 3, 4, 5, 6, and 7. nurse prepares to implement protective isolation
When caring for a client receiving magnesium sulfate therapy, procedures. Which interventions would the nurse
the nurse would monitor maternal vital signs, especially initiate? Select all that apply.
respirations, every 30-60 minutes and notify the physician if 1. Restrict all visitors.
respirations are less than 12, because this would indicate 2. Place the child on a low-bacteria diet.
respiratory depression. Calcium gluconate is kept on hand in 3. Change dressings using sterile technique.
case of magnesium sulfate overdose, because calcium 4. Encourage the consumption of fresh fruits and vegetables.
gluconate is the antidote for magnesium sulfate toxicity. Deep 5. Perform meticulous hand washing before caring for the
tendon reflexes are assessed hourly. Cardiac and renal child.
function is monitored closely. The urine output should be 6. Allow fresh-cut flowers in the room as long as they are
maintained at 30 ml per hour because the medication is kept in a vase with fresh water.
eliminated through the kidneys. 2. A 16-year-old child is brought to the emergency
23. Answer: 1, 3, 5. department by his mother with a complaint that the
In a client who has had an ECG, the P wave represents the child just experienced a tonic-clonic seizure. On arrival
activation of the electrical impulse in the SA node, which is in the emergency department no apparent seizures
then transmitted to the AV node. In addition, the P wave were occurring. The mother states that her son is
represents atrial muscle depolarization, not ventricular taking medication for the seizure disorder. The nurse
depolarization. The normal duration of the P wave is 0.11 plans care, knowing that which of the following
seconds or less in duration and 2.5 mm or more in height. medications are used for long-term control of tonic-
24. Answer: 1, 2, 4, 5. clonic seizures? Select all that apply.
A major concern with intravenous administration of cytotoxic 1. Diazepam (Valium)
agents is vessel irritation or extravasation. The Oncology 2. Alprazolam (Xanax)
Nursing Society and hospital guidelines require frequent 3. Gabapentin (Neurontin)
evaluation of blood return when administering vesicant or non 4. Ethosuximide (Zarontin)
vesicant chemotherapy due to the risk of extravasation. 5. Carbamazepine (Tegretol)
These guidelines apply to peripheral and central venous lines. 6. Methylphenidate (Ritalin)
In addition, central venous lines may be long-term venous 3. A child has been diagnosed with meningococcal
access devices. Thus, difficulty drawing or aspirating blood meningitis. Which of the following isolation
may indicate the line is against the vessel wall or may techniques is appropriate?
indicate the line has occlusion. Having the client cough or 1. Enteric precautions
move position may change the status of the line if it is 2. Neutropenic precautions
temporarily against a vessel wall. Occlusion warrants more 3. No precautions are required as long as antibiotics have
thorough evaluation via x-ray study to verify placement if the been started.
status is questionable and may require a declotting regimen. 4. Isolation precautions for at least 24 hours after the
25. Answer: 3. initiation of antibiotics
A small glass of milk relaxes the body and promotes sleep. 4. A client enters the emergency department confused,
26. Answer: 1, 3, and 4. twitching, and having seizures. His family states he
These symptoms are often reported by clients with insomnia. recently was placed on corticosteroids for arthritis and
Clients report nonrestorative sleep. Arising once at night to was feeling better and exercising daily. On data
urinate (nocturia) is not in and of itself insomnia. collection, he has flushed skin, dry mucous
27. Answer: 2 and 3. membranes, an elevated temperature, and poor skin
turgor. His serum sodium level is 172 mEq/L. Choose 6. Asking the client about a family history of any illness or
the interventions that the health care provider would disease
likely prescribe. Select all that apply. 11. A community health nurse is conducting a teaching
1. Monitor intake and output. session about terrorism with members of the
2. Monitor vital signs. community and discussing information regarding
3. Maintain sodium-reduced diet. anthrax. The nurse tells those attending that anthrax
4. Monitor electrolyte levels. can be transmitted via which route(s)? Select all that
5. Increase water intake orally. apply.
6. Administer sodium replacements. 1. Skin
5. A client has died, and a nurse asks a family member 2. Kissing
about the funeral arrangements. The family member 3. Inhalation
refuses to discuss the issue. The nurse’s appropriate 4. Gastrointestinal
action is to: 5. Direct contact with an infected individual
1. Show acceptance of feelings. 6. Sexual contact with an infected individual
2. Provide information needed for decision making. 12. The emergency room nurse is providing discharge
3. Suggest a referral to a mental health professional. teaching to the parents of a 2-year-old child who
4. Remain with the family member without discussing funeral sustained burns from a hot cup of coffee that had been
arrangements. left on the kitchen counter. The nurse evaluates that
6. A client is scheduled for a myelogram, and the nurse the parents have correctly understood the teaching
provides a list of instructions to the client regarding when they state which of the following?
preparation for the procedure. Which instructions 1. “We will be sure to not leave hot liquids unattended.”
should the nurse place on the list? Select all that apply. 2. “I guess my child needs to understand what the word ‘hot’
1. Jewelry will need to be removed. means.”
2. An informed consent will need to be signed. 3. “We will be sure that our child stays in his room when we
3. A trained x-ray technician performs the procedure. work in the kitchen.”
4. The procedure will take approximately 45 minutes. 4. “We will install a safety gate as soon as we get home so
5. A liquid diet can be consumed on the day of the procedure. that our child can’t get into the kitchen.”
6. Solid food intake needs to be restricted only on the day of 13. A licensed practical nurse is attending an agency
the procedure. orientation meeting about the nursing model of
7. A client with a closed head injury is receiving practice implemented in the facility. The nurse is told
phenytoin (Dilantin), an anticonvulsant medication. that the nursing model is a team nursing approach. The
Which of the following would indicate that the client is nurse understands that which of the following is a
experiencing side effects related to this medication? characteristic of this type of nursing model of practice?
Select all that apply. 1. A task approach method is used to provide care to clients.
1. Ataxia 2. Managed care concepts and tools are used when providing
2. Sedation client care.
3. Constipation 3. Nursing staff are led by a nurse when providing care to a
4. Bleeding gums group of clients.
5. Hyperglycemia 4. A single registered nurse is responsible for providing
6. Decreased platelet count nursing care to a group of clients.
8. A client with carcinoma of the lung develops the 14. A licensed practical nurse is planning the client
syndrome of inappropriate antidiuretic hormone assignments for the day. Which of the following is the
(SIADH) as a complication of the cancer. The nurse most appropriate assignment for the nursing assistant?
anticipates that which of the following may be 1. A client who requires wound irrigation
prescribed? Select all that apply. 2. A client who requires frequent ambulation
1. Radiation 3. A client who is receiving continuous tube feedings
2. Chemotherapy 4. A client who requires frequent vital signs after a cardiac
3. Increased fluid intake catheterization
4. Serum sodium blood levels 15. A male client who has heart failure receives an
5. Decreased oral sodium intake additional dose of bumetanide as prescribed 4 hours
6. Medication that is antagonistic to antidiuretic hormone after the daily dose. The nurse assesses him 15
(ADH) minutes after administering the medication and
9. A client with carcinoma of the lung develops the reminds him to save all urine in the bathroom. Thirty
syndrome of inappropriate antidiuretic hormone minutes later the nurse finds the client on the floor,
(SIADH) as a complication of the cancer. The nurse unresponsive, and bleeding from a laceration.
anticipates that which of the following may be Determine the issues that support the client’s
prescribed? Select all that apply. malpractice claim. Select all that apply.
1. Radiation 1. Failure to replace body fluids
2. Chemotherapy 2. Increased risk of hypotension
3. Increased fluid intake 3. Failure to teach the client adequately
4. Serum sodium blood levels 4. Increased need to protect the client
5. Decreased oral sodium intake 5. Excessive bumetanide administration
6. Medication that is antagonistic to antidiuretic hormone 6. Lack of follow-up nursing actions
(ADH) 16. A nurse develops a plan of care for a client
10. The clinic nurse is assisting to perform a focused following a lumbar puncture. Which interventions
data collection process on a client who is complaining should be included in the plan? Select all that apply.
of symptoms of a cold, a cough, and lung congestion. 1. Monitor the client’s ability to void.
Which of the following would the nurse include for this 2. Maintain the client in a flat position.
type of data collection? Select all that apply. 3. Restrict fluid intake for a period of 2 hours.
1. Auscultating lung sounds 4. Monitor the client’s ability to move the extremities.
2. Obtaining the client’s temperature 5. Inspect the puncture site for swelling, redness, and
3. Checking the strength of peripheral pulses drainage.
4. Obtaining information about the client’s respirations 6. Maintain the client on a nothing-by-mouth (NPO) status for
5. Performing a musculoskeletal and neurological examination 24 hours.
17. A nurse employed in an emergency department is hours after antibiotics are given. Options 1, 2, and 3 are
assigned to assist with the triage of clients arriving to incorrect.
the emergency department for treatment on the 4. Answers: 1, 2, 3, 4, and 5.
evening shift. The nurse would assign the highest Hypernatremia is described as having a serum sodium level
priority to which of the following clients? that exceeds 145 mEq/L. Signs and symptoms would include
1. A client complaining of muscle aches, a headache, and dry mucous membranes, loss of skin turgor, thirst, flushed
malaise skin, elevated temperature, oliguria, muscle twitching,
2. A client who twisted her ankle when she fell while fatigue, confusion, and seizures. Interventions include
rollerblading monitoring fluid balance, monitoring vital signs, reducing
3. A client with a minor laceration on the index finger dietary intake of sodium, monitoring electrolyte levels, and
sustained while cutting an eggplant increasing oral intake of water. Sodium replacement therapy
4. A client with chest pain who states that he just ate pizza would not be prescribed for a client with hypernatremia.
that was made with a very spicy sauce 5. Answer: 4.
18. A nurse enters a client’s room and notes that the The family member is exhibiting the first stage of grief
client’s lawyer is present and that the client is (denial), and the nurse should remain with the family
preparing a living will. The living will requires that the member. Option 1 is an appropriate intervention for the
client’s signature be witnessed, and the client asks the acceptance or reorganization and restitution stage. Option 2
nurse to witness the signature. Which of the following may be an appropriate intervention for the bargaining stage.
is the appropriate nursing action? Option 3 may be an appropriate intervention for depression.
1. Decline to sign the will. 6. Answer: 1, 2, and 4.
2. Sign the will as a witness to the signature only. Client preparation for a myelogram includes instructing the
3. Call the hospital lawyer before signing the will. client to restrict food and fluids for 4 to 8 hours before the
4. Sign the will, clearly identifying credentials and procedure. The client is told that the procedure takes about
employment agency. 45 minutes. An informed consent is required because the
19. A nurse has reinforced instructions to the client procedure is invasive and is therefore performed by the
with hyperparathyroidism regarding home care health care provider. The client will need to remove jewelry
measures related to exercise. Which statement by the and metal objects from the chest area. The client is also told
client indicates a need for further instruction? Select all that pretest medications may be prescribed for relaxation.
that apply. 7. Answers: 3, 4, 5, and 6.
1. “I enjoy exercising but I need to be careful.” Dilantin causes blood dyscrasias, such as decreased platelet
2. “I need to pace my activities throughout the day.” counts and decreased white blood cell counts; it contributes
3. “I need to limit playing football to only the weekends.” to constipation as well. Gingival hyperplasia can occur,
4. “I should gauge my activity level by my energy level.” causing gums to bleed easily, and blood glucose levels can
5. “I should exercise in the evening to encourage a good elevate when taking phenytoin. Sedation is a side effect of
sleep pattern.” barbiturates, not phenytoin. Ataxia is a side effect of
20. A nurse in a medical unit is caring for a client with benzodiazepines.
heart failure. The client suddenly develops extreme 8. Answers: 1, 2, 4, and 6.
dyspnea, tachycardia, and lung crackles, and the nurse Cancer is a common cause of SIADH. In clients with SIADH,
suspects pulmonary edema. The nurse immediately excessive amounts of water are reabsorbed by the kidney and
notifies the registered nurse and expects which put into the systemic circulation. The increased water causes
interventions to be prescribed? Select all that apply. hyponatremia (decreased serum sodium levels) and some
1. Administering oxygen degree of fluid retention. SIADH is managed by treating the
2. Inserting a Foley catheter condition and its cause, and treatment usually includes fluid
3. Administering furosemide (Lasix) restriction, increased sodium intake, and a medication with a
4. Administering morphine sulfate intravenously mechanism of action that is antagonistic to ADH. Sodium
5. Transporting the client to the coronary care unit levels are monitored closely, because hypernatremia can
6. Placing the client in a low Fowler’s side-lying position suddenly develop as a result of treatment. The immediate
institution of appropriate cancer therapy (usually either
Answers and Rationale radiation or chemotherapy) can cause tumor regression so
1. Answer: 2, 3, and 5. that ADH
For the hospitalized neutropenic child, flowers or plants synthesis and release processes return to normal.
should not be kept in the room because standing water and 9. Answers: 1, 2, 4 and 6.
damp soil harbor Aspergillus and Pseudomonas, to which Cancer is a common cause of SIADH. In clients with SIADH,
these children are very susceptible. Fruits and vegetables not excessive amounts of water are reabsorbed by the kidney and
peeled before being eaten harbor molds and should be put into the systemic circulation. The increased water causes
avoided until the white blood cell count rises. The child is hyponatremia (decreased serum sodium levels) and some
placed on a low-bacteria diet. Dressings are always changed degree of fluid retention. SIADH is managed by treating the
with sterile technique. Not all visitors need to be restricted, condition and its cause, and treatment usually includes fluid
but anyone who is ill should not be allowed in the child’s restriction, increased sodium intake, and a medication with a
room. Meticulous hand washing is required before caring for mechanism of action that is antagonistic to ADH. Sodium
the child. In addition, gloves, a mask, and a gown are worn levels are monitored closely, because hypernatremia can
(per agency policy). suddenly develop as a result of treatment. The immediate
2. Answers: 3, 4, and 5. institution of appropriate cancer therapy (usually either
Medications that are prescribed for long-term control of tonic- radiation or chemotherapy) can cause tumor regression so
clonic seizures are gabapentin, ethosuximide, and that ADH synthesis and release processes return to normal.
carbamazepine. Diazepam is a medication that is prescribed 10. Answers: 1, 2, and 4.
to halt tonic-clonic episodes, and methylphenidate is a A focused data collection process focuses on a limited or
medication used to treat attention deficit hyperactivity short-term problem, such as the client’s complaint. Because
disorder. Both of these medications are not suitable for long- the client is complaining of symptoms of a cold, a cough, and
term control of a seizure condition. Alprazolam is a lung congestion the nurse would focus on the respiratory
medication used to treat anxiety. system and the presence of an infection. A complete data
3. Answer: 4. collection includes a complete health history and physical
Meningococcal meningitis is transmitted primarily by droplet examination and forms a baseline database. Checking the
infection. Isolation is begun and maintained for at least 24 strength of peripheral pulses relates to a vascular
assessment, which is not related to this client’s complaints. A establishing priorities of care. The type of illness, the severity
musculoskeletal and neurological examination also is not of the problem, and the resources available govern the
related to this client’s complaints. However, strength of process. Clients with trauma, chest pain, severe respiratory
peripheral pulses and a musculoskeletal and neurological distress, cardiac arrest, limb amputation, or acute
examination would be included in a complete data collection. neurological deficits and those who sustained a chemical
Likewise, asking the client about a family history of any splash to the eyes are classified as emergent, and these
illness or disease would be included in a complete clients are the number 1 priority. Clients with conditions such
assessment. as simple fractures, asthma without respiratory distress,
11. Answers: 1, 3, and 4. fever, hypertension, abdominal pain, or renal stones have
Anthrax is caused by Bacillus anthracis, and it can be urgent needs, and these clients are classified as the number 2
contracted through the digestive system, abrasions in the priority. Clients with conditions such as minor lacerations,
skin, or inhalation. It cannot be spread from person to sprains, or cold symptoms are classified as non urgent, and
person. they are the number 3
12. Answer: 1. priority.
Toddlers, with their increased mobility and developing motor 18. Answers: 1
skills, can reach hot water, open fires, or hot objects placed Living wills are required to be in writing and signed by the
on counters and stoves above their eye level. Parents should client. The client’s signature either must be witnessed by
be encouraged to remain in the kitchen when preparing a specified individuals or notarized. Many states prohibit any
meal and reminded to use the back burners on the stove. Pot employee from being a witness, including a nurse in a facility
handles should be turned inward and toward the middle of the in which the client is receiving care.
stove. Hot liquids should never be left unattended, and the 19. Answers: 3 and 5.
toddler should always be supervised. Options 2, 3, and 4 do The client should be instructed to avoid high-impact activity
not reflect an adequate understanding of the principles of or contact sports such as football. Exercising late in the
safety. evening may interfere with restful sleep. The client with
13. Answer: 3. hyperparathyroidism should pace activities throughout the
In team nursing, nursing personnel are led by a nurse when day and plan for periods of uninterrupted rest. The client
providing care to a group of clients. Option 1 identifies should plan for at least 30 minutes of walking each day to
functional nursing. Option 2 identifies a component of case support calcium movement into the bones. The client should
management. Option 4 identifies primary nursing. be instructed to use energy level as a guide to activity.
14. Answer: 2. 20. Answers: 1, 2, 3, and 4.
The nurse must determine the most appropriate assignment Pulmonary edema is a life-threatening event that can result
on the basis of the skills of the staff member and the needs of from severe heart failure. In pulmonary edema the left
the client. In this case, the most appropriate assignment for a ventricle fails to eject sufficient blood, and pressure increases
nursing assistant would be to care for the client who requires in the lungs because of the accumulated blood. Oxygen is
frequent ambulation. The nursing assistant is skilled in this always prescribed, and the client is placed in a high Fowler’s
task. The position to ease the work of breathing. Furosemide, a rapid-
client who had a cardiac catheterization will require specific acting diuretic, will eliminate accumulated fluid. A Foley
monitoring in addition to that of the vital signs. Wound catheter is inserted to accurately measure output.
irrigations and tube feedings are not performed by unlicensed Intravenously administered morphine sulfate reduces venous
personnel. return (preload), decreases anxiety, and reduces the work of
15. Answers: 2, 3, 4, and 6. breathing. Transporting the client to the coronary care unit is
To prove malpractice against a nurse, the plaintiff must prove not a priority intervention. In fact, this may not be necessary
that the nurse owed a duty to the client, that the nurse at all if the client’s response to treatment is successful.
breached the duty, and that as a result harm was caused to
person or property. The client has an increased risk of NCLEX SATA 3
hypotension (option 2) because hypotension is a common 1. A nurse is admitting a client with a possible
adverse effect of bumetanide, this is the second dose within 4 diagnosis of chronic bronchitis. The nurse collects data
hours, and the client has heart failure. The client can prove from the client and notes that which of the following
that the nurse did not protect him by failing to provide signs supports this diagnosis? Select all that apply.
adequate teaching and perform correct and timely nursing 1. Scant mucus
interventions (options 3, 4, and 6) after administering the 2. Early onset cough
bumetanide. After the first 15-minute check, the nurse should 3. Marked weight loss
continue increased client monitoring to ensure client 4. Purulent mucus production
compliance with safety measures. Replacing fluid volume is 5. Mild episodes of dyspnea
not the issue; furthermore, the goal of therapy is to reduce 2. A nurse is assigned to care for a client admitted to
total body fluid. No data indicate that the dose of bumetanide, the hospital after sustaining an injury from a house
a loop diuretic, was excessive. However, because this fire. The client attempted to save a neighbor involved
medication can cause hypotension, especially after a repeat in the fire but, in spite of the client’s efforts, the
dose, the nurse should instruct the client to remain in bed neighbor died. Which action would the nurse take to
and provide him with a urinal. It may be difficult for the client enable the client to work through the meaning of the
to prove that the second dose of bumetanide caused the crisis?
injury. 1. Identifying the client’s ability to function
16. Answers: 1, 2, 4, and 5. 2. Identifying the client’s potential for self-harm
Following a lumbar puncture, the client remains flat in bed for 3. Inquiring about the client’s feelings that may affect coping
6 to 24 hours, depending on the health care provider’s 4. Inquiring about the client’s perception of the cause of the
prescriptions. A liberal fluid intake (not NPO status) is neighbor’s death
encouraged to replace cerebrospinal fluid removed during the 3. A nurse is assigned to care for a client with a
procedure, unless contraindicated by the client’s condition. peripheral IV infusion. The nurse is providing hygiene
The nurse checks the puncture site for redness and drainage, care to the client and would avoid which of the
and monitors the client’s ability to void and move the following while changing the client’s hospital gown?
extremities. 1. Using a hospital gown with snaps at the sleeves
17. Answers: 4. 2. Disconnecting the IV tubing from the catheter in the vein
In an emergency department, triage involves classifying 3. Checking the IV flow rate immediately after changing the
clients according to their need for care, and it includes hospital gown
4. Putting the bag and tubing through the sleeve, followed by rate
the client’s arm 4. Respirations that are abnormally deep, regular, and
4. A nurse is assigned to care for four clients. When increased in rate
planning client rounds, which client would the nurse 12. Which nursing interventions are appropriate for a
check first? client recovering from surgery for retinal detachment?
1. A client on a ventilator Select all that apply.
2. A client in skeletal traction 1. Monitor for hemorrhage.
3. A postoperative client preparing for discharge 2. Administer eye medications.
4. A client admitted on the previous shift who has a diagnosis 3. Maintain the eye patch or shield.
of gastroenteritis 4. Assist with activities of daily living.
5. A nurse is assisting with collecting data from an 5. Encourage coughing and deep breathing.
African-American client admitted to the ambulatory 6. Educate regarding symptoms of retinal detachment.
care unit who is scheduled for a hernia repair. Which of 13. A nurse is caring for a client with leukemia and
the following information about the client is of least notes that the client has poor skin turgor and flat neck
priority during the data collection? and hand veins. The nurse suspects hyponatremia.
1. Respiratory What additional signs would the nurse expect to note in
2. Psychosocial this client if hyponatremia is present?
3. Neurological 1. Intense thirst
4. Cardiovascular 2. Slow bounding pulse
6. A nurse is assisting with planning care for a client 3. Dry mucous membranes
with an internal radiation implant. Which of the 4. Postural blood pressure changes
following should be included in the plan of care? Select 14. A nurse is caring for a group of clients who are
all that apply. taking herbal medications at home. Which of the
1. Wearing gloves when emptying the client’s bedpan following clients should be instructed not to take
2. Keeping all linens in the room until the implant is removed herbal medications?
3. Wearing a film (dosimeter) badge when in the client’s room 1. A 60-year-old male client with rhinitis
4. Wearing a lead apron when providing direct care to the 2. A 24-year-old male client with a lower back injury
client 3. A 10-year-old female client with a urinary tract infection
5. Placing the client in a semiprivate room at the end of the 4. A 45-year-old female client with a history of migraine
hallway headaches
7. The nurse is caring for a client after a supratentorial 15. A nurse is caring for an infant with a diagnosis of
craniotomy in which a large tumor was removed from tetralogy of Fallot. The infant suddenly becomes
the left side. Choose the positions in which the nurse cyanotic and the oxygen saturation reading drops to
can safely place the client. Select all that apply. 60%. Choose the interventions that the nurse should
1. On the left side perform. Select all that apply.
2. With the neck flexed 1. Call a code blue.
3. Supine on the left side 2. Notify the registered nurse.
4. With extreme hip flexion 3. Place the infant in a prone position.
5. In a semi-Fowler’s position 4. Prepare to administer morphine sulfate.
6. With the head in a midline position 5. Prepare to administer intravenous fluids.
8. A nurse is caring for a client after thyroidectomy and 6. Prepare to administer 100% oxygen by face mask.
notes that calcium gluconate is prescribed for the 16. A nurse is collecting data on a client with severe
client. The nurse determines that this medication has preeclampsia. Choose the findings that would be noted
been prescribed to: in severe preeclampsia. Select all that apply.
1. Treat thyroid storm. 1. Oliguria
2. Prevent cardiac irritability. 2. Seizures
3. Treat hypocalcemic tetany. 3. Contractions
4. Stimulate the release of parathyroid hormone. 4. Proteinuria 3+
9. A nurse is caring for a client with a healthcare- 5. Muscle cramps
associated infection caused by methicillin-resistant 6. Blood pressure 168/116 mm Hg
Staphylococcus aureus who is on contact precautions. 17. A nurse is monitoring a client with Graves’ disease
The nurse prepares to provide colostomy care to the for signs of thyrotoxicosis (thyroid storm). Which of
client. Which of the following protective items will be the following signs and symptoms, if noted in the
required to perform this procedure? client, will alert the nurse to the presence of this crisis?
1. Gloves and a gown Select all that apply.
2. Gloves and goggles 1. Bradycardia
3. Gloves, a gown, and goggles 2. Fever
4. Gloves, a gown, and shoe protectors 3. Sweating
10. A nurse is caring for a client with a nasogastric 4. Agitation
tube that is attached to low suction. The nurse 5. Pallor
monitors the client closely for which acid-base disorder 18. A nurse is monitoring a group of clients for acid-
that is most likely to occur in this situation? base imbalances. Which clients are at highest risk for
1. Metabolic acidosis metabolic acidosis? Select all that apply.
2. Metabolic alkalosis 1. Severely anxious client
3. Respiratory acidosis 2. Pneumonia client
4. Respiratory alkalosis 3. Diabetic mellitus client
11. A nurse is caring for a client with diabetic 4. Malnourished client
ketoacidosis and documents that the client is 5. Asthma client
experiencing Kussmaul’s respirations. Based on this 6. Renal failure client
documentation, which of the following did the nurse 19. The nurse is preparing a teaching plan for a client
most likely observe? who is undergoing cataract extraction with intraocular
1. Respirations that cease for several seconds implant. Which home care measures will the nurse
2. Respirations that are regular but abnormally slow include in the plan? Select all that apply.
3. Respirations that are labored and increased in depth and
1. To avoid activities that require bending over Shoe protectors are not
2. To contact the surgeon if eye scratchiness occurs necessary.
3. To place an eye shield on the surgical eye at bedtime 10. Answer: 2
4. That episodes of sudden severe pain in the eye is expected The loss of gastric fluid via nasogastric suction or vomiting
5. To contact the surgeon if a decrease in visual acuity occurs causes metabolic alkalosis as a result of the loss of
6. To take acetaminophen (Tylenol) for minor eye discomfort hydrochloric acid; this results in an alkalotic condition.
20. The nurse is preparing a teaching plan for a client Options 3 and 4 deal with respiratory problems. Option 1
who is undergoing cataract extraction with intraocular relates to acidosis.
implant. Which home care measures will the nurse 11. Answer: 4.
include in the plan? Select all that apply. Kussmaul’s respirations are abnormally deep, regular, and
1. To avoid activities that require bending over increased in rate. In apnea, respirations cease for several
2. To contact the surgeon if eye scratchiness occurs seconds. In bradypnea, respirations are regular but
3. To place an eye shield on the surgical eye at bedtime abnormally slow. In hyperpnea, respirations are labored and
4. That episodes of sudden severe pain in the eye is expected increased in depth and rate.
5. To contact the surgeon if a decrease in visual acuity occurs 12. Answers: 1, 2, 3, 4, and 6.
6. To take acetaminophen (Tylenol) for minor eye discomfort An eye patch or shield is applied to protect the eye and
prevent any further detachment. Educating the client
Answers and Rationale regarding symptoms is necessary because the client is at risk
1. Answers: 2, 4, and 5. for subsequent retinal detachment. Positioning, activity
Key features of pulmonary emphysema include dyspnea that restrictions, and eye patches hinder the client in the
is often marked, late cough (after onset of dyspnea), scant performance of activities of daily living, and the client needs
mucus production, and marked weight loss. By contrast, the nurse’s assistance with these activities. Eye medications
chronic bronchitis is characterized by an early onset of cough are prescribed postoperatively, and hemorrhage is also a risk
(before dyspnea), copious purulent mucus production, post surgery. Coughing is not encouraged because this can
minimal weight loss, and milder severity of dyspnea. increase intraocular pressure and harm the client.
2. Answer: 3. 13. Answer: 4.
The client must first deal with feelings and negative responses Postural blood pressure changes occur in the client with
before the client is able to work through the meaning of the hyponatremia. Dry mucous membranes
crisis. Option 3 pertains directly to the client’s feelings. and intense thirst are seen in clients with hypernatremia. A
Options 1, 2, and 4 do not directly address the client’s slow, bounding pulse is not indicative of hyponatremia. In a
feelings. client with hyponatremia, a rapid thready pulse is noted.
3. Answer: 2. 14. Answer: 3.
The tubing should not be removed from the IV catheter. With Children should not be given herbal therapies, especially in
each break in the system, there is an increased chance of the home and without professional
introducing bacteria into the system, which can lead to supervision. There are no general contraindications for the
infection. Options 1 and 4 are appropriate. The flow rate clients described in options 1, 2, and 4.
should be checked immediately after changing the hospital 15. Answers: 2, 4, 5, and 6.
gown, because the position of the roller clamp may have been The child who is cyanotic with oxygen saturations dropping to
affected during the change. 60% is having a hypercyanotic episode. Hypercyanotic
4. Answer: 1. episodes often occur among infants with tetralogy of Fallot,
The airway is always a high priority, and the nurse first and they may occur among infants whose heart defect
checks the client on a ventilator. The clients described in includes the obstruction of pulmonary blood flow and
options 2, 3, and 4 have needs that would be identified as communication between the ventricles. If a hypercyanotic
intermediate priorities. episode occurs, the infant is placed in a knee-chest position
5. Answer: 2. immediately. The registered nurse is notified, who will then
The psychosocial data is the least priority during the initial contact the health care provider. The knee-chest position
admission data collection. In the African-American culture, it improves systemic arterial oxygen saturation by decreasing
is considered intrusive to ask personal questions during the venous return so that smaller amounts of highly saturated
initial contact or meeting. Additionally, respiratory, blood reach the heart. Toddlers and children squat to get into
neurological, and cardiovascular data include physiological this position and relieve chronic hypoxia. There is no reason
assessments that to call a code blue unless respirations cease. Additional
would be the priority. interventions include administering 100% oxygen by face
6. Answer: 1, 2, 3, and 4. mask, morphine sulfate, and intravenous fluids, as
A private room with a private bath is essential if a client has prescribed.
an internal radiation implant. This is necessary to prevent the 16. Answers: 1, 4, and 6.
accidental exposure of other clients to radiation. The Severe preeclampsia is characterized by blood pressure
remaining options identify interventions that are necessary higher than 160/110 mm Hg, proteinuria 3+ or higher, and
for a client with a radiation device. oliguria. Seizures (convulsions) are present in eclampsia and
7. Answers: 5 and 6. are not a characteristic of severe preeclampsia. Muscle
Clients who have undergone supratentorial surgery should cramps and contractions are not findings noted in severe
have the head of the bed elevated 30 degrees to promote preeclampsia, although the client is monitored for these
venous drainage from the head. The client is positioned to occurrences.
avoid extreme hip or neck flexion, and the head is maintained 17. Answers: 2, 3, and 4.
in a midline, neutral position. If a large tumor has been Thyrotoxic crisis (thyroid storm) is an acute, potentially life-
removed, the client should be placed on the nonoperative side threatening state of extreme thyroid activity that represents a
to prevent the displacement of the cranial contents. breakdown in the body’s tolerance to a chronic excess of
8. Answer: 3. thyroid hormones. The clinical manifestations include fever
9. Answer: 3. greater than 100° F, severe tachycardia, flushing and
Goggles are worn to protect the mucous membranes of the sweating, and marked agitation and restlessness. Delirium
eye during interventions that may produce and coma can occur.
splashes of blood, body fluids, secretions, and excretions. In 18. Answers: 3, 4, and 6.
addition, contact precautions require the use of gloves, and a Diabetes mellitus, malnutrition, and renal failure lead to
gown should be worn if direct client contact is anticipated. metabolic acidosis because of the increasing acids in the
body. Options 1, 2, and 5 are respiratory problems, not
metabolic, and result in either respiratory acidosis or 6. Use soft tissues to clean any secretions that accumulate
respiratory alkalosis. around the stoma.
19. Answers: 1, 3, 5, and 6. 5. A nurse is reviewing the health records of assigned
After eye surgery, some scratchiness and mild eye discomfort clients. The nurse plans care knowing that which client
may occur in the operative eye and is usually relieved by mild is at risk for fluid volume deficit?
analgesics. If the eye pain becomes severe, the client should 1. The client with cirrhosis
notify the surgeon because this may indicate hemorrhage, 2. The client with a colostomy
infection, or increased intraocular pressure. The nurse would 3. The client with decreased kidney function
also instruct the client to notify the surgeon of purulent 4. The client with congestive heart failure (CHF)
drainage, increased redness, or any decrease in visual acuity. 6. A nurse is told in report that a client has a positive
The client is instructed to place an eye shield over the Chvostek’s sign. What other data would the nurse
operative eye at bedtime to protect the eye from injury expect to find on data collection? Select all that apply.
during sleep and to avoid activities that increase intraocular 1. Coma
pressure such as bending over. 2. Tetany
20. Answers: 1, 3, 5, and 6. 3. Diarrhea
After eye surgery, some scratchiness and mild eye discomfort 4. Possible seizure activity
may occur in the operative eye and is usually relieved by mild 5. Hypoactive bowel sounds
analgesics. If the eye pain becomes severe, the client should 6. Positive Trousseau’s sign
notify the surgeon because this may indicate hemorrhage, 7. A nurse lawyer provides an education session to the
infection, or increased intraocular pressure. The nurse would nursing staff regarding client rights. A nurse asks the
also instruct the client to notify the surgeon of purulent lawyer to describe an example that may relate to
drainage, increased redness, or any decrease in visual acuity. invasion of client privacy. A nursing action that
The client is instructed to place an eye shield over the indicates a violation of this right is:
operative eye at bedtime to protect the eye from injury 1. Threatening to place a client in restraints
during sleep and to avoid activities that increase intraocular 2. Performing a surgical procedure without consent
pressure such as bending over. 3. Taking photographs of the client without consent
4. Telling the client that he or she cannot leave the hospital
8. A nurse notes in the medical record that a client with
NCLEX SATA 4 Cushing’s syndrome is experiencing fluid overload.
1. A nurse is providing a list of instructions to a client Which interventions should be included in the plan of
who is scheduled to have an electroencephalogram care? Select all that apply.
(EEG). Choose the instructions that the nurse places on 1. Monitoring daily weight
the list. Select all that apply. 2. Monitoring intake and output
1. Cola is acceptable to drink on the day of the test. 3. Maintaining a low-potassium diet
2. Tea and coffee are restricted on the day of the test. 4. Monitoring extremities for edema
3. The test will take between 45 minutes and 2 hours. 5. Maintaining a low-sodium diet
4. The hair should be washed the evening before the test. 9. A nurse notes in the medical record that a client with
5. All medications need to be withheld on the day of the test. Cushing’s syndrome is experiencing fluid overload.
6. A nothing-by-mouth (NPO) status is required on the day of Which interventions should be included in the plan of
the test. care? Select all that apply.
2. The nurse is providing discharge teaching to the 1. Monitoring daily weight
client who was given a prescription for nifedipine 2. Monitoring intake and output
(Adalat) for blood pressure management. Which 3. Maintaining a low-potassium diet
instructions should the nurse include? Select all that 4. Monitoring extremities for edema
apply. 5. Maintaining a low-sodium diet
1. “Increase water intake.” 10. Which instruction should the nurse provide to the
2. “Increase calcium intake.” client with diabetes mellitus receiving acarbose
3. “Take pulse rate each day.” (Precose)? Select all that apply.
4. “Weigh at the same time each day.” 1. “Take the medication at bedtime.”
5. “Palpitations may occur early in therapy.” 2. “Take the medication with each meal.”
6. “Be careful when rising from sitting to standing.” 3. “Take the medication on an empty stomach.”
3. A nurse is providing teaching regarding the 4. “Side effects include abdominal bloating and flatus.”
prevention of Lyme disease to a group of teenagers 5. “Take some form of glucose if hypoglycemia occurs.”
going on a hike in a wooded area. Which of the 6. “Report symptoms such as shortness of breath or
following points should the nurse include in the tiredness.”
session? Select all that apply. 11. A nurse prepares a list of home care instructions for
1. Tuck pant legs into socks. the parents of a child who has a plaster cast applied to
2. Wear closed shoes when hiking. the left forearm. Choose the instructions that would be
3. Apply insect repellent containing DEET. included on the list. Select all that apply.
4. Cover the ground with a blanket when sitting. 1. Use the fingertips to lift the cast while it is drying.
5. Remove attached ticks by grasping with thumb and 2. Keep small toys and sharp objects away from the cast.
forefinger. 3. Use a padded ruler or another padded object to scratch the
6. Wear long sleeves and long pants in dark colors when in skin under the cast if it itches.
high-risk areas. 4. Place a heating pad on the lower end of the cast and over
4. A nurse is reinforcing instructions to a client the fingers if the fingers feel cold.
following a total laryngectomy about caring for the 5. Contact the health care provider if the child complains of
stoma. Choose the instructions that the nurse provides numbness or tingling in the extremity.
to the client. Select all that apply. 6. Elevate the extremity on pillows for the first 24 to 48 hours
1. Protect the stoma from water. after casting to prevent swelling.
2. Soaps should be avoided near the stoma. 12. A nurse reinforces instructions to the mother of a
3. Wash the stoma daily using a washcloth. child who has been hospitalized with croup. Which of
4. Use diluted alcohol on the stoma to clean it. the following statements, if made by the mother, would
5. Apply a thin layer of petroleum jelly to the skin indicate the need for further instruction?
surrounding the stoma.
1. “I will give my child cough syrup if a cough develops.” 5. Increased susceptibility to urinary tract infections
2. “During an attack, I will take my child to a cool location.” 6. Increased incidence of awakening after sleep onset
3. “I will give acetaminophen (Tylenol) if my child develops a 20. Which data indicates to the nurse that a client may
fever.” be experiencing ineffective coping?
4. “I will be sure that my child drinks at least three to four 1. Constantly neglects personal grooming
glasses of fluids every day.” 2. Visits her husband’s grave once a month
13. The nurse would anticipate the use of which 3. Visits the senior citizens’ center once a month
medications in the treatment of the client with heart 4. Frequently looks at snapshots of her husband and family
failure? Select all that apply.
1. Diuretics Answers and Rationale
2. Anticoagulants 1. Answers: 2, 3, and 4.
3. Anticholinergics Pre-procedure instructions include informing the client that
4. Cardiac glycosides the procedure is painless. The procedure requires no dietary
5. Phosphodiesterase (PDE) inhibitors restrictions other than avoidance of cola, tea, and coffee on
6. Angiotensin-converting enzyme (ACE) inhibitors the morning of the test. These products have a stimulating
14. The parent of a toddler asks a nurse when it is safe effect and should be avoided. The hair should be washed the
to place the car safety seat in a face-forward position. evening before the test, and gels, hairsprays, and lotion
Which of the following is the best nursing response? should be avoided. The client is informed that the test will
1. When the toddler weighs 20 lb and is 1 year old take 45 minutes to 2 hours and that medications are usually
2. When the weight of the toddler is more than 40 lb not withheld before the test.
3. The seat should not be placed in a face-forward position 2. Answers: 3, 4, 5, and 6.
unless there are safety locks in the car. Nifedipine is a calcium-channel blocker. Its therapeutic
4. The seat should never be placed in a face-forward position outcome is to decrease blood pressure. Its method of action
because of the risk of the child unbuckling the harness. is blockade of the calcium channels in vascular smooth
15. A pregnant woman has a positive history of genital muscle, promoting vasodilation. Side effects that can occur
herpes, but she has not had lesions during her early in therapy include reflex tachycardia (palpitations) and
pregnancy. The nurse plans to provide which of the first-dose hypotension, leading to orthostatic hypotension.
following information to the client? Weight should be checked regularly to monitor for early signs
1. “You will be isolated from your newborn after delivery.” of heart failure. Also the client is taught to take his or her
2. “There is little risk to your baby during your pregnancy, own pulse. Nifedipine does not affect serum calcium levels.
birth, and after delivery.” Increased water intake is not indicated in the client with
3. “Vaginal deliveries can reduce neonatal infection risks, cardiovascular disease.
even if you have an active lesion at birth.” 3. Answers: 1, 2, 3, and 4.
4. “You will be evaluated at the time of delivery for herpetic Measures to prevent tick bites focus on covering the body as
genital tract lesions. If they are present, a cesarean delivery completely as possible and spraying insect repellent
will be needed.” containing DEET on the skin and clothing. Long sleeves and
16. Which of these clients are most likely to develop pants tucked into the socks along with closed shoes will offer
fluid (circulatory) overload? Select all that apply. some protection. Light-colored clothing should be worn so
1. A premature infant that ticks would be easily visible. Hikers should not sit directly
2. A 101-year-old man on the ground and should cover the ground with an item such
3. A client on renal dialysis as a blanket. Ticks should be removed with tweezers.
4. A client with diabetes mellitus 4. Answers: 1, 2, 3, and 5.
5. A 29-year-old woman with pneumonia The client with a stoma should be instructed to wash the
6. A client with congestive heart failure stoma daily with a washcloth. Soaps, cotton swabs, or tissues
17. An unconscious client who is bleeding profusely is should be avoided because their particles may enter and
brought to the emergency department after a serious obstruct the airway. The client should be instructed to avoid
accident. Surgery is required immediately to save the applying alcohol to a stoma because it is both drying and
client’s life. With regard to informed consent for the irritating. A thin layer of petroleum jelly applied to the skin
surgical procedure, which of the following is the best around the stoma helps prevent cracking. The client is
action? instructed to protect the stoma from water.
1. Call the nursing supervisor to initiate a court order for the 5. Answer 2.
surgical procedure. Causes of a fluid volume deficit include vomiting, diarrhea,
2. Try calling the client’s spouse to obtain telephone consent conditions that cause increased respirations or increased
before the surgical procedure. urinary output, insufficient intravenous fluid replacement,
3. Ask the friend who accompanied the client to the draining fistulas, ileostomy, and colostomy. A client with
emergency department to sign the consent form. cirrhosis, CHF, or decreased kidney function is at risk for fluid
4. Transport the client to the operating department volume excess.
immediately, as required by the health care provider without 6. Answers: 2, 3, 4 and 6.
obtaining an informed consent. A positive Chvostek’s sign is indicative of hypocalcemia. Other
18. When caring for a 3-year-old child, the nurse signs and symptoms include tachycardia, hypotension,
should provide which toy for this child? paresthesias, twitching, cramps, tetany, seizures, positive
1. A puzzle Trousseau’s sign, diarrhea, hyperactive bowel sounds, and a
2. A wagon prolonged QT interval.
3. A golf set 7. Answer: 3.
4. A farm set Invasion of privacy takes place when an individual’s private
19. When the nurse is collecting data from the older affairs are intruded on unreasonably. Threatening to place a
adult, which of the following findings would be client in restraints constitutes assault. Performing a surgical
considered normal physiological changes? Select all procedure without consent is an example of battery. Not
that apply. allowing a client to leave the hospital constitutes false
1. Increased heart rate imprisonment.
2. Decline in visual acuity 8. Answers: 1, 2, 4, and 5.
3. Decreased respiratory rate The client with Cushing’s syndrome experiencing fluid
4. Decline in long-term memory overload should be maintained on a high-potassium and low-
sodium diet. Decreased sodium intake decreases renal
retention of sodium and water. Monitoring weight, intake, and dolls are some appropriate toys. A puzzle with large
output, and extremities for edema are all appropriate pieces only may be appropriate. A farm set and a golf set
interventions for such a nursing diagnosis. may contain items that the child could swallow.
9. Answers: 1, 2, 4, and 5. 19. Answers: 2, 5, and 6.
The client with Cushing’s syndrome experiencing fluid Anatomical changes to the eye affect the individual’s visual
overload should be maintained on a high-potassium and low- ability, which leads to potential problems with activities of
sodium diet. Decreased sodium intake decreases renal daily living. Light adaptation and visual fields are reduced.
retention of sodium and water. Monitoring weight, intake, Respiratory rates are usually unchanged. The heart rate
output, and extremities for edema are all appropriate decreases, and the heart valves thicken. Age-related changes
interventions for such a nursing diagnosis. that affect the urinary tract increase an older client’s
10. Answers: 2, 4, 5, and 6. susceptibility to urinary tract infections. Short-term memory
The mechanism of action of acarbose is a delay in absorption may decline with age, but long-term memory is usually
of dietary carbohydrates, thereby reducing the rise in blood maintained. Changes in sleep patterns are consistent, age-
glucose after a meal. To accomplish this, the medication must related changes. Older persons experience an increased
be taken with each meal. Because of its bacterial incidence of awakening after sleep onset.
fermentation of unabsorbed carbohydrates in the colon, side 20. Answer: 1
effects such as borborygmus, cramps, abdominal distention, Coping mechanisms are behaviors that are used to decreased
and flatulence can occur. The medication also can affect stress and anxiety. In response to a death, ineffective coping
absorption of iron, leading to symptoms (shortness of breath, is manifested by an extreme behavior that in some instances
tiredness) of anemia. may be harmful to the individual, physically, psychologically,
11. Answers: 2, 5, and 6. or both. Option 1 is indicative of a behavior that identifies an
While the cast is drying, the palms of the hands are used to ineffective coping behavior as part of the grieving process.
lift the cast. If the fingertips are used, indentations in the cast The remaining options identify effective coping behaviors.
could occur and cause constant pressure on the underlying
skin. Small toys and sharp objects are kept away from the
cast, and no objects (including padded objects) are placed NCLEX SATA 5
inside of the cast because of the risk of altered skin integrity. 1. The nurse notes that a client is quite suspicious
A heating pad is not applied to the cast or fingers. Cold during an assessment interview and believes that her
fingers could indicate neurovascular impairment, and the HCP family is under investigation by the CIA. What would
should be notified. The extremity is elevated to prevent the appropriate nursing interventions be with this
swelling, and the HCP is notified immediately if any signs of client? Select all that apply:
neurovascular impairment develop. 1. Use active listening skills to seek information from the
12. Answer: 1. client.
Cough syrups and cold medicines are not to be given, 2. Encourage the client to describe the problem as she sees
because they may dry and thicken secretions. it.
During a croup attack, the child can be taken to a cool 3. Ask the client to tell you exactly what she thinks is
basement or garage. Acetaminophen is used if a fever happening.
develops. Adequate hydration of 500 to 1000 mL of fluids 4. Tell the client that she is delusional and you can help her.
daily is important for thinning secretions. 5. Explain to the client that most people are not investigated
13. Answers: 1, 4, 5, and 6. by the CIA.
Medications recommended for treatment of heart failure 6. Reassure the client that you are not with the CIA.
include diuretics, cardiac glycosides such as digoxin 2. Which nursing interventions will assist in reducing
(Lanoxin), PDE inhibitors, and ACE inhibitors. Clients in heart pressure points that may lead to pressure ulcers?
failure do not need anticoagulants or anticholinergics. Check all that apply:
14. Answer: 1. 1. Position the client directly on the trochanter when side
The transition point for switching to the forward-facing lying.
position is defined by the manufacturer of the convertible car 2. Avoid use of donut type devices.
safety seat, but it is generally at a body weight of 9 kg (20 lb) 3. Massage bony prominences.
and an age of 1 year. Options 2, 3, and 4 are incorrect. 4. Elevate the HOB no more than 30 degrees when possible.
15. Answer: 4. 5. When the client is side lying, use the 30 degree lateral
If herpetic genital lesions are present at the time of delivery, inclined position.
a cesarean delivery will be necessary to reduce the risk of 6. Avoid uninterrupted sitting in a chair or wheelchair.
infecting the neonate. In the absence of herpetic genital 3. The nurse is evaluating a client recently diagnosed
lesions, a vaginal delivery may be indicated, unless there are with primary open angle glaucoma (POAG). What will
other reasons for performing a cesarean delivery. Maternal an important nursing action be? Select all that apply:
isolation is not necessary, but potentially exposed neonates 1. Review meds the client is currently on to determine
should be cultured on the day of delivery. whether any of them cause an increased intraocular pressure
16. Answers: 1, 2, 3, and 6. as a side effect.
Clients with cardiac, respiratory, renal, or liver diseases and 2. Determine whether the client has any sudden loss of vision
older and very young clients cannot tolerate an excessive accompanied by pain.
fluid volume. The risk of fluid (circulatory) overload exists 3. Discuss with the client the importance of controlling blood
with these clients pressure to decrease the potential loss of peripheral vision.
17. Answer: 4. 4. Instruct the client to take analgesics as soon as any
Generally there are only two instances in which the informed discomfort occurs in the eye and to notify clinic if pain is not
consent of an adult client is not needed. One instance is when relieved.
an emergency is present and delaying treatment for the 5. Have the client demonstrate the use of eye drops.
purpose of obtaining informed consent would result in injury 6. Assess the client for chronic diseases such as diabetes.
or death to the client. The second instance is when the client 4. A nurse understands that a patient may experience
waives the right to give informed consent. Options 1, 2, and 3 pain during peritoneal dialysis because of which of the
are inappropriate. following? Select all that apply:
18. Answer: 2. 1. Warming the dialysate
Toys for the toddler must be strong, safe, and too large to 2. Too rapid installation
swallow or place in the ear or nose. Toddlers need supervision 3. Infiltration of the solution into the bloodstream
at all times. Push-pull toys, large balls, large crayons, trucks,
4. Accumulation of dialysate solution under the diaphragm inflammation.
5. Too rapid outflow of the dialysate. 6. Soak the affected extremity in warm water every evening.
5. The nurse is evaluating a client’s response to 12. A nurse knows the clinical manifestations of a client
hemodialysis. Which lab results will indicate the with Addison’s disease include which of the following?
dialysis was effective? Select all that apply: Select all that apply:
1. Serum potassium level decreases from 5.4 to 4.6 mEq/L 1. Nausea
2. Cr decreases from 1.6 to 0.8 mg/dL 2. Hypothermia
3.Hgb increases from 10-12 g/dL 3. Hypertension
4. WBC increase from 5000 to 8000/mm^3 4. Hyperpigmentation
5. BUN decreases from 110 to 90 mg/dL 5. Hypotension
6. The nurse understands that the following clinical 6. Hypernatremia
findings are indications for dialysis. Select all that 13. A licensed practical nurse is attending an agency
apply: orientation meeting about the nursing model of
1. Volume overload practice implemented in the facility. The nurse is told
2. BUN 18 mg/dL that the nursing model is a team nursing approach. The
3. K 5.2 mEq/L nurse understands that which of the following is a
4. Decreased creatinine clearance. characteristic of this type of nursing model of practice?
5. Metabolic acidosis 1. A task approach method is used to provide care to clients.
6. Cr 5.0 mg/dL 2. Managed care concepts and tools are used when providing
7. The nurse is assessing a client who had a fractured client care.
femur repaired with an external fixator device. Which 3. Nursing staff are led by a nurse when providing care to a
assessment finding would cause the nurse concern group of clients.
regarding the development of compartment syndrome? 4. A single registered nurse is responsible for providing
Select all that apply: nursing care to a group of clients.
1. Decrease in pulse rate in affected leg. 14. A licensed practical nurse is planning the client
2. Paresthesia distal to area of injury. assignments for the day. Which of the following is the
3. Toes on affected leg cool to touch and edematous. most appropriate assignment for the nursing assistant?
4. Complaints that pins are hurting. 1. A client who requires wound irrigation
5. Complaints of leg pain unrelieved by analgesics or 2. A client who requires frequent ambulation
repositioning. 3. A client who is receiving continuous tube feedings
6. Client angry and calling loudly to the nurse every ten 4. A client who requires frequent vital signs after a cardiac
minutes. catheterization
8. The nurse is preparing discharge for a patient with 15. A male client who has heart failure receives an
GERD. What would be important for the nurse to additional dose of bumetanide as prescribed 4 hours
include in this teaching plan? Select all that apply: after the daily dose. The nurse assesses him 15
1. Elevate the HOB. minutes after administering the medication and
2. Decrease intake of caffeine. reminds him to save all urine in the bathroom. Thirty
3. Discuss strategies for weight loss if overweight. minutes later the nurse finds the client on the floor,
4. Increase fluid intake with meals. unresponsive, and bleeding from a laceration.
5. Take ranitidine (Zantac) at hs. Determine the issues that support the client’s
6. Eat a bedtime snack of milk and protein. malpractice claim. Select all that apply.
9. The nurse is preparing a client for cardiac 1. Failure to replace body fluids
catheterization. Which nursing interventions are 2. Increased risk of hypotension
necessary in preparing the client for this procedure. 3. Failure to teach the client adequately
Select all that apply: 4. Increased need to protect the client
1. Verify consent has been signed. 5. Excessive bumetanide administration
2. Explain procedure to client. 6. Lack of follow-up nursing actions
3. Provide clear liquid, no caffeine diet.
4. Evaluate peripheral pulses. Answers and Rationale
5. Obtain a 12 lead ECG 1. Answers: 1,2,3.
6. Obtain history of shellfish allergy. The client is displaying paranoid behaviours, which
10. The nurse has been assigned a group of cardiac necessitates a matter of fact approach that is nonjudgmental
clients. What would be the most important information and accepting the client’s statements and show the nurses
for the nurse to check on the initial evaluation of each willingness to actively listen. The last three do not contribute
client? Select all that apply: to a therapeutic nurse client relationship.
1. Presence of cardiac pain. 2. Answers: 2, 4, 5 ,6.
2. Medications taken before hospitalizations. Elevating the head of the bed to 30 degrees or less will
3. Presence of jugular vein distention. decrease the chance of ulcer development from shearing
4. Heart sounds and apical rate. forces. When placing the client in a side lying position, use
5. Presence of diaphoresis. the 30 degree lateral inclined position. Do not place the client
6. History of difficulty breathing. on their trochanter. Avoid donuts which promote ischemia.
11. The nurse is teaching a client about home care and Don’t massage bony prominences as this causes capillary
treatment of venous stasis ulcers in his leg. What break down and injury leading to pressure ulcers.
should be included in the nurse’s instructions? Select 3. Answers: 1, 5, 6.
all that apply: Medications must be evaluated in terms of their potential for
1. Dressings do not need to be changed frequently because increasing the intraocular pressure. Ophthalmic drops are
there is minimal drainage. often prescribed for glaucoma and clients should know how to
2. Healing will be facilitated by wearing leg compression administer them correctly. Diabetes is a risk factor and its
devices. mgmt is important in helping slow POAG. An increase in
3. When the client is in sitting position, he should keep his intraocular pressure could cause further damage to a patient
legs elevated. with POAG. The questions states the client is already
4. Avoid standing for long periods of time. diagnosed, POAG is painless and not correlated to BP.
5. Cool packs can be applied to the ulcers to decrease 4. Answers: 2,4.
Rapid outflow doesn’t cause pain, warming helps with person or property. The client has an increased risk of
discomfort and the dialysate does not infiltrate the circulation. hypotension (option 2) because hypotension is a common
5. Answers: 1, 2, 5. adverse effect of bumetanide, this is the second dose within 4
Primary action of hemodialysis is to clear nitrogenous waste hours, and the client has heart failure. The client can prove
products. that the nurse did not protect him by failing to provide
6. Answers: 1, 3, 5, 6. adequate teaching and perform correct and timely nursing
Indications for dialysis include volume overload, weight gain, interventions (options 3, 4, and 6) after administering the
hyperkalemia, metabolic acidosis, and rising BUN (normally bumetanide. After the first 15-minute check, the nurse should
10-20 mg/dL) and Cr (normally 0.5-1.5 mg/dL) levels, along continue increased client monitoring to ensure client
with decreased urinary creatinine clearance. The K level is compliance with safety measures. Replacing fluid volume is
hyperkalemic, the BUN is normal. not the issue; furthermore, the goal of therapy is to reduce
7. Answers: 2, 3, 5. total body fluid. No data indicate that the dose of bumetanide,
Paresthesia, edema, and leg pain unrelieved by analgesics are a loop diuretic, was excessive. However, because this
classic indicators of the development of compartmental medication can cause hypotension, especially after a repeat
syndrome. With a femur fracture the will be edema, a dose, the nurse should instruct the client to remain in bed
decrease in rate is not an indication of pressure, a decrease in and provide him with a urinal. It may be difficult for the client
pulse strength is. Anger can be due to immobility, and the to prove that the second dose of bumetanide caused the
pins do not usually cause pain, but this may be a sign of injury.
infection.
8. Answers: 1, 2, 3, 5.
This will all help neutralize stomach acid. Drinking lots with
meals and eating before bed will exacerbate the problem.
9. Answers: 1, 2, 5, and 6.
In cardiac catheterization contrast dye is injected into the
coronary artery and provides info on patency. Informed
consent must be signed prior to any invasive procedure. The
physician is responsible for explaining the procedure, the
nurse can reinforce. Patient would be NPO 6-18 hours prior.
An ECG would be done, but measures electrical not blood
flow. Peripheral pulses is important afterwards. Shellfish is an
indicator of an allergy to the medium injected.
10. Answers: 1, 3, 4, and 5.
A focussed cardiac assessment is directed towards assessing
physiologic symptoms (cardiac pain, JVD, heart sounds and
rate, and presence of diaphoresis) that provide immediate
information regarding the clients condition, which is
appropriate for the nurse to do at the beginning of each shift.
After the physiological parameters have been evaluated the
nurse can determine history of SOB and meds.
11. Answers: 2, 3, and 4.
Healing of venous stasis ulcers in dependent on relieving the
venous congestion in the extremity. Compression devices and
elevation of the extremity are the most effective methods.
The client should avoid standing for long periods since this
increases venous stasis. Moist cool and/or warm packs are
NOT used, but moist environment dressings are utilized.
Dressings need to be changed as frequently as necessary
because there may be excessive drainage.
12. Answers: 1, 4, and 5.
Addison’s disease is due to hypofunctioning of the adrenal
cortex. The clinical manifestations have a very slow onset,
and skin hyperpigmentation is a classic sign. Fatigue, nausea,
weight loss, hypotension, hyponatremia, and hyperkalemia
are other findings associated with the condition.
13. Answer: 3.
In team nursing, nursing personnel are led by a nurse when
providing care to a group of clients. Option 1 identifies
functional nursing. Option 2 identifies a component of case
management. Option 4 identifies primary nursing.
14. Answer: 2.
The nurse must determine the most appropriate assignment
on the basis of the skills of the staff member and the needs of
the client. In this case, the most appropriate assignment for a
nursing assistant would be to care for the client who requires
frequent ambulation. The nursing assistant is skilled in this
task. The
client who had a cardiac catheterization will require specific
monitoring in addition to that of the vital signs. Wound
irrigations and tube feedings are not performed by unlicensed
personnel.
15. Answers: 2, 3, 4, and 6.
To prove malpractice against a nurse, the plaintiff must prove
that the nurse owed a duty to the client, that the nurse
breached the duty, and that as a result harm was caused to