Flashcards 1201 - 1400

1,201.
The nurse is caring for a client who develops Clostridium

difficile colitis after multiple days of antibiotic therapy. Which infection
control measures are appropriate to implement?
Wear a face mask
WRONG. Contact precautions require the caregiver to wear a gown

and gloves. A face mask must be worn as personal protective
equipment if an organism is spread via droplets. However, it is not
required to prevent the spread of a contact-transmissible infection. The
nurse should not wear a mask solely to avoid the unpleasant odor
associated with C difficile diarrhea as this may be offensive and
embarrassing to the client.
1,202. The nurse is caring for a client who develops Clostridium
difficile colitis after multiple days of antibiotic therapy. Which infection
control measures are appropriate to implement?
Wear nonsterile gloves
CORRECT.
1,203. The nurse completes the following drug administrations. Which
would require an incident report?
Client with chronic stable angina and blood pressure of 84/52 mm

Hg; isosorbide mononitrate held
NO NEED TO REPORT. The isosorbide has actions identical to

nitroglycerin and can cause hypotension from vasodilation. It
should be held when the systolic blood pressure is <90 mm Hg.
Perfusion to the kidneys is inadequate if the systolic blood pressure
is <80 mm Hg. Because the pressure is so low, the nurse does not
want to lower it further by giving the drug.
Client with depression stopped phenelzine yesterday;

escitalopram given today
NEEDS INCIDENT REPORT. Selective serotonin reuptake

inhibitors (SSRIs) (eg, escitalopram) cannot be combined with
monoamine oxidase inhibitors (MAOIs) (eg, phenelzine) as there is
a risk of serotonin syndrome. MAOI effects persist long after dosing
stops. An MAOI should be withdrawn at least 14 days before starting
an SSRI.
Client with pulmonary embolism and International Normalized

Ratio (INR) of 2.5; warfarin given
DOES NOT NEED INCIDENT REPORT. The effect of warfarin

(Coumadin) is monitored by the INR. The therapeutic range of INR is
2-3. This result indicates that the current dosing is achieving the
desired effect.
1,206. A nurse cares for a client on life support who has been
declared brain dead. Which intervention is appropriate at this time?
Call the local organ procurement services representative

Local organ procurement services (OPS) are notified for every
client death, per hospital protocol. If the client is deemed appropriate
as a donor, then OPS collaborate with hospital staff in approaching the
client's family about organ donation.
Cardiac support (eg, dopamine, epinephrine) and respiratory
support (eg, ventilator) continue as organ donation is discussed
and/or performed. Life support is withdrawn only if the client is not a
candidate for donation due to physiological reasons or the
client/family does not consent.
Ask the family members about their plans for the funeral service
WRONG. Organ donation is discussed before final arrangements

and funeral plans are made. In most cases, the family is referred to the
hospital chaplain or someone outside the hospital for assistance with
final arrangements.
Discontinue nursing care and provide postmortem care
WRONG. Medical and nursing care would continue as organ donation

is discussed due to organ and tissue perfusion being necessary for
viable donation.
Remove life support as requested by the spouse and family
WRONG. Local OPS (Organ Procurement Services) are contacted

before life support is removed so that physiological support is
continued in the event that the client is a viable donor.
1,210. The emergency department nurse cares for a client with
multiple bruises, a possible arm fracture, and a facial laceration.
The client's spouse is at the bedside and appears angry. Which
action is the priority at this time?
Call social services to assist the client in community resources

for domestic violence victims
WRONG. Notifying social services of suspected abuse should occur

with the client's permission after any immediate threats are removed
and after physiological needs are met. This should not be done in the
presence of any potential abusers.
Clean the facial laceration and prepare to assist the health care
provider with suture placement
WRONG. Cleaning the laceration and preparing for sutures are

appropriate interventions but are done after a suspected abuser is
removed. The nurse also follows facility guidelines for documenting,
gathering evidence, and/or photographing injuries before cleaning and
further treatment.
Have the spouse leave the room so that the client can be spoken
with and examined in private
CORRECT. The priority for possible domestic abuse victims is
to remove them from any sources of immediate danger, including
suspected abusers. Such clients should be questioned and assessed
alone so that the suspected abusers do not guide their answers or
intimidate them from providing truthful responses. In this case, the
spouse appears angry and should, as a priority, be removed from the
room to prevent further potential harm to the client or staff
1,213. There has been a major community disaster. Stable clients
need to be discharged to make more beds available for the victims.
Which clients could be discharged safely?
Diagnosed with endocarditis on antibiotics with a peripherally

inserted central catheter (PICC) line
CORRECT. The long-term antibiotic course (and follow-up lab work)

can continue at home through the PICC line
History of multiple sclerosis with ataxia and diplopia
CORRECT. Ataxia and diplopia are expected signs/symptoms of

multiple sclerosis.
One day postoperative from a hemicolectomy
WRONG. Large intestine peristalsis does not return for up to 3-5

days. The client cannot be discharged until able to tolerate oral
intake with normal elimination. The client has to at least be passing
flatus.
Reporting abdominal pain with coffee ground emesis
WRONG. Coffee ground emesis indicates upper gastrointestinal

bleeding. The etiology and treatment need to be determined before
the client is discharged.
Taking warfarin with prothrombin time/International Normalized

Ratio of 2x control value
CORRECT. Two times the control value demonstrates that warfarin

has reached a therapeutic level.
1,218. The health care provider is starting an elderly client on terazosin to treat
benign prostatic hyperplasia (BPH). Which information should be included when
teaching this client about the new medication?
Change positions slowly when going from lying to standing

CORRECT. Terazosin is an alpha-adrenergic blocker that can relieve urinary
retention in clients with BPH. It relaxes the smooth muscle in the bladder neck
and prostate gland; however, it also relaxes smooth muscle in the peripheral
vasculature, which can cause orthostatic hypotension, syncope (blacking out),
and falls. This is particularly common when the drug is started (first-dose
hypotension) or when the dosage is increased. The serious effects can be avoided
by instructing the client to take the medication at bedtime, change positions
slowly when going from lying to standing, and avoid any medications that also
increase smooth muscle relaxation (eg, phosphodiesterase-5 inhibitors [sildenafil
or vardenafil] used to treat erectile dysfunction). Some clients may also
experience ejaculatory dysfunction (decreased or absent ejaculation).
1,219. The health care provider is starting an elderly client on
terazosin to treat benign prostatic hyperplasia (BPH). Which
information should be included when teaching this client about the
new medication?
Do not drink grapefruit juice when taking this drug
WRONG. Grapefruit juice can cause significant interactions with

drugs such as calcium channel blockers and sildenafil.
However, it does not appear to interact with alpha blockers
such as terazosin.
1,220.The health care provider is starting an elderly client on terazosin
to treat benign prostatic hyperplasia (BPH). Which information
should be included when teaching this client about the new
medication?
Take this medication first thing in the morning, before breakfast
WRONG. Alpha-1-adrenergic antagonists (eg, terazosin,

doxazosin, tamsulosin, alfuzosin) should be taken at bedtime, not in
the morning, to avoid orthostatic hypotension.
1,221. The health care provider is starting an elderly client on
terazosin to treat benign prostatic hyperplasia (BPH). Which
information should be included when teaching this client about the
new medication?
Your stool may become darker and that's normal
WRONG. Oral iron tablets and bismuth salts (Pepto-Bismol) can

turn stools dark, an expected side effect. This can be confused with
upper gastrointestinal bleeding, which can also cause melena.
1,222. The nurse is drawing a blood specimen from a client's central
line. Identify the steps necessary to prevent transmission of
infection while performing this procedure.
Discard the first 6-10 mL of blood drawn from the line
WRONG. When drawing a blood specimen from a central line, the

nurse should discard the first blood drawn to prevent an inaccurate
lab result, but this will not prevent the transmission of infection.
Flush the line with sterile normal saline before and after collection
WRONG. Flushing the line prior to specimen collection will clear any
previous infusions and assist in checking patency. It is important to
flush the line after collection to remove blood and prevent clotting.
Neither action prevents infection transmission.
Place the specimen in a biohazard bag
CORRECT. Blood and bodily fluids are considered hazardous

materials and must be placed in containers identifying them as
biohazards (eg, biohazard bag)
1,225. The nurse is assigned to the following clients. Which client
does the nurse assess/identify as being at greatest risk for the
development of a deep venous thrombosis (DVT)?
An 80-year-old client who is 4 days postoperative from repair of a

fractured hip
CORRECT. The 80-year-old 4-day postoperative client has the most

risk factors: orthopedic hip surgery, prolonged period of
immobility/inactivity, and advanced age, and is at greatest risk for
developing a DVT.
A 25-year-old client with abdominal pain who smokes cigarettes

and takes oral contraceptives
WRONG. Smoking cigarettes and using oral contraceptives increase

plasma fibrinogen and coagulation factors and cause
hypercoagulability of blood, but the client is not at greatest risk.
Hormonal contraceptives are not recommended if the client is age >35
and also smokes.
A 55-year-old ambulatory client with exacerbation of chronic

bronchitis and hematocrit of 56%
WRONG. Elevated hemoglobin/hematocrit level (erythrocytosis)

causes increased blood viscosity and hypercoagulability of blood,
which increases the risk for DVT. However, the client is not at
greatest risk.
1,128. A student nurse is preparing to administer the hepatitis B
vaccine to a newborn. Which statement by the student nurse
requires the preceptor to provide further teaching?
"The medication should be administered into the deltoid muscle.“
FURTHER TEACHING. Intramuscular (IM) injections (eg, hepatitis

B vaccine, vitamin K) are commonly administered
to newborns shortly after birth or before discharge. The vastus
lateralis muscle in the anterolateral middle portion of the thigh is
the preferred site for IM injections in newborns (age <1 month) and
infants (age 1-12 months). The deltoid muscle is an inappropriate
injection site for newborns due to inadequate muscle mass
1,229. A student nurse is preparing to administer the hepatitis B
vaccine to a newborn. Which statement by the student nurse
requires the preceptor to provide further teaching?
"A ⅝-inch, 25-gauge needle is appropriate for intramuscular

injection in newborns.“
DOES NOT NEED FURTHER TEACHING. For IM injections, the

needle length should be ⅝ inch for newborns and ⅝ to 1 inch for
infants; these lengths are adequate for reaching the muscle mass
while avoiding underlying tissues (eg, nerves, bone). A 22- to 25-
gauge needle is appropriate for clients age <12 months.
1,230. A client diagnosed with head and neck cancer has developed
mouth sores related to external radiation therapy. The nurse
teaches the client to use which of the following oral hygiene
practices?
Use palifermin as prescribed to alleviate oral pain
WRONG. Administration of palifermin (Kepivance), a recombinant

human keratinocyte growth factor, prevents oral mucositis in clients
diagnosed with hematologic malignancies. However, it does not help
with pain. Viscous lidocaine HCl (Xylocaine) alleviates the oral pain
caused by mucositis.
1,231. A client with mitral valve prolapse (MVP) has been
experiencing occasional palpitations, lightheadedness, and
dizziness. The health care provider prescribes a beta blocker. What
additional teaching should the nurse include for this client?
Stay well hydrated and avoid caffeine
CORRECT. Adopt healthy eating habits and avoid caffeine as it is a

stimulant and may exacerbate symptoms
Wear a medical alert bracelet
WRONG. There is no need for a medical alert bracelet. MVP is usually

a benign condition.
Ensure you receive antibiotics prior to dental work
WRONG. Although MVP may place the client at an increased risk for
infective endocarditis, there is no clinical evidence to support the
need for prophylactic antibiotics prior to dental procedures.
Antibiotic prophylaxis is indicated for clients who have prosthetic
valve replacement, repaired valves, or a history of infectious
endocarditis.
1,234. The nurse teaches a group of homeless community clients
preventive measures related to transmission of hepatitis A. Which of
these measures would the nurse teach as the priority precaution to
prevent transmission?
Wash hands after bowel movements and before eating

CORRECT. The transmission of hepatitis A occurs most commonly
through the fecal-oral route through poor hand hygiene and improper
food handling by infected persons. It is seen primarily in developing
countries. After infection, the hepatitis A virus reproduces in the liver
and is secreted in bile. Therefore, hand hygiene (especially after
toileting and before meals) is the most important intervention to reduce
the occurrence of hepatitis A infection
1,235. A nurse has completed teaching a client who is being
discharged on lithium for a bipolar disorder. Which statement by the
client indicates a need for further teaching?
"I should use ibuprofen for pain relief.“
FURTHER TEACHING. Lithium is cleared renally. Even a mild

change in kidney function (as seen in elderly clients) can cause serious
lithium toxicity. Therefore, drugs that decrease renal blood flow (eg,
NSAIDs) should be avoided. Acetaminophen would be a better choice
for pain relief
1,236. A client postpartum 3 days scheduled for discharge today was
given education about diaper changes yesterday. The client says to
the nurse, "I'm so glad you are here. I think my baby has a dirty
diaper. I can't change it as well as you can. Will you change my
baby's diaper for me?" What is the nurse's best response?
Suggest that the mother change the diaper as the nurse watches
This mother is still learning to care for the newborn. Therefore, letting
her change the diaper will allow the nurse to assess her diaper
changing skills and provide education as needed.
1,237. The nurse is preparing to administer
medications after assessing a client with a
myocardial infarction. Based on the
collected data, which of the following
prescribed medications are appropriate for
the nurse to administer?
Aspirin
CORRECT. Myocardial infarctions (MIs)
damage heart muscle and require
medications to improve heart function and
prevent reinfarction (eg, aspirin). Aspirin,
an antiplatelet agent, inhibits platelet
aggregation, prevents thrombus formation,
and reduces heart inflammation. Clients
without signs of bleeding or low platelet
levels may safely receive aspirin
1,338. The nurse is preparing to
administer medications after assessing a
client with a myocardial infarction.
Based on the collected data, which of the
following prescribed medications are
appropriate for the nurse to administer?
Atorvastatin
CORRECT. Atorvastatin is a lipid-
lowering medication given to clients to
lower cholesterol levels (ie, LDL
cholesterol), which reduces plaque and
reinfarction risk. However, statins may
cause rhabdomyolysis and require
monitoring for muscle weakness and
pain.
The nurse is preparing to administer
medications after assessing a client with
a myocardial infarction. Based on the
collected data, which of the following
prescribed medications are appropriate
for the nurse to administer?
Docusate sodium
CORRECT. Docusate sodium is a stool
softener that reduces straining during
bowel movements, thereby decreasing
the workload on the heart. Straining can
also cause bradycardia due to vagal
response
Lisinopril
CORRECT. Lisinopril is an ACE
inhibitor often prescribed to clients after
an MI to prevent ventricular
remodeling and progression of heart
failure. Lisinopril may cause
hyperkalemia and hypotension, and
should be administered only to clients
with normokalemia and normotension
Metoprolol
WRONG. Metoprolol is a beta blocker
prescribed to clients after MI to reduce
the risk of reinfarction and heart
failure. Metoprolol lowers blood
pressure and heart rate; therefore, the
nurse should hold the medication and
notify the health care provider of
hypotension or a heart rate <50/min.
1,242. The nurse is caring for a client with liver cirrhosis who was
admitted for cellulitis of the leg. Which assessments would the nurse
perform to determine if the client's condition has progressed to hepatic
encephalopathy?
Ask if the client knows what day it is
CORRECT. Clinical manifestations of HE range from sleep

disturbances (early) to lethargy and coma. Mental status is altered,
and clients are not oriented to time, place, or person
encephalopathy?
Ask the client to extend the arms
CORRECT. A characteristic clinical finding of HE is presence

of asterixis (flapping tremors of the hands). It is assessed by having
the client extend the arms and dorsiflex the wrists
Another sign is fetor hepaticus (musty, sweet odor of the breath) from
accumulated digestive byproducts.
encephalopathy?
Assess for telangiectasia (spider nevi)
WRONG. Spider angiomas (eg, small, dilated blood vessels with

bright red centers), gynecomastia, testicular atrophy, and palmar
erythema are expected findings in cirrhosis due to altered metabolism
of hormone in the liver.
encephalopathy?
Determine if the conjunctiva is jaundiced
WRONG. Jaundice occurs when bilirubin is 2-3 times the normal

value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis
due to increasing functional derangement. It is not related specifically
to encephalopathy.
encephalopathy?
Note amylase and lipase serum levels
WRONG. Amylase and lipase are enzymes from pancreatic tissue.

Alanine aminotransferase and aspartate aminotransferase are liver
enzymes. They would be elevated with hepatitis and are not unique to
cirrhosis or HE. Elevated ammonia levels would be more specific to
cirrhosis.
1,247. A client is diagnosed with diabetic ketoacidosis (DKA). The client reports
frequent urination, thirst, and weakness. The nurse assesses a temperature of
102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and
dry mucous membranes. What is the priority nursing diagnosis (ND) at this time?
Deficient fluid volume related to osmotic diuresis
CORRECT. DKA is a life-threatening emergency caused by a relative or absolute
insulin deficiency. The condition is characterized by hyperglycemia, ketosis,
metabolic acidosis, and dehydration. The most likely contributing factors in this
client include stress associated with illness and infection (elevated temperature) and
inadequate insulin dosage and self-management.
Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as
evidenced by dry mucous membranes and client report of frequent urination, thirst,
and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis,
dehydration, electrolyte imbalance, and possible hypovolemic shock and renal
failure. Therefore, this condition requires rapid correction through the infusion of
isotonic intravenous fluids and poses the greatest risk to the client's survival
1,248. A client is diagnosed with diabetic ketoacidosis (DKA). The
client reports frequent urination, thirst, and weakness. The nurse
assesses a temperature of 102.4 F (39.1 C), fruity breath, deep
labored respirations with a rate of 30/min, and dry mucous
membranes. What is the priority nursing diagnosis (ND) at this time?
Ineffective breathing pattern related to the presence of metabolic

acidosis
WRONG. Tachypnea and deep labored respirations (ie, Kussmaul) are

the body's attempt to eliminate excess acid (pCO2) through
hyperventilation and normalize the pH. However, it does not pose
the greatest risk to survival and is not the priority ND.
1,249. The nurse provides home care education to a client newly
diagnosed with von Willebrand disease. Which of the following client
statements demonstrate correct understanding of the education?
"I will take naproxen to decrease inflammation if I am injured.“
WRONG. Clients should avoid medications that can exacerbate

bleeding, including aspirin and NSAIDs (eg, ibuprofen, naproxen,
ketorolac). Clients should instead use the mnemonic RICE (rest, ice,
compression, elevation) to help with pain and inflammation.
1,250. The nurse is caring for a client at risk for aspiration
pneumonia due to a stroke. What nursing actions help prevent this
potential complication during hospitalization?
Add a thickening agent to the fluids
CORRECT. Thicken liquids (eg, to nectar or honey consistency) for

clients with dysphagia; thin liquids are more difficult to control
when swallowing
1,251. The nurse is caring for a client at risk for aspiration pneumonia
due to a stroke. What nursing actions help prevent this potential
complication during hospitalization?
Restrict visitors who show signs of illness
WRONG. Performing strict handwashing and limiting sick visitors are

important infection-control measures; however, they do not prevent
noninfectious aspiration pneumonia.
1,252. The nurse is caring for a client at risk for aspiration pneumonia
due to a stroke. What nursing actions help prevent this potential
complication during hospitalization?
Teach the client to flex the neck while swallowing
CORRECT. Encourage clients to facilitate swallowing by flexing the

neck (chin to chest)
1,253. The charge nurse on the telemetry unit is making client
assignments. Which client is appropriate to assign to the licensed
practical nurse
Client 2 days after aortic valve surgery who needs a urinary

catheter reinserted due to inability to void
CORRECT. The charge nurse should assign the most

stable and predictable client to the LPN. The client who needs to
have a urinary catheter reinserted is within the scope of practice
for the LPN.
practical nurse
Client being discharged after deep vein thrombosis who needs

teaching on how to self-administer enoxaparin injections
WRONG. The registered nurse (RN) is responsible for initial client

teaching. Teaching self-administration of enoxaparin can be complex
and should be done by the RN. The LPN can reinforce the teaching
done by the RN.
practical nurse
Client who has just been admitted to the telemetry unit from the
emergency department with a rule-out myocardial infarction
WRONG. The client being admitted from the emergency department

requires clinical assessment and clinical judgment, which should be
handled by the RN.
practical nurse
Client with a nitroglycerin infusion with prescription to titrate to

keep systolic blood pressure <150 mm Hg; currently is 110/62
mm Hg
WRONG. The client on nitroglycerin is complex and requires

titration of an intravenous medication; this client should be assigned to
an RN.
1,257. When no changes are made to the diet or prescribed insulin,
which client with type 1 diabetes mellitus does the nurse anticipate
having the highest risk of developing hypoglycemia?
29-year-old with new onset of influenza
WRONG. Clients with an acute illness (eg, influenza, cellulitis) are

more likely to experience hyperglycemia. Increased glucose levels
occur due to the physiological stress response caused by infection
40-year-old experienced cyclist who rides an extra 10 miles (16

km)
CORRECT. Aerobic exercise typically lowers blood glucose levels.

As muscles use up glucose, the liver is unable to produce enough
glucose to keep up with the demand. Even an experienced exerciser
should check blood glucose levels before, during, and after exercise,
and also carry a carbohydrate drink or snack in case of a hypoglycemic
episode
65-year-old with cellulitis of the right leg
WRONG. Clients with an acute illness (eg, influenza, cellulitis) are

more likely to experience hyperglycemia. Increased glucose levels
occur due to the physiological stress response caused by infection
72-year-old with emphysema who is taking prednisone
WRONG. Hyperglycemia is also a side effect of prednisone

1,261. Which issue would a unit quality improvement committee
address?
A 10% decrease in client satisfaction in the registration process
WRONG. The issues addressed by a unit quality improvement

committee should be related to standards and clinical factors
involving the specific unit rather than client perception.
address?
A nurse who made 3 medication errors in the past quarter
WRONG. Individual practice issues or concerns (eg, individual

performance, financial reimbursement) would be addressed by the
nurse's manager or appropriate hospital committee (eg, peer review
committee).
address?
An increase in catheter-associated urinary tract infections
CORRECT. A unit quality improvement committee assesses process
standards (guidelines, systems, and operations) and clinical
issues on a specific unit that affect delivery of client care and client
outcomes. The committee implements a process to improve
performance if the standards are not being met.
Examples requiring unit quality improvement include the following:
1.Medications prescribed STAT are not available in a timely manner
2.Catheter-associated bacterial infections are increasing within the
unit
address?
Staff perception of hospital laboratory personnel incivility
WRONG. Although workplace hostility can potentially affect staff

perceptions and performance, personnel issues should be addressed
by the specific department manager (eg, laboratory personnel
management) or human resources.
1,265. The nurse is providing discharge instructions to a 70-year-old
client newly diagnosed with heart failure who has a low literacy
level. What are some teaching strategies that the nurse can use for
this client?
Discourage the client from using the internet to look up health

information
WRONG. Older adults are using the internet in increasing numbers as

are clients with low literacy. Several organizations are developing and
promoting user-friendly websites. Society in general relies heavily
on web-based health information. It is important for the nurse to
teach the client and possibly supply a list of reputable sites for the
client to view.
1,266. The nurse is providing discharge instructions to a 70-year-old
client newly diagnosed with heart failure who has a low literacy
level. What are some teaching strategies that the nurse can use for
this client?
Have client watch a DVD about heart failure management
CORRECT. Professionally produced programs are beneficial as

they contain high quality visual content as well a delivery of auditory
content in lay person's language.
1,667. The spouse of a client with borderline personality disorder calls the clinic
and reports that the client has self-inflicted superficial lacerations to the arm. The
spouse tells the nurse, "When I prepare to travel for work, my spouse does this
to stop me from leaving. It's not an attempt of serious harm." What is
the best response by the nurse?
"Your spouse should be seen in the clinic today."
CORRECT. Borderline personality disorder (BPD) is a mental health disorder
characterized by unstable relationships and self-image, mood lability, excessive
anger, fear of abandonment, impulsive behaviors, and recurrent suicidal
behavior. Clients with BPD may use these behaviors to gain a response from
others when there is a real or perceived risk of abandonment from a significant other.
Clients with BPD may demonstrate years of benign suicidal threats and gestures
before committing suicide. Predicting a client's risk for completing suicide is difficult
due to the impulsive nature of the behavior. Any potentially suicidal behavior
must be taken seriously, and this client should be evaluated immediately to
assess for suicidal intent
1,268. The spouse of a client with borderline personality disorder
calls the clinic and reports that the client has self-inflicted superficial
lacerations to the arm. The spouse tells the nurse, "When I prepare
to travel for work, my spouse does this to stop me from leaving.
It's not an attempt of serious harm." What is the best response by
the nurse?
"Your spouse is most likely doing this to gain attention, so it is

best to ignore the behavior.“
WRONG. The priority is for the client to be evaluated at the clinic due
to the diagnosis and risk for suicide. The spouse's response to the
client's behavior can be discussed later.
1,269. Which meal should the nurse recommend for a pregnant client
at 13 weeks gestation?
Baked chicken, turnip greens, peanut butter cookie, and grape
juice
CORRECT. During pregnancy, it is important for the client to consume
a balanced diet with appropriate nutrients, vitamins, and minerals.
Foods containing folic acid, protein, whole grains, iron, and omega-
3 fatty acids are especially important. Due to the risk for bacterial
contamination (eg, Listeria, toxoplasmosis), pregnant clients
should avoid consuming unpasteurized milk
products, unwashed fruits and vegetables, deli meat and hot dogs
(unless heated until steaming hot), and raw fish/meat. They
should also avoid intake of fish high in mercury (eg, shark,
swordfish, king mackerel, tilefish).
Baked swordfish, fries, baked apples, and fat-free milk
WRONG. This meal contains swordfish, which is high in mercury

and should be avoided during pregnancy.
Chilled ham and cheese sandwich, broccoli, orange slices, and

water
WRONG. This meal contains cold deli meat, which should be avoided
during pregnancy due to the risk of listeriosis from Listeria
monocytogenes.
Fried liver and onions, pasteurized cheese squares, fresh fruit

cup, and water
WRONG. Liver should be avoided during pregnancy due to high

amounts of vitamin A. Although liver is a good source of iron, the
excessively high amounts of vitamin A can be teratogenic.
1,273. The nurse is caring for a 4-year-old client with cystic fibrosis
who uses a high-frequency chest wall oscillation (HFCWO) vest for
chest physiotherapy. After reinforcing education with the client's
parents, which statement by a parent requires further teaching?
"I will allow my child to have a snack while using the HFCWO vest
to encourage cooperation.“
FURTHER TEACHING. The HFCWO vest's rapid

vibrations may induce nausea and vomiting in some clients.
Therefore, the client should avoid meals and snacks 1 hour
before, during, or 2 hours following CPT to prevent gastrointestinal
upset
1,274. The nurse is caring for a 4-year-old client with cystic fibrosis
who uses a high-frequency chest wall oscillation (HFCWO) vest for
chest physiotherapy. After reinforcing education with the client's
parents, which statement by a parent requires further teaching?
"I will give my child the nebulized bronchodilator treatment during

therapy with the HFCWO vest.“
DOES NOT NEED FURTHER TEACHING. Nebulized bronchodilators

are often given before or during CPT treatments to open the airways
and mobilize secretions.
1,275. A postoperative client is prescribed IV patient-controlled
analgesia (PCA) with morphine. The client tells the nurse, "I am
pushing the button, but I'm still having a lot of pain." What is
the priority nursing action?
Perform a thorough pain assessment
CORRECT. When providing care for a client prescribed IV PCA, the
nurse assesses pain on a regular and as-needed basis. The client's
self-report is considered to be the most reliable indicator of pain, so
the priority nursing action is to perform a thorough pain
assessment to determine the cause of worsening/continuous pain
despite the medication. This includes location, quality, radiation,
severity, and associated factors (eg, nausea, diaphoresis) for the
severe pain. The assessment data will guide the nurse's subsequent
interventions
Administer a bolus dose
WRONG. An IV PCA bolus is an extra, as-needed dose of analgesia

(eg, 1-2 mg) for increased pain (eg, before a painful procedure) that is
prescribed by the HCP when the PCA is initiated. If needed, the
nurse programs the pump to deliver the bolus dose because no one
but the client is permitted to push the button. However, this is not
the priority action.
Notify the health care provider (HCP) to request a higher dose
WRONG. If the client's attempts are twice the number of doses

actually delivered and adequate pain relief is not achieved, the nurse
would notify the HCP to request a dose increase or shorter dose
interval. However, this is done after the pain assessment.
Reinforce the proper use of the IV PCA pump
WRONG. The client learns how to use the IV PCA pump when it is
initiated. The nurse should reassess the client's knowledge level
regarding proper use and reinforce previous teaching. However, it is
not the priority intervention.
1,279. A nurse is caring for a homeless client who is moderately
malnourished and suffering from pneumonia. The client needs a
peripheral IV line for fluid administration. Which IV site should the
nurse select to reduce the risk for infection?
Dorsal surface of hand
CORRECT. Clients most at risk for catheter-related bloodstream
infections are those with compromised immune systems; therefore,
this client is at high risk. The IV site chosen for catheter insertion can
influence the infection risk. The risk is higher using the lower
extremities compared to the upper extremities and using the wrist or
upper arm compared to the hand. Unless the client is very old or
very young, the hand is a good site as it is most distal, allowing
future sites to be selected higher on the arm if needed.
Antecubital fossa
WRONG. The antecubital fossa is commonly selected in emergency

situations due to its size and ease of cannulation but is problem
prone for longer-term needs as it is in the bend of the elbow. Bending
of the arm can move the catheter, causing irritation at the insertion site
and increasing infection risk.
Dorsum of foot
WRONG. The foot is not typically accessed in adults without a

specific health care provider prescription. It is occasionally used in
emergency situations; however, veins in the legs and feet may have
decreased venous return, and complications can lead to
thrombophlebitis or deep vein thrombosis.
Lateral surface of wrist
WRONG. The radial vein is present on the lateral side of the wrist but
is in close proximity to several nerves, which could cause severe
pain or nerve damage.
1,283. The nurse is caring for a client with chronic, stable angina.
The client takes the long-acting nitrate isosorbide mononitrate.
Which client outcome indicates that the drug is effective?
Client is able to shower, dress, and fix hair without any chest pain
CORRECT. Long-acting nitrates are used to reduce the incidence of

anginal attacks. Nitrates are effective if the client is able to do
activities without the incidence of chest pain. The client should be
taught to report any increase in chest pain and how to manage
headaches, a common side effect of nitrates.
Client reports a reduction in stress level and anxiety
WRONG. A reduction in stress level and anxiety, and being able to

sleep through the night are positive outcomes for any client with
cardiovascular disease. However, these outcomes are not directly
related to long-acting nitrate use.
Client reports being able to sleep through the night
WRONG. A reduction in stress level and anxiety, and being able to

sleep through the night are positive outcomes for any client with
cardiovascular disease. However, these outcomes are not directly
related to long-acting nitrate use.
Client's blood pressure is 128/78 mm Hg and heart rate is 82/min
WRONG. Nitrates are vasodilators and may decrease the client's

blood pressure, which is a positive outcome but not the primary
reason for taking the medication. This client is taking the medication
for angina.
1,287. The nurse is caring for a client with a feeding tube that has
become obstructed. Which intervention should the nurse
implement first to unclog the tube?
Flush and aspirate the tube with warm water

Enteral feeding tubes are more likely to become obstructed if the tube
is not flushed frequently enough, medications are not adequately
crushed or diluted before administration, a thick feeding formula is
used, or a small-bore feeding tube is required. Interventions
to unclog a feeding tube are more successful if they are initiated
immediately. The nurse should first attempt to dislodge the clogged
contents by using a large-barrel syringe to flush and aspirate warm
water in a back-and-forth motion through the tube
Instill a digestive enzyme solution into the tube
WRONG. If a feeding tube cannot be unclogged with warm water, the

nurse may then attempt to use a digestive enzyme solution. These
commercial declogging kits contain prefilled syringes of enzymatic
solution that must be added to the tube and dwell in it for a period of
time (usually 30 minutes to 1 hour) before flushing and aspiration
are attempted.
Use a small-barrel syringe to flush the tube
WRONG. Flushing a feeding tube with a small-barrel syringe can

create too much pressure and rupture the tube.
1,290. Which actions should the labor and delivery nurse perform
when caring for a client who has decided to relinquish her newborn
to an adoptive parent?
Avoid discussing the adoption details until after the birth
WRONG. Avoiding discussion of adoption details until after the birth

inhibits the nurse's ability to plan care that respects the birth
mother's wishes for interaction with the newborn and/or involvement
of the adoptive parents in the birth process. Acknowledging the
adoption plan early in the plan of care encourages the client to express
emotions and be involved in decision-making.
1,291. Which actions should the labor and delivery nurse perform when
caring for a client who has decided to relinquish her newborn to an
adoptive parent?
Notify other staff who may interact with the client of the adoption
plan
CORRECT. The nurse protects the client by notifying relevant staff of

the decision, which prevents unintended, potentially hurtful
remarks
1,292. In the emergency department, a pediatric client is placed on
mechanical ventilation by means of an endotracheal tube. Several
hours later, the nurse enters the room and finds the client in
respiratory distress. It is most important for the nurse to take which
of these actions?
Auscultate the client's lung sounds

A client experiencing respiratory distress while receiving mechanical
ventilation should be assessed for proper ventilation first. The nurse
needs to determine if the mechanical ventilation equipment is still
properly placed in the trachea. An endotracheal tube (ET) can become
displaced with movement. By assessing the client's lung sounds, the
nurse can quickly determine if ET placement has been
compromised
1,293. The nurse is caring for a client with a chest tube to evacuate a
hemopneumothorax after a motor vehicle accident. The drainage has
been consistently 25-50 mL/hr for the majority of the shift. However,
over the past 2 hours there has been no drainage. Which actions
should the nurse take?
Auscultate breath sounds
CORRECT. When chest drainage stops abruptly, the nurse must

perform assessments and interventions to ascertain if this is an
expected finding. Auscultating breath sounds helps the nurse detect
whether breath sounds are audible in all lung fields, potentially
indicating that the lung has re-expanded and there is no more
drainage.
Increase amount of suction

WRONG. A change in suction level should be performed only after
obtaining a health care provider (HCP) prescription. The nurse
should perform the assessment of breath sounds, coughing and deep
breathing, and client repositioning before notifying the HCP about a
change in suction level. In general, suction above 20 cm H2O is not
indicated.
Instruct client to cough and deep breathe
CORRECT. Other interventions to facilitate drainage include having the

client cough and deep breathe and repositioning the client . If a
client has been in one position for a prolonged period, drainage may
accumulate and a position change may facilitate improved drainage.
Reposition the client
CORRECT. Other interventions to facilitate drainage include having the

client cough and deep breathe and repositioning the client . If a
client has been in one position for a prolonged period, drainage may
accumulate and a position change may facilitate improved drainage.
Milk the chest tube
WRONG. Milking chest tubes to maintain patency is performed only if

prescribed. It is generally contraindicated due to potential tissue
damage from highly increased pressure changes in the pleural space.
1,298. Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation
warrants the nurse's intervention first?
1. Room 1: Client on a 24-hour urine collection had a specimen discarded by mistake
If any urine is discarded by accident during a 24-hour collection test, the procedure must be
restarted. A new container will need to be labeled with the appropriate times and date, but
immediate intervention is not required.
2. Room 2: Client and family request clergy to administer last rites
The nurse will arrange for a visit from clergy to administer the last rites (Sacrament of the Sick), a
religious ceremony for Roman Catholic clients who are extremely or terminally ill. Although the
situation requires prompt intervention, it does not involve a safety hazard.
3. Room 3: Puncture-resistant sharps disposal container on the wall is full
PRIORITY. Health care workers are required to abide by Occupational Safety and Health
Administration standards and regulations to reduce work-related injuries (eg, sharps) and
exposure to bloodborne pathogens (eg, HIV, hepatitis B and C). A sharps disposal container
should not be overfilled and should be replaced on a regular basis to reduce the risk for a
needle stick during disposal.
4. Room 4: Client with diabetes mellitus has an 8 AM fingerstick glucose of 80 mg/dL (4.4
mmol/L)
A fingerstick glucose of 80 mg/dL (4.4 mmol/L) is normal (70-110 mg/dL [3.9-6.1 mmol/L]) and
requires no intervention unless the client received insulin and refuses or is unable to eat.
1,299. The nurse is teaching a 9-year-old child with asthma how to use
a metered-dose inhaler (MDI). Place the instructions in
the appropriate order.
1,300. The school nurse assesses an 8-year-old with a history of asthma. The nurse
notes mild wheezing and coughing. Which action should the nurse perform first?
Assess the client's peak expiratory flow

Symptoms of an asthma exacerbation include wheezing, chest tightness, dyspnea,
cough (may be nocturnal, dry, or productive), and retractions. A cough is often the
earliest sign of an asthma exacerbation in children. Bronchospasm leads to
CO2 trapping and retention. The bronchospasm forces the client to work harder to
exhale and the expiratory phase becomes prolonged.
The nurse needs to further assess this client to validate the severity of the
exacerbation before implementing an intervention. By assessing the client's peak
expiratory flow, the nurse can determine the severity of the symptoms. The nurse
will also need to assess the client's respiratory rate and lung sounds.
1,301. The nurse is counseling a client with obesity who is starting a
weight reduction diet. The client reports consuming 4-5 regular cola
beverages daily. Which of the following beverages should the nurse
recommend as healthier substitutes?
Flavored club soda
CORRECT.
1,302. LIVE VACCINES
1. varicella-zoster vaccine
2. measles-mumps-rubella
3. Rotavirus
4. yellow fever
1,303. Several 12-month-old infants are brought to the clinic for
routine immunizations. Which situation would be most important for
the nurse to clarify with the provider before administering the
vaccination?
Varicella-zoster vaccine for client recently diagnosed with

leukemia
CLARIFY. Severely immunocompromised children (eg, corticosteroid

therapy, chemotherapy, AIDS) generally should not receive live
vaccines (eg, varicella-zoster vaccine, measles-mumps-rubella,
rotavirus, yellow fever)
vaccination?
Haemophilus influenzae type b vaccine for client allergic to
penicillin
NO NEED TO CLARIFY. Common misperceptions of
contraindications to immunization:
 Penicillin allergy
 Mild illness (with or without an elevated temperature)
 Mild site reactions (eg, swelling, erythema, soreness)
 Recent infection exposure
 Current course of antibiotics
vaccination?
Hepatitis A vaccine for a client with a "cold" and temperature of
99.0 F
vaccination?
Pneumococcal vaccine for client with local swelling after last
immunization
1,307. The nurse receives report for clients on the neurology floor. Which client is important for the
nurse to assess first?
1. A 25-year-old client with multiple sclerosis who had bladder incontinence last night
Bowel and/or bladder incontinence or retention is an expected sign/symptom in clients with multiple
sclerosis.
2. A 37-year-old client with Guillain-Barré syndrome who has "0" deep tendon patellar reflexes
Guillain-Barré syndrome is ascending bilateral paralysis from segmental demyelination (remyelination
eventually occurs). Normal deep tendon reflexes are 2+. Hypotonia (muscle weakness) and
areflexia (loss of reflexes) are common manifestations. The current level of paralysis is at the
knees and is therefore not the priority as it has not yet reached the diaphragm.
3. A 58-year-old client with Parkinson disease who is drooling
Drooling, lack of blinking, mask-like facial expressions, and lack of swinging arms with walking are
expected findings of Parkinson disease. This loss of autonomic movements results from alterations
of the basal ganglia and extrapyramidal portion of the central nervous system.
4. A 78-year-old client with dementia who has new-onset agitation and confusion
PRIORITY. New-onset agitation is a change in mental status for someone with dementia and requires
assessment. It is possible for a client to develop delirium in addition to dementia. Delirium is a sign
of a different issue, such as worsening infection/condition, fluid and electrolyte imbalance, or
drug-drug interaction.
1,308. The nurse evaluating a 52-year-old diabetic male client's
therapeutic response to rosuvastatin would notice changes in which
laboratory values?
Alanine aminotransferase from 20 U/L (0.33 µkat/L) to 80 U/L
WRONG. The adult therapeutic range of alanine aminotransferase

(ALT) is 10-40 U/L (0.17-0.68 µkat/L). Increased aspartate
aminotransferase (AST) and ALT may indicate hepatic dysfunction, a
potential adverse effect of statin medication.
laboratory values?
High-density lipoprotein cholesterol from 48 mg/dL (1.24 mmol/L)

to 30 mg/dL
WRONG. The therapeutic range of high-density lipoprotein (HDL)

cholesterol for adult men is >40 mg/dL (1.04 mmol/L). HDL is good
cholesterol. This client's HDL level is below the therapeutic range,
indicating a nontherapeutic response.
laboratory values?
Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L)
to 98 mg/dL
CORRECT. Statins (rosuvastatin, atorvastatin, simvastatin) are the
most preferred agents to reduce low-density lipoprotein
(LDL) cholesterol, total cholesterol, and triglyceride levels. This
client's LDL level has decreased to a target range, total cholesterol
has decreased to a normal range (adult <200 mg/dL [5.2 mmol/L]), and
triglyceride level has decreased to a normal range (adult <150 mg/dL
[1.7 mmol/L)); all these changes indicate a therapeutic response
laboratory values?
Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL

client's LDL level has decreased to a target range, total cholesterol
has decreased to a normal range (adult <200 mg/dL, and
triglyceride level has decreased to a normal range (adult <150 mg/dL
[1.7 mmol/L)); all these changes indicate a therapeutic response
laboratory values?
Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL

client's LDL level has decreased to a target range, total cholesterol has
decreased to a normal range (adult <200 mg/dL, and triglyceride level
has decreased to a normal range (adult <150 mg/dL); all these
changes indicate a therapeutic response
1,313. A client is being discharged after receiving an implantable cardioverter
defibrillator. Which statement by the client indicates that teaching has been
effective?
"I will let my daughter fix my hair until my health care provider says I can do it.“
CORRECT. An implantable cardioverter defibrillator (ICD) can sense and

defibrillate life-threatening dysrhythmias. It also includes pacemaker capabilities
such as overdrive pacing for rapid heart rhythms or back-up pacing for bradycardias
that may occur after defibrillation. The ICD consists of a lead system placed into the
endocardium via the subclavian vein. The pulse generator is implanted
subcutaneously over the pectoral muscle. Postoperative care and teaching are
similar to those for pacemaker implantation. Clients are instructed to refrain from
lifting the affected arm above the shoulder (until approved by the health care
provider) to prevent dislodgement of the lead wire on the endocardium
1,314. A client is being discharged after receiving an implantable
cardioverter defibrillator. Which statement by the client indicates
that teaching has been effective?
"I'm not worried about the device firing now because I know it
won't hurt."
WRONG. Firing of the ICD may be painful. Clients have described the
feeling as a blow to the chest.
"I will look into public transportation because I won't be able to

drive again.“
WRONG. Driving may be approved by the health care provider after

healing has occurred. Long-term decisions are based on the ongoing
presence of dysrhythmias, frequency of ICD firings, and state laws
regarding drivers with ICDs.
"I will notify my travel agent that I can no longer travel by plane.“
WRONG. Travel is not restricted. The ICD may set off the metal
detector in security areas. A hand-held wand may be used but should
not be held directly over the ICD. The client should carry the ICD
identification card and a list of medications while traveling.
1,317. The postpartum nurse is caring for a client 8 hours after an
uncomplicated cesarean birth. Which of the following interventions
should the nurse include in the client's plan of care to reduce the risk
of thrombus formation?
Administer analgesics as needed 30 minutes prior to ambulation
CORRECT. Promoting early and frequent ambulation by

ensuring adequate pain control (eg, administer analgesic 30 min
before activity)
Assist the client to ambulate starting on the third postoperative

day
WRONG. The nurse should have clients ambulate (with assistance) as

soon as possible after surgery (ie, usually on the first postoperative
day) if they are in stable condition and can support themselves while
standing.
Request a prescription for daily aspirin until the client is

discharged
WRONG. Anticoagulant therapy with heparin, not aspirin, is indicated

for postpartum DVT/PE prevention in clients with additional risk factors
(eg, history of DVT).
1,320. The home health nurse is providing care for a 6-year-old client who has a
tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm
sounds. The nurse finds the client to be unresponsive and pulseless, and there are
no other caregivers present. Which action should the nurse take first?
Begin chest compressions

Cardiac arrest is the sudden cessation of cardiac output that is usually caused by an
arrhythmia. Arrest can be precipitated by a variety of factors (eg, hypoxia, toxins,
electrolyte imbalance) and is a medical emergency. In children, cardiac arrest is
commonly caused by hypoxia and respiratory failure.
If the nurse is a single rescuer in a witnessed cardiac arrest of a pediatric client,
the first action is to promptly initiate CPR, starting with chest compressions. For the
pediatric client, initiating CPR before other interventions (eg, calling 911) helps
minimize risk for end organ damage and brain injury. The nurse should provide 30
chest compressions and 2 rescue breaths in each cycle of CPR.
1,321. A diabetic client is prescribed metoclopramide. Which of the following side effects must
the nurse teach the client to report immediately to the health care provider?
Excess blinking of eyes
REPORT IMMEDIATELY. Metoclopramide (Reglan) is prescribed for the treatment of delayed
gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. Similar to
antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse effects,
including tardive dyskinesia (TD). This is especially common in older adults with long-term use.
The client should call the health care provider immediately if TD symptoms develop, including
uncontrollable movements such as:
 Protruding and twisting of the tongue
 Lip smacking
 Puffing of cheeks
 Chewing movements
 Frowning or blinking of eyes
 Twisting fingers
 Twisted or rotated neck (torticollis)
1,322. A diabetic client is prescribed metoclopramide. Which of the following side effects
must the nurse teach the client to report immediately to the health care provider?
Lip smacking
REPORT IMMEDIATELY. Metoclopramide (Reglan) is prescribed for the treatment of
delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. Similar
to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse
effects, including tardive dyskinesia (TD). This is especially common in older adults with
long-term use. The client should call the health care provider immediately if TD symptoms
develop, including uncontrollable movements such as:
Protruding and twisting of the tongue
Lip smacking
Puffing of cheeks
Chewing movements
Frowning or blinking of eyes
Twisting fingers
Twisted or rotated neck (torticollis)
1,323. A diabetic client is prescribed metoclopramide. Which of the following side effects
must the nurse teach the client to report immediately to the health care provider?
Puffing of cheeks
REPORT IMMEDIATELY. Metoclopramide (Reglan) is prescribed for the treatment of
delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. Similar
to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse
effects, including tardive dyskinesia (TD). This is especially common in older adults with
long-term use. The client should call the health care provider immediately if TD symptoms
develop, including uncontrollable movements such as:
Protruding and twisting of the tongue
Lip smacking
Puffing of cheeks
Chewing movements
Frowning or blinking of eyes
Twisting fingers
Twisted or rotated neck (torticollis)
1,324. The nurse provides discharge instructions to a client at 14
weeks gestation who has received a prophylactic cervical cerclage.
Which client statement indicates an understanding of teaching?
"I need to be on bed rest for the duration of my pregnancy.“
WRONG. Bed rest is usually recommended for a few days after the
procedure. Long-term bed rest is individualized but uncommon and
increases the risk for complications (eg, deep vein thrombosis). Pelvic
rest (eg, avoiding sexual intercourse) is determined by the health care
provider.
"I will notify my health care provider if I start having low back
aches.“
CORRECT. Discharge instructions include activity restriction and

recognition of signs of preterm labor (eg, low back aches,
contractions, pelvic pressure) and rupture of membranes
"Pelvic pressure is to be expected after cerclage placement."
WRONG. Mild abdominal cramping following cerclage placement is

common; however, regular contractions, pelvic pressure, and low
back aches may indicate preterm labor.
"The cerclage will be removed once my baby is at 28 weeks.“
WRONG.The cerclage remains in place until 36–37 weeks gestation.

Early removal is indicated by rupture of membranes (to prevent
infection) or preterm labor (to prevent damage to the cervix as it
dilates).
1,328. The nurse working in an intensive care unit cares for a client with a left triple
lumen subclavian central venous catheter (CVC). The nurse should call the
primary health care provider (HCP) for clarification prior to implementation when
recognizing that which prescription is an error?
Flush unused lumens of the CVC with 1000 units heparin every 12 hours
CLARIFY. Most CVC lumens require anticoagulation in the form of a heparin flush to
maintain patency and prevent clotting when not in use. The nurse should check the
institution's protocol and the HCP prescription to determine the correct dose. Doses
of 2–3 mL containing 10 units/mL–100 units/mL are the standard of care for
flushing a CVC. Doses of 1000–10,000 units are given for cases of venous
thromboembolism; therefore, this prescription is an error and should be clarified
by the nurse. The Centers for Disease Control and Prevention (CDC) recommend
that a single-dose vial or prefilled syringe be used to reduce infection risk. Heparin is
a high-alert medication (at high risk for causing significant harm to the client if given
in error).
1,329. The nurse working in an intensive care unit cares for a client
with a left triple lumen subclavian central venous catheter (CVC).
The nurse should call the primary health care provider (HCP) for
clarification prior to implementation when recognizing that which
prescription is an error?
Administer intravenous (IV) total parenteral nutrition (TPN) at 50

mL/hr
NO NEED TO CLARIFY. TPN should be administered through a CVC.

Because of its viscosity and high glucose, lipids, electrolytes,
vitamins and minerals, it is safest when administered through a
CVC or peripherally inserted central catheter.
Change occlusive central line dressing every 7 days
NO NEED TO CLARIFY. According to the CDC, an occlusive

dressing should be changed every 7 days. The nurse should check
the institution's protocol for frequency of dressing changes.
Use distal port of CVC to monitor central venous pressure (CVP)
NO NEED TO CLARIFY. The distal port of a triple lumen CVC is the

largest lumen (tube) and should be used for CVP (right atrium
pressure) monitoring. The distal end of the CVC is in reverse as
regards the client; therefore, the distal end is at the tip of the catheter in
the superior vena cava vein, closest to the right atrium of the heart.
1,332. The nurse is answering questions at a hospital-sponsored
health fair. What actions should the nurse encourage to help prevent
contracting the West Nile virus?
Use insect (mosquito) repellent
CORRECT. West Nile virus is a mosquito-borne disease

(encephalitis) that occurs mainly during the summer months,
especially during humid weather. Prevention focuses on avoiding
mosquitoes and using an insect repellent. Prevention also includes
wearing long sleeves, long pants, and light colors and avoiding outdoor
activities at dawn and dusk when mosquitoes are most active
Wear long-sleeved, light-colored clothes
CORRECT. West Nile virus is a mosquito-borne disease

(encephalitis) that occurs mainly during the summer months,
especially during humid weather. Prevention focuses on avoiding
mosquitoes and using an insect repellent. Prevention also includes
wearing long sleeves, long pants, and light colors and avoiding outdoor
activities at dawn and dusk when mosquitoes are most active
Avoid raw, unpeeled fruits or vegetables
WRONG. Food and water precautions are emphasized for infectious

diseases contracted through contaminated water or food, such as
hepatitis A or typhoid (enteric) fever.
Limit contact with infected pets
WRONG. Limiting contact with infected pets is classic advice for

avoiding ringworm, a superficial fungal skin infection.
Wash all bedding in hot water
WRONG. Washing bedding in hot water is a classic instruction to help

reduce allergies/asthma (eg, commonly from mites) or scabies (a
contagious skin infection caused by mites).
1,337. The nurse is teaching a client to self-administer enoxaparin subcutaneously for the outpatient
treatment of deep-vein thrombosis (DVT). The client points to the site of planned injection. Which site
indicates that the client understands the instructions?
1,338. The nurse admits a client with newly diagnosed unstable
angina. Which information obtained during the admission health
history is most important for the nurse to report to the health care
provider (HCP) immediately?
Uses sildenafil occasionally
CORRECT. Sildenafil (Viagra) is a phosphodiesterase inhibitor used
to treat erectile dysfunction. The use of sildenafil is most important
for the nurse to report to the HCP. This must be communicated
immediately as concurrent use of nitrate drugs (commonly prescribed
to treat unstable angina) is contraindicated as it can cause life-
threatening hypotension. Before any nitrate drugs can be
administered, further action is necessary to determine when
sildenafil was taken last (ie, half-life is about 4 hours).
1,339. The nurse in a women's health clinic is returning client phone calls. Which client would be the
priority to call first?
1. Client 4 days post cesarean delivery who has not had a bowel movement since surgery
Post-surgical constipation is caused by narcotic and anesthetic administration, decreased ambulation,
and manipulation of the bowels during surgery. Fluids, fiber, ambulation, and stool softeners should
be encouraged. Absence of flatus or associated nausea/vomiting would be more concerning. This is
not an emergent issue; this client would be called third.
2. Client who gave birth vaginally a few days ago who states, "They want to hurt my baby."
PRIORITY. Postpartum psychosis is a rare but serious perinatal mood disorder. Signs appear
within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood
changes, delirium, and feelings that someone will harm the baby. Postpartum psychosis is
a psychiatric emergency requiring hospitalization, pharmacologic intervention, and long-term
supportive care. Women exhibiting signs of postpartum psychosis are at increased risk of suicide and
infanticide, and their assessment should take priority to ensure the safety of mother and baby.
3. Client who gave birth vaginally recently who states, "I think I am experiencing
incontinence."
Urinary incontinence can occur after vaginal birth due to neuromuscular trauma and can improve
with pelvic floor exercises. This client would be called last.
4. Client's spouse who is concerned that the client wants to sleep instead of care for the baby
Fatigue is common with a new baby. However, sleeping too much might indicate postpartum
depression. The nurse should call this client second for further assessment.
1,340. The nurse is documenting assessments of pregnant clients in the antepartum
unit. Which client's assessment findings are most important to report to the health
care provider?
Client at 35 weeks gestation with painful genital lesions
REPORT. Painful genital lesions can be indicative of an outbreak of genital herpes

simplex virus (HSV) and are a priority assessment finding to report to the health
care provider. Herpes in pregnant women can be transmitted to the infant in utero
(congenital HSV), perinatally, or postnatally as a result of direct contact with virus
particles shed from the infected vulva, vagina, cervix, or perineum. Neonatal
HSV infection has serious morbidity (eg, permanent neurologic sequelae)
and mortality. Immediate antiviral therapy (eg, acyclovir) should be initiated to treat
the active infection. Vaginal birth is not recommended in the presence of active
lesions; cesarean birth helps reduce the risk of transmission to the newborn
1,341. The nurse is documenting assessments of pregnant clients in
the antepartum unit. Which client's assessment findings
are most important to report to the health care provider?
Client at 28 weeks gestation with an asymptomatic systolic

murmur
NO NEED TO REPORT. A systolic murmur (swooshing sound heard

during S1) is a common finding in pregnancy. It results from
increased total body volume (flow murmur) and usually resolves after
birth. No further intervention is necessary if the client is
asymptomatic.
1,142. The nurse is documenting assessments of pregnant clients in
the antepartum unit. Which client's assessment findings
are most important to report to the health care provider?
Client at 39 weeks gestation with brownish, mucoid vaginal

discharge
NO NEED TO REPORT. Vaginal discharge increases at the end of

pregnancy and may become mucoid and blood-tinged
(pink/brownish) in the days preceding labor. This assessment finding
may be a sign of approaching labor in this client at term gestation
(39 weeks), but it is not the priority to report to the health care
provider.
1,143. The nurse is preparing to administer a scheduled dose of
metoclopramide IV to a client with diabetic gastroparesis. Which
clinical finding causes the nurse to question the prescription?
Sucking lip motions
QUESTION PRESCRIPTION. Metoclopramide is a commonly used

antiemetic medication that treats nausea, vomiting, and gastroparesis
by increasing gastrointestinal motility and promoting stomach
emptying. With extended use and/or high doses, metoclopramide may
lead to the development of tardive dyskinesia, a movement disorder
that is characterized by uncontrollable motions (eg,
sucking/smacking lip motions) and is often irreversible
1,344. The health care provider prescribes 2 mEq (2 mmol)/kg of 8.4%
sodium bicarbonate IV to be administered over the next 4 hours. The
client weighs 150 lb, and the pharmacy supplies the following IV
solution: 8.4% sodium bicarbonate in 1000 mL of D5W with 150 mEq
(150 mmol) of sodium bicarbonate. At what rate in milliliters per hour
(mL/hr) should the nurse set the infusion pump? Record your answer
using a whole number.
227 mL/hour
1,345. A 2-month-old infant has been admitted to the hospital with suspected shaken
baby syndrome (abusive head trauma). In reviewing the infant's chart, the nurse
expects to encounter which of these clinical findings?
Irritability and vomiting

Shaken baby syndrome (SBS) is a type of abusive head injury and is defined by the
Centers for Disease Control and Prevention (CDC) as severe physical child abuse
resulting from violent shaking of an infant by the arms, legs, or shoulders. The
impact of the shaking causes bleeding within the brain or the eyes.
It is not uncommon for the diagnosis of SBS to be missed as the clinical findings are
often vague and nonspecific—vomiting, irritability, lethargy, inability to suck or
eat, seizures, and inconsolable crying. Usually, there are no external signs of
trauma except for occasional small bruises on the chest or upper arms where the
child was held during the shaking episode.
1,346. The nurse has just received report. Which client should the nurse assess first?
1. Client admitted from coronary angiography in the past hour with back pain
PRIORITY. The first hour after cardiac catheterization requires assessment every 15 minutes. Any report
of back or flank pain should be assessed for possible retroperitoneal bleeding as back pain,
tachycardia, and hypotension may be the only indication of internal bleeding. More than a liter of blood
can pool behind the peritoneum in the pelvis undetected, and it may take up to 12 hours before a
significant drop in hematocrit can be measured. Internal bleeding after cardiac catheterization is
particularly dangerous due to frequent use of anticoagulant prescriptions in these clients.
2. Client with a deep vein thrombosis (DVT) on heparin drip at 1250 units/hr with an activated
partial thromboplastin time (aPTT) of 60 seconds
A heparin infusion is used for a client with DVT. An aPTT of 60 indicates a therapeutic value. The
therapeutic range for a client on anticoagulation is usually 46-70 seconds (1½ -2 times the normal value).
3. Client with a head injury and a Glasgow Coma Scale of 14
This client should be evaluated hourly for any change in neurological status. However, because the
highest possible score on the Glasgow Coma Scale is 15 for a fully alert person, a client with a score of 14
is not in need of urgent reassessment.
4. Postoperative day 2 coronary artery bypass graft client with incisional pain rated 6 on pain scale
The report of incisional pain on postoperative day 2 would take second priority for further assessment,
but evaluating a client with possible internal bleeding takes priority.
1,347. A client with primary hypothyroidism has been taking levothyroxine for a
year. Laboratory results today show high levels of TSH. Which statement by the
nurse to the client is appropriate?
"Dosages of levothyroxine may need to be increased to improve TSH levels."

CORRECT. Thyroid-stimulating hormone (TSH) is released from the pituitary gland
to stimulate the thyroid to secrete hormones (T3, T4). When sufficient thyroid
hormone is circulating, negative feedback causes a normally functioning
pituitary to slow or stop the release of TSH.
In primary hypothyroidism, the thyroid is unable to synthesize enough T3 or T4,
slowing the metabolic rate. In response to low circulating thyroid hormones, the
pituitary continues to release TSH, resulting in high
TSH levels. Levothyroxine (Synthroid), a thyroid hormone replacement drug, is
commonly used to treat hypothyroidism. Levothyroxine dosing is adjusted to regulate
circulating thyroid hormone levels; this creates a euthyroid (normal) state and TSH
levels are decreased
1,348. A client with primary hypothyroidism has been taking
levothyroxine for a year. Laboratory results today show high levels
of TSH. Which statement by the nurse to the client is appropriate?
"A new prescription will likely be issued for a decreased dose of

levothyroxine.“
WRONG. Decreasing the dose or discontinuing levothyroxine would

lead to increased TSH and worsening hypothyroidism as the
amount of circulating thyroid hormone decreases.
"Levothyroxine should be held, and the TSH levels will be

reassessed in 3 months.“
WRONG. Decreasing the dose or discontinuing levothyroxine would

lead to increased TSH and worsening hypothyroidism as the
amount of circulating thyroid hormone decreases.
"Start taking your levothyroxine with dietary fiber or calcium to

increase its effectiveness.“
WRONG. Levothyroxine should be taken on a consistent morning

schedule, at least 30 minutes before a meal. Foods containing certain
ingredients (eg, walnuts, soy products, dietary fiber, calcium) can
decrease drug absorption.
1,351. The nurse is teaching a class on nutrition and feeding practices
for young children. What should the nurse recommend as
the best snack for a toddler?
Slices of cheese
CORRECT. Healthy snacks for a toddler include pieces of cheese,

whole-wheat crackers, banana slices, yogurt, cooked vegetables, and
cottage cheese with thinly sliced fruit
½ cup orange juice
WRONG. Although orange juice is a source of vitamin C, it contains a

large amount of sugar and lacks fiber. Toddlers should have no
more than 4-6 oz of 100% fruit juice per day.
Dry, sweetened cereal
WRONG. Sweetened cereals, especially those marketed toward

children, can be high in sugar and low in nutrients.
Raw carrot sticks
WRONG. Raw carrot sticks are hard and pose a choking risk.
Parents should serve carrots and other hard vegetables grated or
cooked.
1,355 . The nurse is caring for a client diagnosed with influenza who
has had high fever, muscle aches, headache, and sore throat for 36
hours. The health care provider prescribes ibuprofen and
oseltamivir. Which of the following actions by the nurse are
appropriate?
Clarify the prescription for oseltamivir with the health care

provider
WRONG. Oseltamivir is an appropriate antiviral medication for this

client who reports onset of influenza symptoms 36 hours ago.
1,356. nurse is caring for a client diagnosed with influenza who has
had high fever, muscle aches, headache, and sore throat for 36 hours.
The health care provider prescribes ibuprofen and oseltamivir.
Which of the following actions by the nurse are appropriate?
Place a mask on the client when transporting the client through

the halls
CORRECT. To prevent spreading influenza, infected clients should be

on droplet precautions (eg, surgical mask, private room), wear a
mask when being transported out of the room, and be taught to cover
the mouth and nose while coughing or sneezing
1,357. The nurse is caring for a client diagnosed with influenza who
has had high fever, muscle aches, headache, and sore throat for 36
hours. The health care provider prescribes ibuprofen and
oseltamivir. Which of the following actions by the nurse are
appropriate?
Use contact precautions when providing care for the client
WRONG. The influenza virus is spread via droplet transmission

when infected persons cough or sneeze. Hospital personnel caring
for clients with influenza should adhere to droplet precautions in
addition to standard (universal) precautions.
1,358. A school-age child is brought to the emergency department due
to nausea, vomiting, and severe right lower quadrant pain. The
child's white blood cell count is 17,000/mm3 (17.0 x 109/L). Which
statement by the child is of most concern to the nurse?
"My belly doesn't hurt anymore."

A child with acute-onset right lower quadrant abdominal pain, nausea,
and vomiting and a high white blood cell count likely has
acute appendicitis. Appendicitis is a serious condition that usually
requires emergency surgery due to the risk of appendix rupture. The
pain results from swelling and inflammation of the appendix.
However, once the appendix ruptures, pain is relieved only
temporarily and will return with full-blown peritonitis and sepsis.
1,359. The home health hospice nurse visits a client who is newly prescribed
extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat
severe chronic cancer pain. Which information is most important to reinforce to
the client's caregiver?
Administer the medication around the clock even if the client denies having
pain
Extended-release oxycodone (Oxycontin) is a long-acting opioid

agonist prescribed to manage severe chronic pain when nonopioids and
immediate-release opioids (eg, immediate-release oxycodone, hydrocodone) are
inadequate. The nurse should teach the client's caregiver to administer extended-
release oxycodone as scheduled, even if the client does not report pain.
Administration twice daily is necessary to maintain a therapeutic level and provide
continuous relief as the duration of the analgesic effect is 12 hours.
1,360. The nurse is interviewing a non-English-speaking client.
Which best practices will the nurse use when working with a
professional medical interpreter for clients of limited English
proficiency?
Hold a pre-conference with the interpreter
CORRECT. Hold a pre-conference with the medical interpreter to

review the goals of the interview
1,361. The nurse in the outpatient clinic is speaking with a client diagnosed with
cerebral arteriovenous malformation. Which statement would be a priority for the
nurse to report to the health care provider?
"I took an acetaminophen in the waiting room for this bad headache."
PRIORITY. An arteriovenous malformation (AVM) is a tangle of veins and
arteries that is believed to form during embryonic development. The tangled vessels
do not have a capillary bed, causing them to become weak and dilated. AVMs are
usually found in the brain and can cause seizures, headaches, and neurologic
deficits.
Clients with AVMs are at high risk for having an intracranial bleed as the veins can
easily rupture because they lack a muscular layer around their lumen.
Any neurologic changes, sudden severe headache, nausea, and vomiting should
be evaluated immediately as these are usually the first symptoms of a hemorrhage
1,362. The nurse is preparing a client for a magnetic resonance
cholangiopancreatography. Which statements by the client would
require the nurse to obtain further assessment data?
"I ate lunch about 4 or 5 hours ago.”
NO NEED FOR FURTHER ASSESSMENT. Many clients should be

NPO for 4 hours prior to the procedure to allow better visualization
of the anatomical features.
"I got a rash the last time I had IV contrast.“
FURTHER ASSESSEMENT. A client with a history of rash following

prior IV contrast administration should be assessed to determine the
type of contrast that caused the reaction. Although allergies to
iodine-based contrast material are more common, the nurse must rule
out a gadolinium allergy
“I had my last period 6 weeks ago.“
FURTHER ASSESSEMENT. Pregnancy also is a contraindication for

MRCP as gadolinium crosses the placenta and may adversely
affect the fetus. Delayed/irregular menses may be a normal variation
in some clients; however, delayed menses may indicate pregnancy and
should be reported for further investigation prior to MRCP
"I have a hearing aid implanted in my ear.“
FURTHER ASSESSEMENT. The nurse must assess

for contraindications before the procedure, including the presence of
certain metal and/or electrical implants (eg, aneurysm clip,
pacemaker, cochlear implant) or any previous allergy or reaction to
gadolinium
cholangiopancreatography. Which statements by the client would require the
nurse to obtain further assessment data?
"I smoked a cigarette about an hour ago.“
DOES NOT NEED FURTHER ASSESSEMENT. Smoking does not affect MRI
visualization and is not a contraindication.
1,367. The nurse prepares to administer a prescribed dose of sodium polystyrene
sulfonate to a client with hyperkalemia. Which action by the nurse is most
important prior to administering the dose?
Assessing the client's abdomen and reviewing the medical record for
frequency of stools
CORRECT. Sodium polystyrene sulfonate (Kayexalate) is used to treat mild to
moderate hyperkalemia. Potassium is exchanged for sodium in the intestines and
excreted in the stool, thereby lowering the serum potassium. In clients without
normal bowel function (eg, post surgery, constipation, fecal impaction), there is a risk
for intestinal necrosis. During sodium polystyrene sulfonate therapy, severe
hypokalemia (palpitations, lethargy, cramping) can develop. Frequent monitoring of
electrolyte status is required. Because potassium exchanges with sodium content of
the resin, excess sodium absorption could put clients at risk of developing volume
overload (water follows sodium). The client should be monitored for signs of fluid
overload (eg, crackles, jugular venous distension, edema) and have daily weights
and intake and output assessment.
1,368. The nurse is caring for a client with suspected Graves disease.
Which assessment finding requires priority intervention?
Agitation and confusion
PRIORITY INTERVENTION. Thyroid storm is a serious and

potentially life-threatening emergency for clients with Graves
disease. This condition occurs when the thyroid gland releases large
amounts of thyroid hormone in response to stress (eg, trauma,
surgery, infection). Characteristic features include tachycardia,
hypertension, cardiac arrhythmias (eg, atrial fibrillation), and fever up
to 104-106 F (40-41 C). Other findings include severe nausea,
vomiting, anxiety, altered mentation, and seizures.
Heat intolerance
WRONG. Heat intolerance is an expected symptom in

hyperthyroidism, including Graves disease.
Pulse of 110/min, irregular rhythm
WRONG. Tachycardia and arrhythmias (eg, atrial fibrillation) are

commonly seen with hyperthyroidism of any cause, including Graves
disease. These alone cannot differentiate whether the client has
simple hyperthyroidism or life-threatening thyroid storm.
Red and bulging eyes
WRONG. Exophthalmos (protruding eyeball) is commonly seen in

Graves disease. The eyelids do not close over the eyeballs properly,
leading to excessive dryness and resultant corneal damage (exposure
keratitis). Although it is important to treat exophthalmos, it is not
immediately life-threatening.
1,372. The nurse is reviewing phone messages from clients in a surgery clinic. Which client would be the
priority to call back first?
1. Client 1 week postoperative appendectomy who has not had a bowel movement in 4 days
Constipation is common after abdominal surgery due to opioid usage and decreased peristalsis from
bowel manipulation. Increasing food or fluids might help the client have a bowel movement.
2. Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal
bloating
PRIORITY. Nausea, vomiting, abdominal distension, and decreased stool production may signal
a bowel obstruction or obstructed ileostomy. It is urgent and potentially life-threatening. The client
must be evaluated by the health care provider in a timely manner.
3. Client postoperative right below-the-knee amputation who is concerned about a new tingling
sensation in the right foot
Phantom limb pain is a sensation of pain or tingling in the amputated body part. Wrapping the extremity
or applying ice or heat might help until the client can be evaluated by the health care provider.
4. Client with a temperature of 101.2 F (38.4 C) who is scheduled for a shoulder arthroplasty the
next morning
Active infection is a relative contraindication for elective surgical procedures. The client should be called
back for assessment and likely rescheduling of surgery but would not take priority over a client with
bowel obstruction.
1,373. The nurse working on an orthopedic unit is receiving report on 4 clients with
recent fractures. Which client should the nurse assess first?
Client who has a femur fracture with a rash of pin-sized red spots on the chest and
increased restlessness
ASSESS FIRST. Clients with orthopedic injuries, particularly pelvic and long bone
injuries (eg, femoral fracture), may develop a fat embolus. Fat emboli are thought to
occur from the release of fat globules (lipids) from bone marrow or the systemic release
of triglycerides into the bloodstream following a mechanical insult. The circulating lipids
can occlude small vessels in the lungs (similar to pulmonary embolism), brain, and
skin, which impair circulation and oxygenation, leading to:
 Respiratory distress syndrome (eg, dyspnea, tachycardia, sudden and worsening
chest pain, hypoxemia, restlessness, anxiety)
 Altered mental status (eg, confusion, memory loss)
 Petechial hemorrhages in the arms, chest, and/or neck
The nurse should call the primary health care provider to obtain a new
prescription prior to administering which medication to a client with
type 1 diabetes mellitus?
20 units NPH insulin IV push administered every morning at 7:00

AM
OBTAIN A NEW PRESCRIPTION. Subcutaneous injection is the

indicated route for NPH insulin administration; it should never be
administered via IV push. Regular insulin is the only insulin that can
be administered via IV push; this is typically performed only in an
acute care facility under close observation by the nurse.
1,375. The nurse should call the primary health care provider to obtain
a new prescription prior to administering which medication to a client
with type 1 diabetes mellitus?
10 units regular insulin IV push for blood glucose >250 mg/dL
NO NEED TO OBTAIN A NEW PRESCRIPTION. Administration of 10

units regular insulin IV push for blood glucose >250 mg/dL (13.9
mmol/L) is appropriate and a new prescription is not required.
14 units glargine insulin subcutaneous injection every night at

8:00 PM

units glargine insulin subcutaneous injection every night at 8:00 PM is
appropriate and a new prescription is not required.
18 units aspart insulin subcutaneous injection 15 minutes before

breakfast

units aspart insulin subcutaneous injection 15 minutes before breakfast
is appropriate and a new prescription is not required.
1,378. The nurse in the endocrinology clinic is reviewing phone messages from clients. Which
client would be the priority to call first?
1. Client with a history of thyroidectomy who needs a refill for levothyroxine
The post-thyroidectomy client who needs a refill of the thyroid replacement medication should be
contacted third. Without thyroid replacement therapy, this client would experience signs and
symptoms of hypothyroidism (eg, extreme fatigue, bradycardia).
2. Client with Addison disease who is taking corticosteroids and reports new mood swings
Clients on corticosteroids may report moods swings and irritability; these are common side
effects.
3. Client with diabetes who reports blood sugars of 250-300 mg/dL (13.9-16.7 mmol/L) in the
past week
The client with diabetes who is asymptomatic but has elevated blood sugars should be contacted
second as prolonged hyperglycemia may lead to dehydration and acidosis.
4. Client with hyperthyroidism who has a new temperature reading of 101.5 F
PRIORITY. Hyperthyroidism results from excessive secretion of thyroid hormones. Affected
clients are at risk for developing thyroid storm, a life-threatening form of hyperthyroidism.
Symptoms of thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial fibrillation),
nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing
fever, maintaining hydration, and preventing cardiac compromise (eg, heart failure).
1,379. When caring for a client with severe burns, the nurse can
expect to administer pain medication via which route?
Intravenous
The best way to get medication into the system of a client with severe
burns is to access the circulatory system directly via the intravenous
route.
1,380. The registered nurse (RN) on a medical-surgical unit is working
with a licensed practical nurse (LPN) and unlicensed assistive
personnel (UAP). Which tasks are most appropriate to assign to the
LPN?
Assisting with bathing, feeding, and dressing a client with

multiple sclerosis
WRONG. UAP have the appropriate skills and knowledge to meet

clients' elimination, hygiene, and comfort needs. Although these tasks
could be safely carried out by an LPN, underutilizing UAP would be an
ineffective use of resources.
1,281. The registered nurse (RN) on a medical-surgical unit is working
with a licensed practical nurse (LPN) and unlicensed assistive
personnel (UAP). Which tasks are most appropriate to assign to the
LPN?
Providing incontinence care and linen change for a client with

diarrhea
WRONG. UAP have the appropriate skills and knowledge to meet

clients' elimination, hygiene, and comfort needs. Although these tasks
could be safely carried out by an LPN, underutilizing UAP would be an
ineffective use of resources.
1,382. The nurse is preparing to discharge a client who is stable
following a head injury. Which statement by the client indicates
a need for further discharge instructions?
"I have a leftover prescription at home I can use if I have pain.“
FURTHER INSTRUCTIONS. Opioid pain medications should

be avoided following a head injury; therefore, the nurse should clarify
what medication the client has at home
1,383. The nurse is admitting a client with cholelithiasis and acute
cholecystitis. Suddenly, the client vomits 250 mL of greenish-
yellow stomach contents and reports severe pain in the right upper
quadrant with radiation to the right shoulder. Which intervention would
have the highest priority?
Maintain nothing-by-mouth (NPO) status

The highest priority intervention for an actively vomiting client with
cholelithiasis is maintenance of strict NPO status to avoid additional
gallbladder stimulation. Additional collaborative interventions (see
table) for cholecystitis should also be taken into account.
1,384. The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted
to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak?
SECTION
C
Section A is the suction control
chamber. Gentle, continuous bubbling
indicates that suction is present.
Section B is part of the water seal
chamber, but an air leak will not be
evident in this upper portion. Tidaling of
fluid is expected in this portion of the
chamber and indicates patency of the
tube.
Section D is the collection chamber,
where drainage from the client will
accumulate. The nurse will assess
amount and color of the fluid and record
these as output.
1,387. A nurse cares for a client with impairment of cranial nerve VIII.
What instructions will the nurse provide the unlicensed assistive
personnel prior to delegating interventions related to the client's
activities of daily living?
"Make sure the items needed by the client are within reach."
CORRECT. The client has an impairment of cranial nerve (CN) VIII,
the vestibulocochlear (or auditory) nerve. Symptoms of impairment
may include loss of hearing, dizziness, vertigo, and motion sickness,
which place the client at a high risk for falls. Therefore, when
instructing the unlicensed assistive personnel (UAP) about helping the
client with activities of daily living, the nurse emphasizes the need to
keep items at the bedside within the client's reach
1,388. After a prolonged surgical procedure, the client reports
unilateral leg pain. Which client assessment finding
is most concerning?
Right calf is 4 cm larger than left calf
MOST CONCERNING. Deep venous thrombosis (DVT) is a major

concern in clients with unilateral leg pain after prolonged immobilization
(eg, air travel, surgery) or those with obesity, pregnancy, or other
hypercoagulable states (eg, cancer). Eighty percent of DVTs start in
the veins of the calf and move into the popliteal and femoral veins.
Classic symptoms include unilateral leg edema, local warmth,
erythema, and low-grade fever. Therefore, the swelling in one leg is
highly concerning.
1,389. A client with diabetes mellitus is admitted to the surgical unit
after a vaginal hysterectomy. The client received 6 units of regular
insulin subcutaneously and metoprolol 50 mg by mouth in the post-
anesthesia care unit. Which statement by the unlicensed assistive
personnel would require immediate action by the nurse?
"I changed the client's perineal pad 3 times in the last 2 hours.“
NEEDS IMMEDIATE ACTION. The nurse should take immediate

action when a client recovering from a vaginal hysterectomy
saturates more than one perineal pad in an hour. The nurse should
further assess the client and report these findings and excessive
vaginal bleeding to the health care provider
1,390. The nurse is teaching a client with insomnia about techniques
to improve sleep habits. Which statement by the client requires
further teaching?
"I will keep the bedroom temperature cool.“
DOES NOT NEED FURTHER TEACHING. The client should keep the
bedroom slightly cool, quiet, and dark for comfort.
1,391. The nurse is teaching a client with insomnia about techniques
to improve sleep habits. Which statement by the client requires
further teaching?
"I will read in bed before trying to go to sleep.“
FURTHER TEACHING. Sleep hygiene refers to a group of practices

that promote regular, restful sleep. The nurse should encourage clients
who have trouble sleeping (insomnia) to maintain good sleep habits. A
primary objective is reducing stimuli in the bedroom. Clients should
be taught to avoid non–sleep-related activities (eg, reading,
television, working) other than sex in bed. Relaxed reading before
bed is helpful for stimulating sleep but should occur in a different
setting, not in bed
1,392. The home health nurse reviews the laboratory results for 4
clients. Which laboratory value is most important for the nurse to
report to the health care provider?
Client with rheumatoid arthritis taking adalimumab has a white

blood cell count of 14,000/mm3
REPORT. Adalimumab (Humira) is a tumor necrosis factor (TNF)

inhibitor, a biologic disease-modifying antirheumatic drug (DMARD)
classified as a monoclonal antibody. Its major adverse effects are similar
to those of other TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab
[Remicade]) and include immunosuppression and infection (eg,
current, reactivated). An elevated white blood cell count in this client
can indicate underlying infection and should be reported immediately.
Client with Clostridium difficile infection receiving metronidazole

has a white blood cell count of 15,000/mm3
NO NEED TO REPORT. This client with Clostridium difficile infection

will have an elevated white blood cell count. The client is receiving
appropriate therapy (eg, metronidazole, oral vancomycin). The
nurse will need to monitor the white cell count and, if it keeps
increasing, report it.
The home health nurse reviews the laboratory results for 4 clients.
Which laboratory value is most important for the nurse to report to
the health care provider?
Client with liver cirrhosis has an International Normalized Ratio of

1.5
NO NEED TO REPORT. The liver produces most blood clotting

factors. Clients with liver cirrhosis will lose this ability and are at risk
for bleeding. This client's International Normalized Ratio is mildly
elevated (normal 0.75-1.25), which is expected with cirrhosis.
Client with mild asthma exacerbation receiving prednisone has a

blood glucose of 250 mg/dL
NO NEED TO REPORT. Corticosteroids increase blood glucose.

This is expected, and the client may need treatment if the glucose
levels are markedly increased for a prolonged period. Most clients with
asthma exacerbation are expected to take a 5- to 7-day course of
steroids.
1,396. The nurse is providing community health screening. Which of the following
clients should be referred to a health care provider for further evaluation?
55-year-old client missing all the hair on the lower legs and failing the pinprick
test
NEEDS FURTHER EVALUATION. Failure of pinprick testing indicates peripheral

neuropathy. Loss of hair on the lower extremities indicates poor perfusion. The
combination of these suggests peripheral neuropathy and peripheral arterial disease,
likely from undiagnosed diabetes mellitus and atherosclerosis.
Nearly a third of clients diagnosed with diabetes mellitus will already have
complications from years of uncontrolled hyperglycemia. Diabetes mellitus
dramatically accelerates the buildup of plaque on the arterial walls (atherosclerosis)
when blood glucose levels are uncontrolled.
1,397. The nurse is providing community health screening. Which of
the following clients should be referred to a health care provider for
further evaluation?
30-year-old athlete with a heart rate of 50/min
DOES NOT NEED FURTHER EVALUATION. Asymptomatic

bradycardia in a healthy young adult is rarely pathological.
Professional-level athletes will commonly develop athletic heart
syndrome; increased efficiency results in resting sinus bradycardia
(40-60/min).
further evaluation?
45-year-old client with a body mass index of 35 kg/m2 and

fingerstick glucose of 150 mg/dL
DOES NOT NEED FURTHER EVALUATION. Fasting blood glucose of

150 mg/dL (8.3 mmol/L) would need to be evaluated for diabetes.
However, in this case it would be important to verify whether the
client has eaten recently.
further evaluation?
80-year-old client with a blood pressure of 150/90 mm Hg
DOES NOT NEED FURTHER EVALUATION. The Joint National

Committee guidelines recommend against treating blood pressure
readings <150/90 mm Hg in clients age >60.
1,400. The nurse plans care for a pediatric client who has just
undergone a cleft palate repair. Which of the following interventions
should the nurse include in the plan of care?
Offer a pacifier in between feedings to promote the child's

comfort
WRONG. Hard objects (eg, utensils, tongue depressors, pacifiers,

straws) should not be placed into the mouth as they may damage the
surgical site, which can lead to hemorrhage.

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1,201.

The nurse is caring for a client who develops Clostridium

Wear a face mask

WRONG. Contact precautions require the caregiver to wear a gown

Wear nonsterile gloves

Client with chronic stable angina and blood pressure of 84/52 mm

NO NEED TO REPORT. The isosorbide has actions identical to

Client with depression stopped phenelzine yesterday;

NEEDS INCIDENT REPORT. Selective serotonin reuptake

Client with pulmonary embolism and International Normalized

DOES NOT NEED INCIDENT REPORT. The effect of warfarin

Call the local organ procurement services representative

WRONG. Organ donation is discussed before final arrangements

Discontinue nursing care and provide postmortem care

WRONG. Medical and nursing care would continue as organ donation

Remove life support as requested by the spouse and family

WRONG. Local OPS (Organ Procurement Services) are contacted

Call social services to assist the client in community resources

WRONG. Notifying social services of suspected abuse should occur

WRONG. Cleaning the laceration and preparing for sutures are

Diagnosed with endocarditis on antibiotics with a peripherally

CORRECT. The long-term antibiotic course (and follow-up lab work)

History of multiple sclerosis with ataxia and diplopia

CORRECT. Ataxia and diplopia are expected signs/symptoms of

One day postoperative from a hemicolectomy

WRONG. Large intestine peristalsis does not return for up to 3-5

Reporting abdominal pain with coffee ground emesis

WRONG. Coffee ground emesis indicates upper gastrointestinal

Taking warfarin with prothrombin time/International Normalized

CORRECT. Two times the control value demonstrates that warfarin

Change positions slowly when going from lying to standing

Do not drink grapefruit juice when taking this drug

WRONG. Grapefruit juice can cause significant interactions with

Take this medication first thing in the morning, before breakfast

WRONG. Alpha-1-adrenergic antagonists (eg, terazosin,

Your stool may become darker and that's normal

WRONG. Oral iron tablets and bismuth salts (Pepto-Bismol) can

Discard the first 6-10 mL of blood drawn from the line

WRONG. When drawing a blood specimen from a central line, the

Place the specimen in a biohazard bag

CORRECT. Blood and bodily fluids are considered hazardous

An 80-year-old client who is 4 days postoperative from repair of a

CORRECT. The 80-year-old 4-day postoperative client has the most

A 25-year-old client with abdominal pain who smokes cigarettes

WRONG. Smoking cigarettes and using oral contraceptives increase

A 55-year-old ambulatory client with exacerbation of chronic

WRONG. Elevated hemoglobin/hematocrit level (erythrocytosis)

"The medication should be administered into the deltoid muscle.“

FURTHER TEACHING. Intramuscular (IM) injections (eg, hepatitis

"A ⅝-inch, 25-gauge needle is appropriate for intramuscular

DOES NOT NEED FURTHER TEACHING. For IM injections, the

Use palifermin as prescribed to alleviate oral pain

WRONG. Administration of palifermin (Kepivance), a recombinant

Stay well hydrated and avoid caffeine

CORRECT. Adopt healthy eating habits and avoid caffeine as it is a

Wear a medical alert bracelet

WRONG. There is no need for a medical alert bracelet. MVP is usually

Ensure you receive antibiotics prior to dental work

Wash hands after bowel movements and before eating

"I should use ibuprofen for pain relief.“

FURTHER TEACHING. Lithium is cleared renally. Even a mild

Ask if the client knows what day it is