A 67 year-old client is admitted with substernal chest pain with that radiates to the jaw. The admitting diagnosis is acute myocardial infraction (MI). The priority nursing diagnosis for this client during the first 24 hours is
A) constipation related to immobility
B) high risk for infection
C) impaired gas exchange
D) fluid volume deficit
Review Information: The correct answer is C: impaired gas exchange
In the immediate post MI period, impaired gas exchange related to oxygen supply and demand is a major problem.
On admission to the hospital a client with an acute asthma episode has intermittent nonproductive coughing and a pulse oximeter reading of 88%. The client states, “I feel like this is going to be a bad time this admission. I wish I would not have gone into that bar with all those people who smoke last night.” Which nursing diagnoses would be most important for this client?
A) Anxiety related to hospitalization
B) Ineffective airway clearance related to potential thick secretions
C) Altered health maintenance related to preventative behaviors associated with asthma
D) Impaired gas exchange related to bronchoconstriction and mucosal edema
Review Information: The correct answer is D: Impaired gas exchange related to bronchoconstriction and mucosal edema
Pulse oximetry reflects oxygenation of arterial blood. While the other diagnoses may be appropriate for this client, they are not the most appropriate priority at the time of admission.
While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication?
A) Positive Homan's sign
B) Fever and chills
C) Dyspnea and cough
D) Sensory impairment
Review Information: The correct answer is C: Dyspnea and cough
Vegetation from the infected heart valves often leads to pulmonary embolism in the client with infective endocarditis. Cough, pleuritic chest pain and dyspnea are early symptoms.
With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select?
A) An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago
B) An adolescent admitted the prior night with Tylenol intoxication
C) A middle-aged client with an internal automatic defibrillator and complaints of “passing out at unknown times” admitted yesterday
D) A school-aged child diagnosed with suspected bacterial meningitis and was admitted at the change of shifts
Review Information: The correct answer is A: An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago
This client is the most stable and has a chronic condition. Tylenol intoxication requires at least 3 to 4 days of intensive observation for the risk of hepatic failure. The other clients would be considered unstable.
Which tasks, if delegated by the new charge nurse to a unlicensed assistive personnel (UAP), would require intervention by the nurse manager?
A) To help an elderly client to the bathroom
B) To empty a Foley catheter bag
C) To bathe a woman with internal radon seeds
D) To feed a 2 year-old with a broken arm
Review Information: The correct answer is C: To bathe a woman with internal radon seeds
A client with internal radiation is complex care and not suitable to be assigned to a UAP. Additionally, the client would not receive a complete bath because of the radiation risks.
A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager implement initially?
A) Set daily goals and establish priorities for each hour and each day.
B) Ask for additional assistance when you feel overwhelmed.
C) Keep a time log of your day in hourly blocks for at least 1 week.
D) Complete each task before beginning another activity in selected instances.
Review Information: The correct answer is C: Keep a time log of your day in hourly blocks for at least 1 week.
Apply the nursing process to time management, so the assessment of the current activities is the initial step. A baseline is established for activities and time use so that needed changes can be pinpointed.
The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate?
A) Non-intention tremors and urgency with voiding
B) Echolalia and a shuffling gait
C) Muscle spasm and a bent over posture
D) Intention tremor and jerky movement of the elbows
Review Information: The correct answer is B: Echolalia and a shuffling gait
Clients with Parkinson''s disease have a very distinctive gait with quick short steps (shuffling) which may increase in speed so that they are unable to stop. They also have echolalia which means the repeating of phrases or words that are directed to them during conversation. In the other options, only one of the findings is associated with Parkinson’s disease: non-intention tremors, bent over posture, and the cogwheel or jerky movement of the elbows.
A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would need to be explored by the nurse to clarify his understanding?
A) "This surgical procedure involves removing one or both testicles through a cut in the groin. My lymph nodes in my lower belly also may be removed."
B) "I have a good chance to regain my fertility later. However if I am concerned, I can have my sperm frozen and preserved (cryopreserved) before chemotherapy."
C) "If I have cancer at stage 3 it means I have less involvement of the cancer."
D) "After the surgical removal of a testicle, I can have an artificial testicle (prosthesis) placed inside my scrotum. This artificial implant has the weight and feel of a normal testicle."
Review Information: The correct answer is C: "If I have cancer at stage 3 it means I have less involvement of the cancer."
Stage 3 is the most extensive involvement of cancer with any type.
A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the "evil eye." The nurse should communicate to other personnel that the appropriate approach is to
A) touch the baby after looking at him
B) talk very slowly while speaking to him
C) avoid touching the child
D) look only at the parents
Review Information: The correct answer is A: touch the baby after looking at him
In many cultures, an "evil eye" is cast when looking at a person without touching him. Thus, the spell is broken by touching while looking or assessing.
A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not voided in 14 hours. When assessing for bladder distention, the best method for the nurse to use is to assess for
A) rebound tenderness
B) left lower quadrant dullness
C) rounded swelling above the pubis
D) urinary discharge
Review Information: The correct answer is C: rounded swelling above the pubis
Swelling above the pubis is representative of a distended bladder in the male client.
Which of these statements by the nurse is incorrect if the nurse has the goal to reinforce information about cancers to a group of young adults?
A) "You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods."
B) "Prostate cancer is the most common cancer in American men with results to threaten sexuality and life."
C) "Colorectal cancer is the second-leading cause of cancer-related deaths in the United States."
D) "Lung cancer is the leading cause of cancer deaths in the United States. Yet it's the most preventable of all cancers."
Review Information: The correct answer is A: "You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods."
It is recommended that only red meat be limited for the prevention of stomach cancer. All of the other statements offer correct information.
Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective?
A) "I may experience seizures if I stop the medication abruptly."
B) "I may experience an increase in my heart rate for a few weeks."
C) ”I can expect to feel nervousness the first few weeks."
D) “I can have a heart attack if I stop this medication suddenly."
Review Information: The correct answer is D: “I can have a heart attack if I stop this medication suddenly."
Discontinuing beta blockers suddenly can cause angina, hypertension, dysrhythmias, or an MI.
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
Review Information: The correct answer is A: Bradycardia
The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an infant).
A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note
A) high protein
B) clear color
C) elevated sed rate
D) increased glucose
Review Information: The correct answer is A: high protein
A positive CSF for meningitis would include presence of protein, a positive blood culture, decreased glucose, cloudy color with an increased opening pressure, and an elevated white blood cell count.
During the beginning shift assessment of a client with asthma who is receiving oxygen per nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding?
A) Pulse oximetry reading of 89%
B) Crackles at the base of the lungs on auscultation
C) Rapid shallow respirations with intermittent wheezes
D) Excessive thirst with a dry cracked tongue
Review Information: The correct answer is C: Rapid shallow respirations with intermittent wheezes
Of the given findings this has the greatest risk for potential complications. Shallow and rapid respirations may indicate that the client is losing muscle strength required to breath. The intermittent wheezes could be an indication of an increase in narrowed small airways and a worsening condition.
A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?
A) Weight gain of 2 pounds or more in a 48 hour period
B) Urinating 4 to 5 times each day
C) A significant decrease in appetite
D) Appearance of non-pitting ankle edema
Review Information: The correct answer is A: Weight gain of 2 pounds or more in a 48 hour period
It is critical for clients to report and be treated for rapid weight gain, decreased urinary output, worsening nocturnal orthopnea, pitting ankle edema, and other findings of chronic heart failure. Hospitalization may be avoided with early intervention.
The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?
A) Confront the nurse about the suspicions in a private meeting
B) Schedule a staff conference, without the nurse present, to collect information
C) Consult the human resources department about the issue and needed actions
D) Counsel the employee to resign to avoid investigation
Review Information: The correct answer is C: Consult the human resources department about the issue and needed actions
To avoid legal repercussions, the nurse needs to consult with the human resources department for proper procedure for documentation, counseling and available resources. The employee may be protected under the Americans with Disabilities Act.
The nurse would teach a client with Raynaud's phenomenon that, after smoking cessation, it is most important to
A) avoid caffeine
B) keep feet dry
C) reduce stress
D) wear gloves
Review Information: The correct answer is A: avoid caffeine
The most important teaching for this client is avoid caffeine after stopping smoking. The question is asking what is the most important teaching. The other approaches tend to be needed less frequently and so are less of a priority.
The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best statement by the nurse should be that,
A) "A child's bone is more flexible and can be bent 45 degrees before breaking."
B) "Bones of children are more porous than adults’ and often have incomplete breaks."
C) "Compression of porous bones produces a buckle or torus type break."
D) "Bone fragments often remain attached by a periosteal hinge."
Review Information: The correct answer is B: "Bones of children are more porous than adults’ and often have incomplete breaks."
This allows the pliable bones of growing children to bend, buckle, and break in a "greenstick" manner. A greenstick fracture occurs when a bone is angulated beyond the limits of bending. The compressed side bends and the tension side fails, causing an incomplete fracture.
While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
A) Jaundice evident at 26 hours
B) Hematocrit of 55%
C) Serum bilirubin of 12mg
D) Positive Coombs' test
Review Information: The correct answer is C: Serum bilirubin of 12mg
The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum bilirubin of 12 mg., the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines the therapy appropriate after reviewing all laboratory findings.
The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?
A) Right ventricle, left ventricle, right atrium, left atrium
B) Left ventricle, right ventricle, left atrium, right atrium
C) Right atrium, right ventricle, left atrium, left ventricle
D) Right atrium, left atrium, right ventricle, left ventricle
Review Information: The correct answer is C: Right atrium, right ventricle, left atrium, left ventricle
This is the pathway of blood flow through the heart.
The nurse uses the DRG (Diagnosis Related Group) manual to
A) classify nursing diagnoses from the client's health history
B) identify findings related to a medical diagnosis
C) determine reimbursement for a medical diagnosis
D) implement nursing care based on case management protocol
Review Information: The correct answer is C: determine reimbursement for a medical diagnosis
DRG''s are the basis of prospective payment plans for reimbursement for Medicare clients.
A client comes into the community health center upset and crying stating “I will die of cancer now that I have this disease.” And then the client hands the nurse a paper with one word written on it: "Pheochromocytoma." Which response should the nurse state initially?
A) "Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid)"
B) This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline
C) "Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor"
D) "You probably have had episodes of sweating, heart pounding and headaches"
Review Information: The correct answer is A: "Pheochromocytomas usually aren''t cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid)"
All of the options are correct information. The best response of the nurse is to address the issue presented by the client “fear of cancer.” Pheochromocytomas may release large amounts of adrenaline into the bloodstream after an injury or during surgery. For this reason, they can be life-threatening if unrecognized or untreated.
The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the "unfreezing" phase of change. With this approach the nurse manager should:
A) discuss with the staff how to deal with any defensive behavior
B) explain to the unit staff why change is necessary
C) assist the staff during the acceptance of the new changes
D) clarify what the changes mean to the community and hospital
Review Information: The correct answer is B: explain to the unit staff why change is necessary
The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it. The phase is completed when staff comprehend the need for change.
A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a
A) chest x-ray
B) blood culture
C) sputum culture
D) PPD intradermal test
Review Information: The correct answer is D: PPD intradermal test
The administration of the PPD intradermal test determines the presence of the infection with the Mycobacterium tuberculosis organism. It is effective at 3 to 6 weeks after the initial infection.
During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?
A) Pleuritic pain on inspiration
B) Dry mucus membranes in the mouth
C) A decrease in respiratory rate from 34 to 24
D) Decrease in chest wall expansion
Review Information: The correct answer is D: Decrease in chest wall expansion
The respiratory status of a client with this acute bacterial pneumonia known as Legionnaires'' disease is critical. Note that all of these findings would be of concern -- the task is to select the priority. Chest wall expansion reflects a possible decrease in the depth and effort of respirations. Further findings of restlessness may indicate hypoxemia. If these occurred the client may then need mechanical ventilation. Option A is expected with such infections of the lung. Option B indicates dehydration which may result in
The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ("knocked out"). After recovering the tooth, the initial response should be to
A) rinse the tooth in water before placing it in the socket
B) place the tooth in a clean plastic bag for transport to the dentist
C) hold the tooth by the roots until reaching the emergency room
D) ask the child to replace the tooth even if the bleeding continues
Review Information: The correct answer is A: rinse the tooth in water before placing it in the socket
Following avulsion of a permanent tooth, it is important to rinse the dirty tooth in water, saline solution or milk before re-implantation. If possible, replace the tooth in its socket within 30 minutes, avoiding contact with the root. The child should be taken to the dentist as soon as possible.
A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is
A) high risk for infection related to vomiting
B) altered family processes related to chronic illness
C) fluid volume deficit related to vomiting
D) risk for aspiration related to loss of consciousness
Review Information: The correct answer is D: risk for aspiration related to loss of consciousness
The tonic-clonic seizure appears suddenly and often leads to brief loss of consciousness. The greatest risk for the child is from airway blockage, as might follow aspiration.
A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to
A) suggest 3 to 4 warm sitz baths per day
B) cleanse the genitalia twice a day with soap and water
C) spray warm water over genitalia after urination
D) apply heat or cold to lesions as desired
Review Information: The correct answer is A: suggest 3 to 4 warm sitz baths per day
Frequent sitz baths may sooth the area and reduce inflammation. The other actions are correct actions however, they would not address the entire group of findings.
An 82 year-old client is prescribed eye drops for treatment of glaucoma. What assessment is needed before the nurse begins teaching proper administration of the medication?
A) Determine third party payment plan for this treatment
B) The client’s manual dexterity
C) Proximity to health care services
D) Ability to use visual assistive devices
Review Information: The correct answer is B: The client’s manual dexterity
Inability to self administer eye drops is a common problem among the elderly due to decreased finger dexterity.
The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by
A) inserting a fenestrated catheter with a whistle tip without suction
B) completing suction pass in 30 seconds with pressure of 150 mm Hg
C) hyperoxygenation with 100% O2 for 1 to 2 minutes before and after each suction pass
D) minimizing suction pass to 60 seconds while slowly rotating the lubricated catheter
Review Information: The correct answer is C: hyperoxygenation with 100% O2 for 1 to 2 minutes before and after each suction pass
Administer supplemental 100% oxygen through the mechanical ventilator or manual resuscitation bag for 1 to 2 minutes before, after and between suctioning passes to prevent hypoxemia.
Which finding would be the most characteristic of an acute episode of reactive airway disease?
A) auditory gurgling
B) inspiratory laryngeal stridor
C) auditory expiratory wheezing
D) frequent dry coughing
Review Information: The correct answer is C: auditory expiratory wheezing
In an acute episode of reactive airway disease, breathing is likely to be characterized by wheezing on expiration. This sound is made as air is forced through the narrowed passages and often can be heard by the naked ear without a stethoscope.
The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information?
A) "The infant will get the hepatitis B vaccine and the hepatitis B immune globulin within 12 hours at birth at separate injection sites."
B) "The second dose can be given at 1 to 2 months of age."
C) "The third dose should be given at least 16 weeks from the second dose."
D) "The last dose in the series is not to be given before age 24 weeks."
Review Information: The correct answer is C: "The third dose should be given at least 16 weeks from the second dose."
The third dose is to be given 16 weeks from the first dose and 8 weeks from the second dose. All of the other options are correct information. These infants will also need to have the blood tested for hepatitis titers and antibodies between 9 and 15 months.
The nurse is caring for a client with status epilepticus. The most important nursing assessment(s) of this client is/are
A) intravenous drip rate
B) level of consciousness
C) pulse and respiration
D) injuries to the extremities
Review Information: The correct answer is B: level of consciousness
Cerebral blood flow undergoes a 250% increase during seizure activity depleting oxygen at the neuronal level. Cerebral anoxia may result in progressive brain tissue injury and destruction. The nurse should monitor the client’s level of consciousness continuously. Even when seizures are controlled, the client may be unconscious for a while.
At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about pre-conception diet changes. Which of the statements made by the nurse is best?
A) "Include fibers in your daily diet."
B) "Increase green leafy vegetable intake."
C) "Drink a glass of milk with each meal."
D) "Eat at least 1 serving of fish weekly."
Review Information: The correct answer is B: "Increase green leafy vegetable intake."
Folic acid sources should be included in the diet and are critical in the pre-conceptual and early gestational periods to foster neural tube development and prevent birth defects such as spina bifida.
A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client?
B) Dorsal recumbent
Review Information: The correct answer is C: Semi-Fowler
The semi-Fowler position assists drainage and prevents spread of infection throughout the abdominal cavity.
A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to
A) gently rub the skin with a cotton swab to relieve itching
B) place the favorite books and push-pull toys in the crib
C) check every few hours for the next day or 2 for swelling in the baby's feet
D) turn the baby with the abduction stabilizer bar every 2 hours
Review Information: The correct answer is C: check every few hours for the next day or 2 for swelling in the baby''s feet
A child in a hip spica cast must be checked for circulatory impairment. The extremities are observed for swelling, discoloration, movement and sensation. For children beyond the neonatal period, traction and/or surgery followed by hip spica casting are usually needed.
A client is admitted for COPD. Which findings would require the nurse's immediate attention?
A) Nausea and vomiting
B) Restlessness and confusion
C) Low-grade fever and cough
D) Irritating cough and liquefied sputum
Review Information: The correct answer is B: Restlessness and confusion
Respiratory failure may be signaled by excessive somnolence, restless, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, arterial blood gases (ABGs) should be obtained.
Which of these tests would the nurse expect to monitor for the evaluation of clients aged 18 and older with poor glycemic control?
A) A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than 3-month intervals
B) A glycosylated hemoglobin is to be obtained at least twice a year
C) A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessment
D) A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment
Review Information: The correct answer is A: A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than 3-month intervals
The American Diabetes Association (ADA) recommends obtaining a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care. In the absence of well-controlled studies that suggest a definite testing protocol, expert opinion recommends glycosylated hemoglobin be obtained at least twice a year in patients who are meeting treatment goals and who have stable glycemic control and more frequently (quarterly assessment) in patients whose therapy was changed or who are not meeting glycemic goals. The goals for persons with diabetes define the target A1c level as less than or equal to 6.5% or less than 7.0%. American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommends that a glycosylated hemoglobin be performed during an initial assessment and during follow-up assessments, which should occur at no longer than three-month intervals. Most would agree, however, that an A1c level greater than 9.0% is poor control for all patient types.
The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?
A) Reduce the environmental stimuli
B) Offer formula every 2 hours
C) Talk to the newborn while feeding
D) Rock the baby frequently
Review Information: The correct answer is A: Reduce the environmental stimuli
This newborn appears to be withdrawing from substances taken by the mother before its birth. Reducing noise and light will reduce the central nervous system responses to stimuli.