Elsevier Adaptive Quizzing - Quiz performance_Safety and Infection Control_ 673 out of 836 questions

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Performance Exit

Safety and infection control Due Apr 10, 2023 by 11:59 pm

Passed 673 out of 836 questions answered correctly

Completed on Feb 28, 2023 10:42 pm

Incorrect (163) Correct (673)

Which required noninvasive assessment and management skills certification would the nurse need to perform airway maintenance and cardiopulmonary resuscitation (CPR)?

Basic Life Support (BLS) Certified Emergency Nurse (CEN) Advanced Cardiac Life Support (ACLS) Pediatric Advanced Life Support (PALS)

Rationale BLS is the certification for emergency nursing that includes assessment and management skills for airway maintenance and CPR. CEN is emergency nursing certification that validates the core emergency nursing knowledge base. ACLS involves invasive airway management skills, pharmacology, electrical therapies, and special resuscitation. PALS involves neonatal and pediatric resuscitation.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

The nurse explains to the parents of a 6-year-old child with a pinworm infestation how pinworms are transmitted. Which statement indicates that the teaching has been understood?

"We need to keep the cat off the bed."

"She needs to wash her hands before eating anything."

"She needs to cover her mouth whenever she coughs."

"We need to tell the school so that the cafeteria can be cleaned."

Rationale Pinworm infestation is transferred by way of the oral-anal route, and effective hand washing is the best way to prevent transmission. Cats do not transmit pinworms.

The hands should be kept away from the nose and mouth; the child should be taught to cough into a tissue or the inside elbow of the arm. Pinworms are not transmitted by coughing. Cleaning the cafeteria is not an effective means of preventing the transmission of pinworms.

Which information would the nurse share with an adolescent girl with a seizure disorder refusing to wear a medical alert bracelet that may help her wear the bracelet consistently?

Hide the bracelet under long-sleeved clothes.

Wear the bracelet when engaging in contact sports.

Ask her friends to wear bracelets that look like hers.

Select a bracelet similar to bracelets worn by her peers.

Rationale Because adolescents have a developmental need to conform to their peers, the teenager should be able to select a bracelet of a design similar to that of those worn by her peers. Hiding the bracelet under long-sleeved clothes might be acceptable in cool weather, but not when it is warm and friends are wearing T-shirts. The bracelet should be worn at all times when the girl is not with responsible family members.

Asking friends to wear a similar bracelet may be difficult, especially if the girl does not wish to tell her friends why she needs the bracelet.

Which team member acts as a liaison between the health care facility and the media?

Triage officer Public information officer Medical command physician Hospital incident commander

Rationale The public information officer acts as a liaison between the health care facility and the media. The triage officer applies disaster triage tags after evaluating the client’s condition. The medical command physician decides the number, acuity, and resource needs of clients. The hospital incident commander assumes overall leadership for implementing the emergency plan.

Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question.

Which hospital department plays a primary role in disaster preparedness?

Medical department Surgical department Emergency department Mental health department

Rationale The emergency department plays a primary role in emergency disaster preparedness. Although all departments in the hospital contribute to disaster planning, the only department that plays a primary role is the emergency department.

Which nursing objective would the nurse add to the plan of care for a child with attention-deficit/hyperactivity disorder (ADHD) who engages in self-destructive behavior?

Keeping the child from inflicting any self-injury Assisting the child to improve communication skills Helping the child formulate realistic ego boundaries Providing the child with opportunities to discharge energy

Rationale The nursing objective is to keep the child from inflicting any self-injury. All nursing care would be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills are important, this is usually not an issue with ADHD. Although formulation of realistic ego boundaries is important, it is not the priority. Opportunities to discharge energy are important, but prevention of injury is the priority.

Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.

Which action transmits the human immunodeficiency virus (HIV)?

Select all that apply. One, some, or all responses may be correct.

Multiple mosquito bites Sharing syringe needles Breast-feeding a newborn Dry kissing an infected individual Anal intercourse Sharing drinking glasses

Rationale Fluids such as blood and semen are highly concentrated with HIV. HIV may be transmitted parenterally by sharing needles and postnatally through breast milk.

HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites, dry kissing, or sharing of drinking glasses. Deep kissing involving a large amount of salvia does transmit HIV.

Which evaluation method is the most effective way for the nurse to evaluate the teachers’ knowledge of hand-washing techniques after a program for teachers about infection-control and hand-washing techniques?

Observe the teachers lecture the children about hand hygiene.

Administer an objectively written final examination to the teachers.

Have the teachers share their knowledge of hand washing.

Watch the teachers demonstrate infection-control techniques.

Rationale The best way to evaluate learning is by feedback demonstration of precautions related to infection control, such as hand-washing techniques. This method is observable and must meet objective criteria. Although observing a lecture, giving a written examination, or sharing what has been learned in a seminar are all evaluation techniques that may be used, none of these methods are as objective and definitive as observing an actual psychomotor demonstration of techniques.

For which client illness would airborne precautions be implemented?

Influenza Chickenpox Pneumonia Respiratory syncytial virus

Rationale Chickenpox is known or suspected to be transmitted by air. Diseases that are known or suspected to be transmitted by droplet include influenza and pneumonia. A disease that is known or suspected to be transmitted by direct contact is respiratory syncytial virus.

Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

Which antibody forms first, after exposure to an antigen?

Immunoglobulin A (IgA) Immunoglobulin E (IgE)

Immunoglobulin G (IgG) Immunoglobulin M (IgM)

Rationale IgM is the first antibody formed by a newly sensitized B-lymphocyte plasma cell.

IgA has very low circulating levels and is responsible for preventing infection in the upper and lower respiratory tracts, and the gastrointestinal and genitourinary tracts.

IgE has variable concentrations in the blood and is associated with antibodymediated hypersensitivity reactions. IgG is heavily expressed on second and subsequent exposures to antigens to provide sustained, long-term immunity against invading microorganisms.

Which product would the nurse instruct intravenous drug users (IDUs) to use for cleaning of needles and syringes between uses?

Bleach Hot water Ammonia Rubbing alcohol

Rationale IDUs should be instructed to fill syringes with household bleach and shake the syringe for 30 to 60 seconds. Hot water, ammonia, or rubbing alcohol is not used to disinfect used syringes.

Which reaction is an example of a type I hypersensitivity reaction?

Anaphylaxis

Serum sickness Contact dermatitis Blood transfusion reaction

Rationale An example of a type I hypersensitivity reaction is anaphylaxis. Serum sickness is a type III immune complex reaction. Contact dermatitis is a type IV delayed hypersensitivity reaction. A blood transfusion reaction is a type II cytotoxic reaction.

Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

Which term describes the practice of placing clients with the same infection in a semi-private room?

Isolating Cohorting Colonizing Cross-referencing

Rationale Cohorting is the practice of grouping clients who are colonized or infected with the same pathogen. Isolating is limiting the exposure to individuals with an infection.

Colonizing refers to the development of an infection in the body. Cross-referencing has nothing to do with an infectious process.

Which manifestation indicates tertiary syphilis?

Which manifestation indicates tertiary syphilis?

Chancre Alopecia Gummas Condylomata lata

Rationale Gummas are chronic, destructive lesions affecting the skin, bone, liver, and mucous membranes occur during tertiary syphilis. A chancre appears during primary syphilis. Alopecia and condylomata lata occur during secondary syphilis.

Which sexually transmitted infection (STI) is most commonly reported?

Syphilis Chlamydia Gonorrhea Human immunodeficiency virus

Rationale Chlamydial infections are the most commonly reported STIs. Syphilis, gonorrhea, and human immunodeficiency virus are not the most commonly reported STIs. Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

Which sexually transmitted infection causes condylomata acuminate?

Chlamydia Gonorrhea Herpes simplex Human papillomavirus (HPV)

Rationale Condylomata acuminate are genital warts that are caused by HPV. Genital warts are not caused by chlamydia, gonorrhea, or herpes simplex.

Which criteria would the nurse consider when determining if an infection is a health care–associated infection?

Originated primarily from an exogenous source Is associated with a medication-resistant microorganism Occurred in conjunction with treatment for an illness Still has the infection despite completing the prescribed therapy

Rationale Health care–associated infections are classified as those that are contracted within a health care environment (e.g., hospital, long-term care facility) or result from a treatment (e.g., surgery, medications). Originating primarily from an exogenous source is not a criterion for identifying a health care–associated infection. The source of health care–associated infections may be endogenous (originate from within the client) or exogenous (originate from the health care environment or service personnel providing care); most health care–associated infections stem from endogenous sources and are caused by Escherichia coli and Staphylococcus aureus.

Association with a medication-resistant microorganism is not a criterion for identifying a health care–associated infection. A health care–associated infection may or may not be caused by a medication-resistant microorganism. Still having the infection despite completing the prescribed therapy is not a criterion for identifying a health care–associated infection.

Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

The nurse is caring for a child who has an external fixation device on the leg. Which is the nurse’s priority goal when providing pin care?

Easing pain Minimizing scarring Preventing infection Avoiding skin breakdown

Rationale Pin sites provide a direct avenue for organisms into the bone. Pin site care is priority over easing pain. Some scarring will occur at the pin insertion site regardless of pin site care. Skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented.

Which action would the nurse take when a client who had a total hip replacement states that the plan is to go swimming at the community pool the day after discharge?

Tell the client to take a friend along for safety.

Encourage participation in this activity because it provides excellent rangeof-motion exercise.

Explain that the incision should not be immersed in water until it has healed.

Let the client know that swimming can substitute for the prescribed physical therapy.

Rationale Because of the risk for infection, the client should avoid tub baths, hot tubs, pools, and immersion in other bodies of water until after the wound has healed and these activities are approved by the primary health care provider. Immersion in water for a prolonged period interferes with wound healing, because water may macerate tissue. Having a friend along does not change the fact that immersion in water for a prolonged period will interfere with wound healing. The client needs to continue physical therapy after discharge whether or not the client goes swimming.

An 8-year-old girl who is hospitalized for intravenous (IV) antibiotic therapy tells the nurse that she is bored. The nurse has a discussion with the parent about appropriate activities. Which activity suggested by the parent would indicate a need for further teaching?

"I’ll bring a radio and CD player."

"I’ll bring homework and school supplies."

"She’ll enjoy having a rubber baseball and plastic bat."

"She’ll enjoy rubber stamps and a pretty box to keep them in."

Rationale

Playing with a bat and ball is an unsafe activity in a hospital setting; the IV catheter could be dislodged, and boisterous activity is dangerous to the other children on the unit. A radio and CD player, homework and school supplies, and rubber stamps and a collection box are all appropriate for the school-aged child.

Which nursing action would be included in the plan of care for a child with acute poststreptococcal glomerulonephritis?

Encouraging fluids Monitoring for seizures Measuring abdominal girth Checking for pupillary reactions

Rationale Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures. Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring abdominal girth is appropriate for children with nephrotic syndrome, in which the child has hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity. Glomerulonephritis will not alter pupillary reactions.

The school nurse is planning to teach the importance of hand washing to the children in first grade. Which is the most effective approach for this age group?

Showing a video of the correct hand-washing technique Demonstrating hand washing and asking for return demonstrations Involving them in a discussion about the importance of hand washing

Describing how germs cause illness and how hand washing prevents disease

Rationale Six-year-old children are still in the perceptual phase of cognitive development.

They base judgments on what they see rather than on what they reason; reasoning begins around age 7. These children are at the developmental stage when they want to show off their accomplishments; just watching the technique without feedback is not sufficient at this age. These children are too young to understand the abstract concepts involved in a discussion of the cause and effect regarding pathogens or to understand why hand washing is so important in preventing illness.

The nurse is planning to teach the four-point alternate crutch gait to a 9-year-old child with cerebral palsy. How would the nurse explain this choice to the parent?

The child has minimal step ability in the lower extremities.

It provides for two points of support on the floor at all times.

It provides for equal but partial weight bearing on each limb.

The child has more power in the upper extremities than in the lower extremities.

Rationale The four-point alternate crutch gait is a simple, slow, stable gait because there are always three points of support on the floor, with equal but partial weight bearing on each limb. The child has the ability to move, but the movement in the lower extremities is uncoordinated. The four-point gait provides for three points of support, not two, at all times. A four-point gait divides weight bearing equally

among the limbs.

Which parental statement would the nurse recognize as indicating the need for further education about bicycle safety for a school-aged client?

"My child should be able to place both feet on the ground while seated."

"My child should be able to easily grasp the brake handles and squeeze them."

"My child will be required to wear a bicycle helmet if he or she wants to ride a bike."

"My child should be able to safely ride after being supervised for a couple of days."

Rationale Children may not safely be able to ride their bike after a couple of days of learning.

The child should be able to place the balls of both feet on the ground while sitting on the bike. The child should easily be able to grasp the brake handles and squeeze them. The child should always wear the appropriate safety equipment while riding his or her bike.

Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds.

Continue to analyze the options. If you can eliminate one more choice in a fouroption question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

After the nurse provides education about all-terrain vehicle (ATV)

safety for a parent of a 11-year-old child, which statement made by the parent indicates an understanding of the information?

"I will have my child ride with an adult."

"I will make sure my child wears a helmet."

"I will make sure my child does not get on an ATV." "I will make sure my child has had safety training before he or she rides."

Rationale The American Academy of Pediatrics recommends that children under 16 years of age not ride in or operate an ATV. The child should not ride with another adult.

When the child is 16 years of age and begins riding an ATV, safety gear such as a helmet should be worn and proper safety training should be implemented.

Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

Which response would the nurse provide the parent of a 15-monthold child who expresses feelings of guilt when their child was hospitalized after ingesting toilet bowl cleaner?

"Anyone could make a mistake. Don’t dwell on it."

"Let’s not worry about the past. Your child is going to get better."

"It was an accident, but you should consider special locks on your closets."

"That was careless of you. Please make sure that you poison-proof your house."

Rationale Describing the incident as an accident and recommending locks on closets accepts the parent’s statement and helps the parent express their guilt while providing directions to safeguard the child. Poisoning is not an everyday occurrence; teaching should be incorporated to protect the child. Telling the parent that the child will get better is false reassurance; the child’s condition is still in question. Calling the parent careless only increases the parent’s guilt and provides nothing more than a vague suggestion of how to remedy the problem.

In which way do toddlers learn self-protection?

Through trial-and-error strategies By imitating playmates and siblings By obeying orders from their parent By playing with age-appropriate toys and puzzles

Rationale The toddler is developing autonomy, is curious, and learns self-protection from experience. Toddlerhood play is parallel, not interactive. The struggle for autonomy at this age limits learning from siblings, even though the toddler attempts to copy their behavior. The toddler is still learning from experiences, not from others. The toddler is still attempting to distinguish the self as separate from their parent; the struggle for autonomy limits learning from parents. Toddlers learn gross and fine motor skills as they play with their toys, not self-protection.

A child becomes cyanotic during a generalized tonic-clonic seizure.

Which action would the nurse take?

Insert an oral airway Administer oxygen (O 2) by mask Continue to observe the seizure Notify the health care provider immediately

Rationale The child’s status and the progression of the seizure should be monitored; the child will not breathe until the seizure is over, and cyanosis should subside at that time. Attempting to open a clenched jaw may result in injury to the child. O 2 is useless until the child breathes when the seizure is over. The health care provider may be notified later; provisions for the child’s safety and observation are the priorities.

Which action would the nurse take first if an allergic reaction to a blood transfusion occurs?

Shut off the infusion.

Slow the rate of flow.

Administer an antihistamine.

Call the health care provider (HCP).

Rationale The client is experiencing an allergic reaction, and the infusion must be stopped immediately to prevent serious complications. Slowing the rate of infusion will not

halt the allergic reaction to the transfused blood. Administering an antihistamine is dangerous as an initial action because the degree of allergic reaction cannot be determined at this time. Also, it requires an HCP’s prescription. The HCP should be notified after the infusion has been stopped.

Which action would the nurse take when caring for an older adult with a history of recent memory loss?

Instruct the client to move slowly when changing positions.

Remind the client to look where he or she places the feet while walking.

Adjust the daily schedule to accommodate sleep pattern.

Employ electronic devices that provide alerts.

Rationale Providing electronic devices that give alerts can help an older adult who has developed recent memory loss. Instructing the client to move slowly when changing positions can prevent dizziness and falls caused by orthostatic blood pressure changes or altered balance/coordination. Reminding the client to check where the feet are placed can help older adults with a decreased sensory perception of touch.

Adjusting the daily schedule can aid older adults who have changes in their sleep pattern.

Which nursing intervention would the nurse take for an older adult with delirium who begins acting out while in the dayroom?

Instructing the client to be quiet Allowing the client to act out until fatigue sets in Immediately guiding the client from the room by gently holding the client’s arm

Giving the client one simple direction at a time in a firm, low-pitched voice

Rationale Clients with delirium typically respond to simple directions stated one at a time in a firm, low-pitched voice. "Be quiet" is a nontherapeutic order; furthermore, it is demeaning to the client. Allowing the client to act out until fatigue sets in will not help the client gain control and might be frightening to other clients in the dayroom. Guiding the client from the room by gently holding the client’s arm is done only after giving simple directions and attempting to calm the client has failed. Touch should also be used cautiously in clients who have delirium because the client may misinterpret the gesture as aggressive.

In which order would clients receive care based on triage tag color?

1.

Red

2.

Yellow

3.

Green

4.

Black

Rationale Clients with a red tag generally have life-threatening conditions involving airway obstruction and shock. Red-tagged clients should be seen immediately. Clients who are dead or expected to die are labeled with black tags, are classified as expectant,

and are given the lowest priority. Green-tagged clients have minor injuries that can receive treatment within 2 hours and are classified as nonurgent. Clients with yellow tags have injuries or conditions that need treatment within 30 minutes to 2 hours and who can be treated after red-tagged clients.

Which type of needs would the nurse identify as a high priority in the prioritization of client care?

Developmental needs Long-term care needs Potential needs in care Needs that affect safety

Rationale Needs related to survival and safety are the highest priority because these are an immediate threat to client health. Developmental needs and long-term care needs are low priority when prioritizing care because they are not an immediate threat to health. Potential needs in care are intermediate priority because they are best addressed before complications follow.

Which substance will the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site?

Sterile saline Steroid cream Oil-based lubricant Mild soap and water

Rationale Mild soap and water are used to cleanse the stoma site. Sterile saline, a humidifier, or pans of water can be used to humidify the air entering the stoma. There is no need to use steroid cream at the site unless instructed by the health care provider.

Non–oil-based, rather than oil-based, lubricants can be used as needed for lubrication of the site.

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which condition would the nurse monitor for in the client on aminoglycoside therapy and skeletal muscle relaxants?

Stroke Respiratory arrest Myocardial infarction Abdominal discomfort

Rationale Aminoglycosides can intensify the effect of skeletal muscle relaxants, placing the client at risk for respiratory arrest. Aminoglycoside therapy with muscle relaxants does not increase the risk of stroke, myocardial infarction, or abdominal discomfort.

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which effect has resulted in the avoidance of tetracycline use in children under 8 years old?

children under 8 years old?

Birth defects Allergic responses Severe nausea and vomiting Permanent tooth discoloration

Rationale Tetracycline use in children under the age of 8 years has been discontinued because it causes permanent tooth discoloration. Birth defects, allergic responses, and severe nausea and vomiting are not prevalent reasons for the discontinuation of tetracycline medications in children under 8 years old.

Which issue related to antibiotic use is an increased risk for the older adult?

Allergy Toxicity Resistance Superinfection

Rationale The older adult is at increased risk for toxicity related to antibiotic use because of reduced metabolism and excretion of medications. Allergy, resistance, and superinfection are a risk for all antibiotic recipients but not an increased risk in the older adult population.

Test-Taking Tip: Multiple-choice questions can be challenging, because students

think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which medication for treatment of gastroesophageal reflux disease would be contraindicated in the pregnant client?

Ranitidine Misoprostol Esomeprazole Calcium carbonate

Rationale Misoprostol is contraindicated in pregnancy because it can cause uterine contractions, expelling the developing fetus. Ranitidine, esomeprazole, and calcium carbonate are not contraindicated during pregnancy.

Which behavior is an early sign of an abusive personality? Select all that apply. One, some, or all responses may be correct.

Verbal abusive Jealous, controlling Enforces rigid sex roles Hypersensitive, easily insulted Isolates partner from family and friends Makes others responsible for their feelings

Rationale Abuser behavior has several characteristics. A typical abuser has poor emotional control, a superior attitude toward women, a history of substance abuse, high levels of jealousy and insecurity, and hypersensitivity. Other characteristics include making others responsible for their feelings and using threats, such as verbal abuse, punishment, and physical violence, to control another’s behavior. Control may extend to enforcing rigid sex roles and isolating a partner from family and friends.

Early recognition of the characteristics of potential violence allows for effective intervention.

Which initial action would the nurse take when a toddler with autism spectrum disorder suddenly runs to the wall and starts banging his head on it?

Allow the toddler to act out feelings.

Ask the toddler to stop this behavior.

Restrain the toddler to prevent head injury.

Tell the toddler that the behavior is unacceptable.

Rationale The nurse would restrain the toddler to prevent head injury. The child with autism spectrum disorder needs protection from self-injury. Permitting the child to act out feelings is possible only if the acting out does not place the child in jeopardy. The child with autism spectrum disorder has difficulty following directions, especially when out of control; therefore, asking the toddler to stop this behavior will be ineffective. The child with autism spectrum disorder cannot separate self from behavior; a punitive approach will decrease the child’s self-esteem.

STUDY TIP: Establish your study priorities and the goals by which to achieve these priorities. Write them out and review the goals during each of your study periods to ensure focused preparation efforts.

Which primary objective of nursing interventions would the nurse maintain for clients with dementia, delirium, and other neurocognitive disorders?

Safety within the environment Enhancement of psychological faculties Participation in educational activities Face-to-face contact with other clients

Rationale Safety within the environment is the primary objective of nursing interventions.

Clients with neurocognitive disorders need an environment that will keep them safe, because their own abilities to interpret and respond appropriately are diminished. People with dementia, delirium, and other neurocognitive disorders usually have a declining level of function in all areas. Maintaining psychological function is often not possible. The primary objective is not to participate in education activities or have face-to-face contact with other clients. People with dementia, delirium, and other neurocognitive disorders have a limited ability to participate in educational activities and may also have a limited ability to interact socially with other clients.

Which emergency medical service agency offers service such as first aid stations and special-need shelters during a disaster or pandemic disease outbreak?

Medical Reserve Corps (MRC)

National Disaster Medical System (NDMS) Disaster Medical Assistance Team (DMAT) Federal Emergency Management Agency (FEMA)

Rationale The MRC may help staff hospitals or community health settings that face shortages and provide first aid stations or special-need shelters. The NDMS manages mass fatalities, emergency animal care, and establishes fully functional field surgical facilities. A DMAT is a medical relief team deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. FEMA provides Community Emergency Response Team (CERT) training so that people are better prepared for disasters and hazard situations in their own communities.

Test-Taking Tip: Choose the best answer for questions asking for a single answer.

More than one answer may be correct, but one answer may contain more information or more important information than another answer.

To which disaster triage class would the nurse infer a client with a green triage tag belongs?

Class I Class II Class III Class IV

Rationale The green disaster triage tag is issued to nonurgent or "walking-wounded" clients

who belong to class III. A red disaster triage tag is issued to clients who require immediate treatment and belong to class I. Clients with yellow and black tags belong to class II and IV respectively.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

Which intervention is the best approach to condom use for prevention of sexually transmitted infection?

Use of spermicide Use of oil-based lubricants Use of a condom with oral sex Use of natural membrane condoms

Rationale Condoms should be used with all sexual encounters, including oral sex, to reduce sexually transmitted infection. There is no evidence that spermicides prevent sexually transmitted infection. Oil-based lubricants can break down latex condoms permitting the transfer of disease. Natural membranes condoms allow the transfer of some infections.

Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

Which report by the client post transrectal prostate biopsy needs to be communicated to the health care provider as a possible sign of infection?

Soreness Rust-colored semen Light rectal bleeding Discharge from the penis

Rationale Discharge from the penis should be communicated to the health care provider for possible infection because discharge is an indication of infection. Soreness, rustcolored semen, and light rectal bleeding are expected after transrectal prostate biopsy.

Where is the blood pressure cuff placed on a client with a dialysis access fistula in the right arm?

On the left arm Over the fistula Below the fistula Above the fistula

Rationale If the fistula is located in the right arm, then the left arm should be used for blood pressure cuff placement. Blood pressure cuffs or any other restrictive devices should not be placed on the arm with a dialysis access fistula including above, below, or

over the fistula site.

Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

Which initial action would the nurse take for a newly admitted client who reports memory loss, nervousness, insomnia, and fear of leaving the house?

Evaluate the client’s adjustment to the unit.

Provide the client with a sense of security and safety.

Explore the client’s memory loss and fear of going out.

Assess the client’s perception of reasons for the hospitalization.

Rationale The initial action is to provide the client with a sense of security and safety. The client is anxious and afraid of leaving home; the priority is the client’s safety and security needs. It is too early to evaluate the client’s adjustment to the unit.

Additionally, if the client is not provided with a sense of security, adjustment probably will be unsatisfactory, because the anxiety will most likely escalate.

Exploring the client’s memory loss and fear of going out cannot be done until anxiety is reduced. The client is experiencing memory loss and may not be able to remember what precipitated admission to the hospital; some memory loss may be a result of high anxiety and thought blocking.

Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the "old" material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of

the topics. Start this review process on the first day of the semester. Don’t wait until the middle to end of the semester to try to cram information.

Which color tag would the nurse use to triage a victim of a train derailment who is able to walk independently to the first aid station?

Red Black Green Yellow

Rationale An emergency triage system uses colored tags to designate both the seriousness of the injury and the likelihood of survival. Green would be used for minor injuries such as the victim who is able to ambulate independently. Red indicates lifethreatening injuries requiring immediate attention. Black indicates that the victim is expected to die. Yellow indicates urgent but not life-threatening injuries.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

Which is the minimum number of disaster drills the hospital disaster plan committee must plan and implement each year?

Two Three Four Five

Rationale Although it is appropriate to have more than the minimum number of disaster drills each year, the minimum that must be implemented per The Joint Commission (TJC) requirements is twice per calendar year. Three, four, and five are too many.

Which agent of terrorism can cause death within a few minutes?

Sarin gas Uranium Iodine-131 Mustard gas

Rationale Sarin gas is an agent for bioterrorism that can cause death within minutes of exposure by paralyzing respiratory muscles. Uranium and iodine-131 can be dangerous in close proximities but are not as harmful as sarin gas. Mustard gas causes blisters on the skin but does not cause death within a few minutes.

Which object would the nurse teach the client with a newly implanted pacemaker to avoid?

Strong magnet Microwave oven Mobile telephone Remote control device

Rationale The client with a newly implanted pacemaker is taught to avoid strong magnets because they can change the settings and function of the pacemaker. Microwave oven use is not a concern for a client with a pacemaker. Mobile phones should be used in the ear opposite the pacemaker.Remote control devices are not contraindicated for the client with a pacemaker.

Which threats included in the term "NBC" led to the implementation of improved emergency medical services (EMS) and hospital safety programs? Select all that apply. One, some, or all responses may be correct.

Nuclear Biological Botulism Chemical Nipah virus

Rationale The term "NBC" was coined to describe nuclear, biological, and chemical threats. In response, EMS agencies and hospitals improved safety by upgrading their decontamination facilities, equipment, and all levels of personal protective equipment to better protect staff. Botulism and Nipah virus are two specific examples of biological threats.

Which intervention would provide the greatest safety for a client admitted to a mental health unit because of suicidal ideation?

Seclusion room

Four-point restraints Continual one-on-one supervision Removal of unsafe objects from the environment

Rationale The intervention that would provide the greatest safety is continual one-on-one supervision. A member of the health team provides a continuous presence to ensure the safety of a client who is at high risk for suicide. Seclusion and four-point restraints are overly restrictive. Although removing unsafe objects from the environment is important, clients who are intent on self-harm will find ways even if such objects are removed.

Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review. Also, it will help you see how correct your guessing can be.

Which method of delivering client care works well in disaster situations?

Team nursing Primary nursing Functional nursing Total client care nursing

Rationale The functional method of delivering care works well in emergency and disaster situations. Each care provider knows the expectations of the assigned role and

completes the tasks quickly and efficiently. Team nursing, primary nursing, and total client care nursing are not the ideal models for delivering client care during disaster situations.

Which team would be mobilized to manage the deceased at the earthquake zone where many people lost their lives?

Medical Reserve Corps (MRC) National Veterinary Response Teams (NVRTs) International Medical-Surgical Response Teams (IMSRTs) Disaster Mortuary Operational Response Teams (DMORTs)

Rationale DMORTs are a part of the DMAT. This team is specialized in managing mass fatalities during a disaster. The MRC helps staff hospitals or community health care settings that face shortages of nurses. They establish first aid stations and specialneeds shelters in disasters. NVRTs provide emergency care to animals. IMSRTs provide fully functional field surgical facilities all over the world, wherever it is required.

Two nurses are planning to help a client with one-sided weakness move up in bed. Which principle of body mechanics would the nurses observe?

Instruct the client to position one arm on each shoulder of the nurses.

Direct the client to extend the legs and remain still during the procedure.

Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed.

Position the nurses on either side of the bed with their feet apart, gather the turn sheet close to the client, turn toward the head of the bed, and then move the client.

Rationale Positioning the nurses on either side of the bed with their feet apart, gathering the turn sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses would assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client’s assistance to the best of the client's ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction in which the client is being moved.

Which action would the nurse implement when caring for a client reporting a recent bee sting presenting with localized redness, swelling, intense localized pain, and itching?

Applying cold compresses to the affected area Ensuring the client keeps the skin clean and dry Monitoring for neurological and cardiac symptoms Advising the client to launder all clothes with bleach

Rationale

A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse would apply cold compresses to the affected area to reduce the pain and edema at the sting site. A client with Candida albicans infection should keep his or her skin clean and dry to prevent further fungal infections. A client with a Borrelia burgdorferi infection may suffer from cardiac, arthritic, and neurological manifestations, which requires monitoring by the nurse.

Direct contact may transmit a Sarcoptes scabiei infection; the nurse should make sure the client bleaches his or her clothes to prevent the transmission of the infection.

Test-Taking Tip: Read the question carefully before looking at the answers: (1) determine what the question is really asking; look for key words; (2) read each answer thoroughly and see if it completely covers the material asked by the question; (3) narrow the choices by immediately eliminating answers you know are incorrect.

Which action is the priority when the nurse is establishing a therapeutic environment for a client?

Ensuring the client's safety Accepting the client's individuality Promoting the client's independence Explaining to the client what is being done

Rationale Safety is the priority before any other intervention is provided. Accepting the client's individuality, promoting the client's independence, and explaining to the client what is being done are all important, but less of a priority.

Who is responsible for triaging the victims of a multiple motor vehicle

Who is responsible for triaging the victims of a multiple motor vehicle crash on a major interstate?

Emergency first responders Nurses in the acute care areas Nurses in the emergency department Health care providers in the emergency department

Rationale For a mass casualty incident, triaging will occur in the field or at the site of the incident. In this case, the emergency first responders will triage the victims of the crash. Nurses in the acute care areas may or may not have victims admitted for care.

The victims should be triaged before arriving in the emergency department, so it would be incorrect to expect the nurses and health care providers in the emergency department to perform triage.

A client has been placing used insulin needles in a container sealed with heavy-duty tape. Where would the nurse tell the client to dispose of the container?

The local hazardous waste collection site The regular household trash The local health department for disposal The Environmental Protection Agency (EPA) through the mail

Rationale Each state (province) has its own waste management guidelines for proper disposal

of sharps containers, as well as hazardous waste collection sites. Clients cannot place needles in the regular household trash because sharps are considered medical waste. The local health department does not collect sharps containers. Sharps containers are not mailed directly to the EPA.

Which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)?

Insert a urinary catheter.

Initiate droplet precautions.

Move the client to a private room.

Use a high-efficiency particulate air (HEPA) respirator during care.

Rationale Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter, because this can increase the risk for additional infection.

Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. A HEPA respirator is not indicated with contact precautions.

Which response by the nurse is best when a client expresses concern regarding the lack of annual flu vaccines because of a supply and demand problem?

"This is an unfortunate situation, but there was such a limited supply available."

"There are many others who were unable to obtain a flu vaccine this month."

"The limited supply doesn’t really matter because the vaccine is for one particular strain."

"There are other things you and your family can do to prevent the flu, such as hand washing."

Rationale The statement "There are other things you can do to prevent the flu, such as hand washing" is a teaching opportunity of which the nurse can take advantage and show the client the things that can be done to avoid infection. The response "It’s unfortunate, but there was such a limited supply available" is empathic, but it does not address the client’s concern of vulnerability. The response "There are many others who also were unable to get a flu vaccine" belittles the client for being concerned. The response "It doesn’t matter because the vaccine is for just one particular strain" may be true, but it belittles the client’s concern.

Which event would the nurse state is an example of a natural disaster?

Floods Terrorism Fire explosion Building collapse

Rationale External disasters can be natural, such as floods, earthquakes, or tornadoes. Acts of terrorism are external disasters that use technology such as explosive devices or a malfunction of a nuclear reactor. A fire explosion is an internal disaster. A building collapse is a consequence of internal or external disaster.

Which action would the nurse identify as a potential contributor to

Which action would the nurse identify as a potential contributor to staff post-traumatic stress disorder (PTSD) during a mass casualty assessment?

Working less than 12 hours Encouraging and motivating team members Working continuously without any breaks Discussing feelings with the team members

Rationale Working continuously without any breaks will result in increased stress. Working less than 12 hours may reduce stress. By motivating team members, PTSD can be prevented. By discussing feelings with team members or nurse managers, stress can be reduced.

Which event would the nurse describe as an example of an internal disaster?

Tornado Hurricanes Fire or explosion Terrorism attacks

Rationale An internal disaster refers to an event that impairs the hospital’s normal functioning and disrupts normal client care activities. Examples include a fire or explosion and the loss of critical utilities. Tornado, hurricanes, and terrorist attacks are external

disasters that result in the loss of lives and property.

Which statement would the nurse include in the teaching plan of a client anticipating discharge with acquired immunodeficiency syndrome (AIDS)?

"Wash used dishes in hot, soapy water."

"Let dishes soak in hot water for 24 hours before washing."

"You should boil the client’s dishes for 30 minutes after use."

"Have the client eat from paper plates so they can be discarded."

Rationale A person cannot contract human immunodeficiency virus (HIV) by eating from dishes previously used by an individual with AIDS; routine care is adequate.

Washing used dishes in hot, soapy water is sufficient care for dishes used by the AIDS client. Dishes do not need to soak for 24 hours before being washed. The client’s dishes do not need to be boiled for 30 minutes after use. Paper plates are fine to use but are not indicated to prevent the spread of AIDS.

When caring for a client who is receiving enteral feedings, the nurse would take which measure to prevent aspiration?

Elevate the head of the bed between 30 and 45 degrees.

Decrease flow rate at night.

Check for residual daily.

Irrigate regularly with warm tap water.

Rationale To prevent aspiration, the nurse would keep the head of the bed elevated between 30 and 45 degrees. Elevating the head any higher causes increased sacral pressure and increases the risk of skin breakdown. Decreasing flow rate, checking for residual, and irrigating regularly will not prevent aspiration.

Which strategy is most effective for preventing the transmission of infection?

Wearing gloves and a gown Applying face mask and a gown Applying a face mask and gloves Wearing gloves and hand hygiene

Rationale The combination of hand hygiene and wearing gloves is the most effective strategy for preventing infection transmission. A gown and face mask are considered personal protective equipment; however, they are not considered the most effective strategy to prevent the transmission of infection.

Which precaution would the nurse identify as a prevention for transmission of human immunodeficiency virus (HIV) and other bloodborne illnesses?

Barrier Droplet Contact Standard

Rationale Standard precautions need to be consistently used by all health care professionals to prevent the transmission of HIV and other bloodborne diseases. Barrier contraception decreases the risk of sexual transmission of HIV and other sexually transmitted diseases. Droplet precautions are used to prevent the spread of influenza. Contact precautions are used for illnesses such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).

Which strategy would the nurse include in a plan of care for a client with Alzheimer disease?

Implement remotivational therapy.

Structure the environment for safety.

Arrange for long-term custodial care.

Stimulate thinking with new experiences.

Rationale Structuring the environment for safety supports the client’s ability to function in a protected, safe milieu. Attempting to remotivate the client is not the priority; also, it is not always possible to remotivate a client with Alzheimer disease. There are no data to indicate that the client needs long-term custodial care at this time. Structure and routines will decrease anxiety and increase performance of activities of daily living; whereas, stimulating thinking with new experiences would be too overwhelming for a client with Alzheimer disease. Cognitive maintenance should be part of the focus of care.

Which nursing action is effective in controlling the spread of infection for an infant with diarrhea?

Wearing a gown and gloves during care Allowing only registered nurses to give direct care Restricting visitors to the infant’s immediate family Washing hands before and after contact with the infant

Rationale The most effective method of preventing the spread of infection is hand washing not only before and after care but also before and after using gloves. A gown and gloves are not required for contact precautions. The level of education of the caregiver does not guarantee the correct technique for preventing the spread of infection. The risk for spread of infection is not in the number of visitors but in the aseptic technique practiced by these visitors.

Which statement by parents indicates that teaching has been effective regarding their child’s pinworm infestation?

"I need to make sure the cat stays off her bed at night."

"I’ll have to reinforce her hand-washing habits before she handles food."

"I need to disinfect the toilet seat after she has a bowel movement for the next few days."

"I’ll report that the school’s dirty toilet seats caused my child to get pinworms."

Rationale

Pinworms are transferred by way of the anal-oral route; hand washing is the most effective method for preventing transmission. Cats do not transmit pinworms. It is unnecessary to disinfect the toilet seat because pinworms are found in the rectum or colon and travel to the perianal area only when the person sleeps. Dirty toilet seats are not the usual mode of transmission.

Which goal would be priority for the child with autism spectrum disorder who has frequent episodes of self-biting and head-banging and needs help with feeding and toileting?

Controlling repetitive behaviors Being able to feed independently Remaining safe from self-inflicted injury Developing control of urinary elimination

Rationale The priority goal is remaining safe from self-inflicted injury. The priority is safety; the child must be protected from self-harm. Repetitive behaviors are comforting, and unless they are harmful their limitation is not a priority. Although feeding independently is a basic need that may be achieved, it is not the priority. Although control of urinary elimination is important, it is not the priority.

STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture

recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too.

Which diagnostic test result indicates if a client will develop acquired immunodeficiency syndrome (AIDS) from the human immunodeficiency virus (HIV)?

Level of immunoglobulin M (IgM) in the client’s blood The number of CD4+ T cells available Presence of antigen-antibody complexes Speed with which the virus invades the ribonucleic acid (RNA)

Rationale Whether HIV becomes AIDS depends on the number of CD4+ T cells. IgM and the presence of antigen-antibody complexes have no effect on HIV. The speed with which HIV invades the RNA has no effect on the future development of AIDS.

The nurse would instruct a client with type I diabetes to dispose of a used syringe in which container?

Bubble wrap/packaging wrap A garbage bag in the trash can A cardboard box with a firmly secured lid A plastic liquid detergent bottle with a screw-top lid

Rationale

Most states (provinces) allow clients to place used needles/pen needles and lancets (sharps) in a household container such as a laundry detergent bottle, bleach bottle, or other opaque, sturdy plastic container with a screw-top lid. Some states (provinces) do have disposal drop-off locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the containers at risk for needle sticks.

Which important information would the nurse determine regarding the care provided by a mother diagnosed with acquired immunodeficiency syndrome (AIDS) who has been caring for her baby despite not feeling well?

If she has ever kissed the baby and how If the mother is breast-feeding her baby When the baby last received antibiotics How long she has been caring for the baby

Rationale Epidemiological evidence has identified breast milk as a source of human immunodeficiency virus (HIV) transmission. Kissing is not believed to transmit HIV. When the baby last received antibiotics is unrelated to transmission of HIV. HIV transmission does not occur from contact associated with caring for a newborn.

Which information would the nurse include in a community education session on decreasing the risk for musculoskeletal injuries?

Select all that apply. One, some, or all responses may be correct.

Use of seatbelts Obeying speed limits Wearing safety equipment

Avoiding impaired vehicle use Refraining from distracted driving

Rationale The nurse can provide several proactive steps for preventing musculoskeletal injuries at home, at work, and in the community. Community members should be advised to wear seatbelts, follow the speed limit, and refrain from distracted or impaired driving. Employees should be instructed to follow workplace safety procedures and practices, including wearing safety equipment.

Test-Taking Tip: What happens if you find yourself in a slump over the exam? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.

Which intervention would the nurse include in the plan of care for a client admitted with herpes zoster? Select all that apply. One, some, or all responses may be correct.

Acyclovir Silvadene Gabapentin Wet compresses Contact isolation

Rationale

A client with herpes zoster would receive antiviral medications such as acyclovir.

Silvadene can be applied to open vesicles. Gabapentin can be used to treat the nerve pain associated with herpes zoster. Wet compresses can be applied to the vesicles to relieve discomfort. Herpes zoster is highly contagious, and the client would be placed in contact isolation precautions.

Which information will the nurse explain to a burn client receiving the open method for wound treatment?

"Bathing will not be permitted."

"Dressings will be changed daily."

"Personal protective equipment will be worn by staff."

"Room temperature will be kept below 72°F [22.2°C]."

Rationale Personal protective equipment (disposable hats, masks, gowns, and gloves) are essential for the prevention of infection in clients with the open method of treatment. Hydrotherapy in a large tank tub may be used to clean burn wounds.

Dressings are not used with the open method. Clients are more comfortable with a room temperature of 85°F (29.4°C).

The nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first dose of intravenous antibiotics?

Red blood cell count Wound culture Knee x-ray

Urinalysis

Rationale A wound culture always should be completed before the first dose of antibiotic. A wound culture is obtained to determine the organism that is growing. A broad spectrum antibiotic often is given first; after the organism has been identified an organism-specific antibiotic can be given. There is no indication that a red blood cell count is needed; however, a white blood cell count would be beneficial. A urinalysis is not needed, because data gathered during the assessment indicate an incisional infection. At the early stage of the infection, there is no need to obtain a knee x-ray.

Which group has the highest rate of meningococcal infection?

Infants Toddlers Older adults Young adults

Rationale Those between the ages of 16 and 21 years, many of whom are young adults, are most at risk for meningococcal infection and are the main target group for vaccination. Infants and toddlers can contract meningococcal infection, but it is not as prevalent in these groups as in the young adult population. Older adults do not have a higher prevalence of meningococcal infection than young adults; however, individuals in this group who are immunocompromised may benefit from receiving the vaccination or boosters.

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which clinical condition is associated with lead poisoning?

Asthma Anemia Metabolic acidosis Systemic infection

Rationale Lead can interfere with the binding of iron onto the heme molecule. This can cause anemia even though the child is not iron deficient. Asthma, metabolic acidosis, and a systemic infection are not associated with lead poisoning.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

The nurse is preparing a child who has undergone a myringotomy for discharge. Which would the parent be taught about their child’s care at home?

Insert earplugs whenever a bath is given.

Keep cotton in the ears until drainage subsides.

Keep the child out of school until the ears are healed.

Clean the child’s ears with cotton-tipped swabs after each bath.

Rationale Water in the ears after myringotomy supports the growth of pathogens and should be avoided. The ears should be kept open to the air and allowed to drain naturally.

There is no reason to keep the child isolated. Cleaning the ears with cotton swabs is contraindicated because it may result in trauma.

A child with meningitis suddenly assumes an opisthotonic position. In which position would the nurse position the child?

Side-lying Knee-chest High-Fowler Trendelenburg

Rationale Maximal safety and comfort are ensured with the side-lying position because the child’s neck and back are hyperextended. The knee-chest position is impossible because the child is in a rigid opisthotonic position, with the neck and back hyperextended. The high-Fowler is impossible because the child is in a rigid position with the neck and back hyperextended. The Trendelenburg position increases intracranial pressure and is contraindicated in meningitis.

Which condition is commonly seen following infestation with pediculosis capitis (head lice)?

Eczema Impetigo Cellulitis

Folliculitis

Rationale Impetigo may develop as a secondary bacterial infection because of breaks in the skin caused by scratching. Eczema is an allergic response and not related to episodes of pediculosis. Cellulitis is an extended inflammation that is not commonly found in children with pediculosis. Folliculitis is a pimple or an infection of the hair follicle; it does not occur as a result of pediculosis.

Which statement shows that the newly diagnosed asthma patient understands how to use a peak expiratory flow meter (PEFM)?

"I have to blow out as fast and hard into the machine as I can."

"I can stand or sit to use the flow meter. I just can’t lie down."

"I have to take three readings and record the average on the flow sheet."

"I’ll use the meter whenever I can throughout the day; it doesn’t really matter when."

Rationale A PEFM is used to measure the amount of air being exhaled. To adequately measure this, the client must blow out fast and hard. The client should use the PEFM while in a standing position to permit better expansion of the lungs. The highest of three readings, not the average, is recorded. The readings should be obtained close to the same time each day to ensure consistency.

At which height is it no longer safe for a toddler to sleep in a crib?

26 inches

28 inches 33 inches 36 inches

Rationale A toddler who has reached the height of 35 inches should be transitioned from a crib to a bed. At that height, children likely can pull themselves up and over the crib rail, putting them at risk for injury. Toddlers 26, 28, and 33 inches in height can remain in a crib because falling is not a concern.

Which position increases cardiac output in the obstetrical client with cardiac disease?

Trendelenburg Low semi-Fowler Lateral positioning Supine with legs elevated

Rationale Lateral positioning improves the cardiac output of an obstetrical client with cardiac disease. Trendelenburg, low semi-Fowler, and the supine position are not appropriate positions to improve the cardiac output of an obstetrical client with cardiac disease. Placing the client in these positions allows the weight of the uterus to remain on the vena cava, impeding the blood flow.

Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.

Which technique would the nurse employ for an obstetrical client with a foreign body airway obstruction?

Back blows Chest thrusts Suprapubic thrusts Abdominal thrusts

Rationale Chest thrusts are performed for an obstetrical client with a foreign airway body obstruction. Back blows, suprapubic thrusts, or abdominal thrusts are not used to dislodge a foreign body causing airway obstruction.

Test-Taking Tip: Come to your test prep with a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation).

Which would be included in the plan of care for an obstetrical client who has been taking carbamazepine throughout the first trimester of pregnancy?

Evaluation for fetal hydramnios Evaluation for a neural tube defect Evaluation for cardiac malformation Chromosomal assessment for Down syndrome

Rationale Carbamazepine is associated with neural tube defects. Fetal hydramnios, cardiac malformation, and Down syndrome are not related to the use of carbamazepine.

Which occurs immediately after birth that increases the risk for cardiac decompensation in a client with a compromised cardiac system?

Increased pressure is placed on the veins.

Intra-abdominal pressure is significantly increased.

The blood flow to the heart is decreased considerably.

Extravascular fluid is remobilized into the vascular compartment.

Rationale During the immediate period after birth the extravascular fluid is remobilized into the vascular compartment, increasing the client’s risk for cardiac decompensation.

At the moment of birth, the pressure on the veins is removed, the intra-abdominal pressure decreases dramatically, and the blood flow to the heart is significantly increased.

Which cardiac disease has the lowest risk for maternal mortality?

Endocarditis Aortic stenosis Patent ductus arteriosus Pulmonary hypertension

Rationale A client with patent ductus arteriosus has the lowest risk for maternal mortality. A client with aortic stenosis has a higher risk of maternal mortality. A client with endocarditis or pulmonary hypertension has the highest risk of maternal mortality.

Which risk would the nurse consider when providing care for a client in the acute phase of treatment for a full-thickness burn?

The risk of septicemia and its potential complications from treatment The risk of psychosocial adjustments and resuming previous roles The risk of oral mucous membrane injury and its associated risks The risk of insufficient community resources and emotional support

Rationale Skin is the first line of defense against infection. When much of it is destroyed, the client is vulnerable to infection. Complications, such as infection and contractures, still may occur during the acute phase and as the client is healing. Psychosocial adjustments, previous roles, and insufficient community resources are priorities in the rehabilitative phase. Risk of oral mucous membrane injury is in the emergent (resuscitation) stage. Emotional support is provided in all three phases.

Which type of isolation precautions would the postpartum nurse plan to implement for a client who has given birth by urgent cesarean section related to active herpes simplex virus (genitalia) following onset of labor and rupture of membranes 8 hours ago?

Standard Droplet Contact

Airborne

Rationale Contact precautions include a gown, mask, and gloves; the client should be in a private room. Airborne and droplet precautions are not necessary for a person with genital herpes. The client and newborn should be placed in contact precautions until infant culture results are available and neonatal infection has been ruled out.

This neonate may have been exposed to genital herpes when the client arrived with ruptured membranes in active labor. Normally, the amniotic sac serves as another protection against neonatal exposure. Maternal genital herpes, when neonatal exposure is not suspected following rupture of membranes, requires only standard precautions.

Which client would the nurse provide care to first?

Client A Client B Client C Client D

Rationale Client A with an airway obstruction has an immediate threat to life and the condition is considered emergent, which meets the criteria for class 1. Client B with extensive full-thickness burns should be triaged under class 4 because the client with this condition is expected to die. Client C with open fractures implies a major injury that requires treatment and is considered urgent. This client is triaged under class 2. Client D with a closed fracture and abrasions indicates a minor injury that does not require immediate treatment and is triaged under class 3.

Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. No real absolutes exist in life; however, every rule has its exceptions, so answer with care.

The client with which color tag would be treated first, according to the disaster triage tagging system?

Red Black Green Yellow

Rationale The red tag is applied to clients who require immediate treatment according to the disaster triage tag system, so client A requires immediate treatment. A black tag is applied to clients who are dead or expected to die and are not prioritized for immediate critical care. The green tags are applied to clients who can ambulate on their own, and there is no need to attend to these clients first. The yellow tag is applied to clients who can wait a short duration for treatment and who can be treated after clients with red tags are treated.

Which client condition would require the highest priority for treatment among four clients admitted at the same time under mass casualty conditions?

Client A Client B Client C Client D

Rationale Client C reporting with shock is identified with a red tag, indicating an immediate threat to life. The client with massive head trauma is labeled with a black tag, which indicates the client is deceased or is expected to die, so treatment will not be provided to maximize resources to save the most clients possible. The client reporting with an open fracture with distal pulse is triaged as class 3, in which the treatment is considered urgent but less so than for a red-tagged client. Strains and contusions are minor injuries and are considered nonurgent; client D should be triaged as class 3.

A child’s mother asks the school nurse how her child got head lice.

Which explanation would the nurse share with the mother?

Transmission occurs through contact with animals and birds.

Infestation is most common where there are crowded conditions.

Infestation is more widespread among lower socioeconomic groups.

Transmission occurs through contact with contaminated children and objects.

Rationale Transmission occurs through direct contact with infected individuals and contaminated objects such as infested clothing, personal articles, and bedding.

Animals and birds do not carry or transmit head lice. Although crowded conditions can contribute to an infestation, direct contact with contaminated people and objects is the origin of an infestation. All socioeconomic groups are affected equally.

When a client with a health care–acquired respiratory tract infection asks the nurse what this means, which response will the nurse give?

"You developed an infection that requires antibiotics."

"This is a highly contagious infection requiring isolation."

"An infection you had before beginning treatment has flared up."

"Your infection occurred because of exposure to a health care facility. "

Rationale A health care–acquired infection is contracted during treatment in a health care facility, such as a hospital or nursing home. Both community-acquired and health care–acquired infections may require antibiotics. Community-acquired and health care–acquired infections may require isolation. An infection that occurred before hospitalization would be called a community-acquired infection.

The nurse is preparing to administer methylphenidate to an older adult with apathy and depression. Which assessment would be included to monitor for complications? Select all that apply. One, some, or all responses may be correct.

Vision

Weight Heart rate Skin turgor Bowel sounds

Rationale When methylphenidate is administered to older adults, the nurse will monitor the client’s vision for signs of glaucoma, as well as their weight, heart rate, and blood pressure. Skin turgor and bowel sounds are not affected by methylphenidate.

Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to 2 minutes.

Which level of trauma center provides a full continuum of care for the trauma client?

Level I Level II Level III Level IV

Rationale Level I trauma centers are likely an urban academic center that provides the full continuum of care for the trauma client and conducts research for trauma center verification. Level II trauma centers provide care to most trauma clients and are located in the community hospital. Level III trauma centers stabilize and transfer trauma clients from the community hospital setting. Level IV trauma centers are

likely rural with basic support that transfers out to a higher-level care center.

Which characteristic aligns with prioritizing care into the triage level of "emergent"?

Immediate threat to life or limb Condition is unlikely to deteriorate Could wait for several hours for care May be seen soon but not immediately

Rationale The triage level of "emergent" indicates that there is an immediate threat to life or limb. Conditions that are unlikely to deteriorate or could wait several hours for care are triaged as nonurgent. A case triaged as urgent should be seen soon but not immediately.

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which medication would the nurse instruct a client to avoid while taking alprazolam? Select all that apply. One, some, or all responses may be correct.

Opioids Alcohol Barbiturates Antidepressants

First-generation antipsychotics

Rationale Respiratory depression can occur if a client combines benzodiazepines with opioids, alcohol, or barbiturates. Antidepressants and first-generation antipsychotics are safe to take with benzodiazepines.

Which type of needs would the nurse identify as an intermediate priority in the prioritization of client care?

Developmental needs Potential needs in care Needs related to survival Needs that affect safety

Rationale Potential needs in care are intermediate priority because they are best addressed before complications follow. Developmental needs and long-term care needs are low priority when prioritizing care because they are not an immediate threat to health. Needs related to survival and safety are the highest priority because these are an immediate threat to client health.

Which type of needs would the nurse identify as low priority in the prioritization of client care?

Developmental needs Potential needs in care

Needs related to survival Needs that affect safety

Rationale Developmental needs and long-term care needs are low priority when prioritizing care because they are not an immediate threat to health. Potential needs in care are intermediate priority because they are best addressed before complications follow.

Needs related to survival and safety are the highest priority because these are an immediate threat to client health.

How would the nurse position a client to practice supraglottic swallowing after tracheostomy?

In bed Upright Lying down Position of comfort

Rationale The safest position for supraglottic swallowing is sitting upright. Clients should be out of bed, if possible. Clients are at risk for aspiration if swallowing while supine.

Comfort is always a goal of positioning clients, but upright is the priority for safe swallowing.

Which information would the nurse provide a client with diabetes mellitus (DM) regarding alcohol consumption?

Before meals

One drink per week Complete abstinence With or shortly after meals

Rationale A person with DM should only drink alcohol with or shortly after meals to prevent alcohol-induced delayed hypoglycemia. Alcohol should not be consumed before meals. The client with DM does not need to limit to one drink per week nor completely abstain from drinking.

Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

Which infection control measures would the nurse provide a client regarding blood glucose monitoring? Select all that apply. One, some, or all responses may be correct.

Wear gloves.

Reuse lancets.

Perform hand washing.

Clean site before fingerstick.

Share blood glucose monitor.

Rationale

The nurse would instruct the client to perform hand washing and to clean the site before the fingerstick. The nurse would wear gloves, not the client. Lancets should not be reused nor should the meter be shared.

The nurse is educating a client about managing hypoglycemia unawareness. Which information would the nurse provide?

Refrain from alternative testing sites.

Use any available meter to monitor levels.

Initiate continuous blood glucose monitoring.

Calibrate the meter before managing hypoglycemia.

Rationale When the client is managing hypoglycemia, the same site should be used to obtain blood glucose levels. This provides consistent readings because blood glucose levels are changing rapidly. The client should use his or her meter to monitor blood glucose levels for consistency. Continuous blood glucose monitoring should be implemented when the client is stable, not during hypoglycemic episodes. The client should calibrate the meter once a day, but not when hypoglycemic. The client needs a meter that can provide instant results without waiting for tests to be performed on the meter itself.

The nurse educator is providing information about different insulin types. Which type of insulin can be safely mixed with regular human insulin in the same syringe?

Insulin glargine Insulin detemir Insulin lispro mix 75/25

Isophane insulin neutral protamine hagedorn (NPH)

Rationale Isophane insulin NPH is safe to mix with regular human insulin. No other insulin type should be mixed with insulin glargine, insulin detemir, or insulin lispro mix 75/25.

Which information would the nurse provide to a client taking dulaglutide?

Give with insulin.

Administer medication orally.

Works without exercise.

Perform self-injection weekly.

Rationale Dulaglutide is an injection that, unlike insulin, is only administered subcutaneously once a week. It is not administered with insulin, it is not an oral medication, and it works with modified diet and exercise.

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which information would the nurse discuss with a group of adolescents wearing orthodontic appliances to prevent infection?

Select all that apply. One, some, or all responses may be correct.

Brushing teeth twice a day Flossing after each meal Visiting the dentist twice a year Drinking unsweetened drinks Cleaning around orthodontic gear

Rationale The adolescent needs to understand the importance of good dental hygiene, especially when wearing orthodontic appliances. Food can get caught in the spaces and lead to infection. Therefore, the nurse would instruct adolescents to brush their teeth a minimum of twice a day, floss after each meal to remove food particles, and clean around the orthodontic gear. Dental appointments should occur twice a year.

The nurse would encourage the consumption of unsweetened drinks, as sugar can lead to dental caries.

Which risky adolescent behavior has increased in occurrence in recent years?

Binge drinking alcohol Having unprotected sex Using electronic vapor products Experimentation with hard drugs

Rationale The use of electronic vapor products is on the rise. Almost 50% of adolescents report using these products. Binge drinking alcohol, having unprotected sex, and experimenting with hard drugs are ongoing, but have not increased over time.

Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

Which topic will the nurse include when educating the parents of an adolescent on home safety?

Nutrition needs Monitoring of schoolwork Limiting video game time Keeping firearms locked away

Rationale Parents will be instructed to keep firearms locked and put away to promote safety in the home. Nutrition, grades and schoolwork, and limiting video game time are factors related to maintaining adolescent health but are unrelated to safety.

Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds.

Continue to analyze the options. If you can eliminate one more choice in a fouroption question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

Which factor increases an adolescent’s risk for injury in the

Which factor increases an adolescent’s risk for injury in the community?

Employment Eating disorders Sleep deprivation Distracted driving

Rationale Studies show 60% of teens report texting and emailing while driving. Employment, eating disorders, and sleep deprivation are not factors that increase the risk of injury in the community setting.

Which instruction would the nurse include when teaching the client how to perform peritoneal dialysis and the importance of preventing peritonitis? Select all that apply. One, some, or all responses may be correct.

Wear a mask during the procedure.

Clean the catheter exit site every day.

Maintain meticulous aseptic technique.

Wash your hands before the exchange.

Store supplies in a clean and dry location.

Rationale The location of the peritoneal dialysis catheter makes it a direct portal to the peritoneum, which increases the client’s risk for peritonitis. The nurse would ensure

that the client understands the importance of preventing peritonitis when providing instructions on performing peritoneal dialysis. The client would be instructed to wear a mask during the procedure, especially when changing connector sets. The nurse would show the client how to properly clean the area around the catheter exit site and instruct that this be done every day to remove secretions. The client must be aware that meticulous aseptic technique throughout all phases of the exchange is essential. Proper hand-washing technique would be demonstrated and the client instructed on the importance of hand washing before the exchange. Supplies would be stored in a clean and dry place.

Which laboratory value would the nurse assess when preparing a client for a renal biopsy? Select all that apply. One, some, or all responses may be correct.

Hematocrit Hemoglobin Platelet count Prothrombin time (PT) with international normalized ratio (INR) Partial thromboplastin time (PTT)

Rationale The nurse would assess the client’s hematocrit and hemoglobin before and after the procedure to determine blood loss. The nurse would also check the client’s platelets, PT/INR, and PTT to determine if the client is at risk for hemorrhage.

Which instruction on infection prevention would the nurse include when providing discharge education to a client who received a cadaveric renal transplant? Select all that apply. One, some, or all responses may be correct.

responses may be correct.

Avoid eating from buffets.

Obtain annual flu vaccinations.

Perform regular hand hygiene.

Stay away from crowded areas.

Report a temperature greater than 100.5°F.

Rationale Clients who receive an organ transplant need to take immunosuppressant medications for the rest of their lives to prevent organ rejection. These medications put the client at increased risk for infection. The nurse would provide infection prevention teaching to the client after renal transplant, which would include instructions to avoid eating from buffets, get an annual flu vaccine, practice regular hand hygiene, and avoid crowded areas. Clients would also be instructed to report a temperature greater than 100.5°F to their health care provider as it could indicate infection or organ rejection and requires treatment.

Which statement made by the nurse requires correction when discussing registered nurse licensure in the United States with peers?

"Candidates must pass the NCLEX-RN® examination to become licensed in their state."

"The scope of practice for registered nurses is found in each state’s Nurse Practice Act." "The examination for RN licensure is exactly the same in every state in the United States."

"Passing the NCLEX-RN® examination indicates maximal knowledge base for safe nursing practice."

Rationale The nurse requires correction when stating, "Passing the NCLEX-RN examination indicates maximal knowledge base for safe nursing practice." Passing the NCLEXRN examination means the candidate possesses the minimum knowledge base for nurses to practice safely. Candidates must pass the NCLEX-RN examination to become licensed in their state. The scope of practice for registered nurses is found in each state’s Nurse Practice Act. The examination for RN licensure is exactly the same in every state in the United States regardless of educational preparation (i.e., diploma nurse program, associate’s degree in nursing program, baccalaureate degree in nursing program).

Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.

Which actions by the staff of a mental health unit can lead to client violence? Select all that apply. One, some, or all responses may be correct.

Displaying hyperactivity Inconsistent limit setting Controlling staff members Avoiding direct eye contact Randomly taking away privileges

Rationale Actions that occur in the mental health unit can increase the risk for client violence.

These include inconsistent limit setting, staff members who are controlling, and randomly taking away privileges from clients. Hyperactivity and avoiding direct eye contact do not present the same risk.

Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time, can provide a clue to the most appropriate response or, in some cases, responses.

The nurse is discussing suicide risk with the parents of a group of adolescents. Which types of suicide would the nurse discuss when talking about soft methods? Select all that apply. One, some, or all responses may be correct.

Guns Hanging Ingesting pills Carbon monoxide Cutting one’s wrists

Rationale Ingesting pills and cutting one’s wrists are lower-risk methods and are soft methods. Higher-risk methods include using guns, hanging, or carbon monoxide.

Which information would be placed in the medical record before implementing the use of restraints?

A prescription from the health care provider

Approval of the department of mental health Documentation that the client is not alert and oriented Pharmacological efforts to control the client have failed.

Rationale Federal requirements indicate that use of any restraint, physical or chemical, requires a prescription from the health care provider. The facility does not require approval from the department of mental health. Clients requiring restraints may be combative or at risk for self-harm and not just disoriented. Pharmacological efforts are considered a form of chemical restraint.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = a low-fat, high-protein, low-calorie diet).

Which information would the nurse provide an older adult and caregivers regarding medication safety? Select all that apply. One, some, or all responses may be correct.

Use a pill organizer.

Read all medication labels.

Place pills in unlabeled bottles.

Review medications with pharmacist.

Empty medicine cabinet every 2 years.

Rationale The nurse would instruct the client and caregivers regarding medication safety. This includes using a pill organizer or calendar to remember doses and days to take medications. The nurse would also emphasize the importance of reading all medication labels for possible warnings. The client should review medications with the pharmacist or health care provider. Pills should never be placed in unlabeled bottles because this can lead to confusion about which medication it is. The medicine cabinet should be emptied at least every year for expired medications and old prescriptions.

Which finding would lead the nurse to contact the state bureau of motor vehicles to obtain a driving evaluation for an older adult?

Cancer Arthritis Dementia Depression

Rationale A client with cognitive deficits such as dementia may lead the nurse to contact the state bureau of motor vehicles. Confusion that accompanies dementia could place the client and others at risk if the client were driving. Cancer, arthritis, and depression do not normally lead to driving impairment.

Which explanation is the rationale for performing sponge, needle, and instrument counts in the operating room?

The hospital is not liable if a client is injured resulting from a retained sponge or instrument.

The nursing student is liable for client injuries resulting from a retained sponge or instrument.

The nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards.

The primary health care provider is responsible for providing an accurate count of sponges and instruments.

Rationale The nurse would perform sponge and instrument counts in the operating room as part of routine surgical standards to help prevent injuries and lawsuits. If a client suffers from an injury resulting from a retained sponge or instrument, the hospital is liable if the nurse recorded an accurate count. A nursing student is not allowed to perform vital tasks such as counting sponges and instruments in the operating room. Even though the primary health care provider may insert sponges and instruments in a client, the provider relies on the nurse to maintain an accurate count at the end of the procedure.

Which assessment would the nurse complete to promote safety before administering pain medication to an older adult?

Blood pressure Client’s pain level rating Bowel sounds and function Other prescribed medications

Rationale Older adults are frequently prescribed multiple medications that can have side effects when combined with analgesics. Therefore, the nurse would assess which

other medications the client is taking before administering analgesics. Blood pressure, pain level, and bowel sounds should be assessed, but these assessments do not promote safety.

The nurse is working with an older adult brought to the emergency department after sustaining multiple falls at home. The nurse suspects alcohol abuse. Which finding places the client at risk for injury?

Depression Self-neglect Malnutrition Lack of insight

Rationale Lack of insight can occur in older adults who have excessive alcohol intake. This can place the client at risk for injury because the client is unable to think through the ramifications of his or her actions. Depression, self-neglect, and malnutrition are physical and mental manifestations of alcohol abuse but do not directly place the client at risk for injury.

Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely.

Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatmentspecific option.

To meet the criteria of ethical practice, which action would the nurse who witnessed the spouse of a client fall take?

Initiate an agency incident report.

Report the fall to the state (provincial) health department.

Write a brief description of the incident to be kept by the nurse manager.

Determine that no documentation is needed because the visitor is not a client in the hospital.

Rationale Health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor. Falls by visitors are not required to be reported to state (provincial) health departments. However, incident reports are required to be presented to accrediting agencies for review when an agency is in the process of being accredited. Writing a brief description of the incident to be kept by the nurse manager is not a requirement of ethical practice. However, the nurse who is involved in an incident or is a witness to an incident would write an accurate description of the event, along with the names of individuals involved. This documentation would be kept by the nurse at home.

Lawsuits may take several years before they come to trial, and personal notes may help the nurse recall the event. The documentation must accurately contain the same elements included in the formal incident report. Taking no action is irresponsible. All events out of the ordinary that result in or have the potential to harm a visitor would be documented in an agency incident report.

Which action would a nurse take to prevent a parallax error and to ensure accuracy when assessing a client’s blood pressure?

Elevate the head of the bed.

Use the appropriate-sized cuff.

Read the manometer at eye level.

Place the cuff at the level of the heart.

Rationale A parallax error is the apparent displacement of an observed object, such as the indicators on the manometer, because of the position of the observer. Elevating the head of the bed is not associated with a parallax error. If the appropriate-sized cuff is not used, an inaccurate reading will result, but it will not be caused by a parallax error. If the cuff is not placed at the level of the heart, an inaccurate reading will result, but it will not be caused by a parallax error.

Which professional strategy is most effective for nurse leaders and managers to implement in improving safety and quality of clientcentered care?

Autonomy Guidance Delegation Accountability

Rationale Delegation is the most effective strategy for nurse leaders and managers to implement to improve safety and quality of client-centered care. Delegation requires knowing the level of competence of the individual delegatee and understanding the concepts of responsibility, authority, and accountability.

Autonomy for the nurse is the ability to control one’s practice. "Guidance" is a general term meaning providing direction or instruction. Accountability is assuming personal responsibility for actions.

Which nursing resource must be available to effectively meet potential

needs during a disaster? Select all that apply. One, some, or all responses may be correct.

Staff Medication Hospital beds Mechanical ventilators Personal protective equipment

Rationale Preparation for disasters includes ensuring resources are available to meet potential needs. The nurse leader must ensure there is adequate staff, medication, hospital beds, medical devices such as mechanical ventilators, and personal protective equipment available to address potential needs during a disaster.

Which safety precaution would the nurse employ when assisting with the removal of a client’s vaginal radium seeds?

Clean the radium in ether or alcohol.

Wear foil-lined rubber gloves while handling the radium.

Ensure long forceps are available for removing the radium.

Document how long the radium seeds were in the vaginal vault.

Rationale Radium must be handled with long forceps because distance helps limit exposure.

The nurse does not clean radium implants. Foil-lined rubber gloves do not provide

adequate shielding from the gamma rays emitted by radium. The amount and duration of exposure are important in assessing the effect on the client; however, documentation will not affect safety during removal.

Test-Taking Tip: Reread the question if the answers do not seem to make sense because you may have missed words such as not or except in the statement.

Which postpartum complication would the nurse monitor for in a client with hydramnios?

Infection Hemorrhage Hypertension Thromboembolism

Rationale A client with hydramnios is at risk for hemorrhage in the postpartum period.

Infection, hypertension, and thromboembolism are not specific risk factors related to hydramnios.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

When caring for a client in the third trimester of pregnancy with a history of myocardial infarction, which statement made by the client would concern the nurse the most?

"I have been tired throughout this pregnancy."

"When I stand for a while, my legs get swollen."

"I experienced quite a bit of nausea in the first trimester."

"I have been using cough drops to try and get rid of my cough."

Rationale Obstetrical clients with a history of myocardial infarction are at risk for cardiac decompensation. A frequent moist cough is a finding associated with cardiac decompensation and should be investigated. The feeling of fatigue throughout the pregnancy has been ongoing and is not a new symptom for the client. Swelling in the lower extremities after standing for long periods and nausea in the first trimester are not uncommon symptoms associated with pregnancy.

Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question.

A newly pregnant client reports that she is taking isotretinoin. Which

A newly pregnant client reports that she is taking isotretinoin. Which statement applies to the care of this client?

Isotretinoin is used to suppress hunger in individuals trying to lose weight, so the client should stop taking the medication.

Isotretinoin is often used to treat migraines associated with hormonal changes and should be safe for continued use as needed.

Isotretinoin is teratogenic and is associated with major fetal malformations, so the client should stop the medication immediately.

Isotretinoin is an atypical antipsychotic, and the woman needs to make an immediate appointment with her mental health care provider to discuss alternative medications.

Rationale Isotretinoin is used to treat severe acne that has not responded to other forms of treatment. It is teratogenic, and pregnancy should be avoided by female clients taking the medication. Isotretinoin is not used in a weight-loss program, is not used to treat migraines, and is not an antipsychotic.

Which is the priority nursing intervention for a client with severe preeclampsia?

Isolating in a dark room Maintaining supine position Encouraging ample amounts of clear fluids Promoting a calm environment without noxious stimuli

Rationale Bed rest, a quiet room, and minimal stimulation are implemented to reduce the

risk of seizures. The client will need frequent monitoring and should not be isolated. Maintaining a supine position may cause temporary supine hypotension and resultant fetal bradycardia; it also may result in aspiration if a seizure occurs.

Fluids may be restricted in the pre-eclamptic client.

A client is admitted in active labor at 39 weeks’ gestation. During the initial examination, the nurse identifies multiple red, blisterlike lesions on the edges of the client’s vaginal orifice. Which is the priority nursing action?

Administering the intravenous antibiotic Preparing for an urgent cesarean birth Obtaining a culture swab of the lesions for testing Documenting the presence of the lesions

Rationale The lesions are probably a herpes infection, which can be fatal to the newborn if it is transmitted during a vaginal birth. A cesarean birth is indicated when lesions are present to prevent transmission to the neonate. Herpes is a viral infection that does not respond to antibiotics. Obtaining a culture swab is not the priority as herpes lesions may be diagnosed by the provider without culture results. Documenting the lesions would be important, but may be completed following urgent care of the client in active labor.

A full-term client in active labor arrives to the birthing unit with a recent history of a chlamydial infection. She reports not taking all of her prescribed medication because she "felt better." Which would the nurse anticipate as part of the plan of care?

Administration of antibiotics before delivery Administration of antiviral medication before delivery Administration of epidural anesthesia before delivery Administration of oxytocin before delivery

Rationale A maternal chlamydial infection can be transmitted to the newborn during passage through the birth canal; therefore, administration of antibiotics before delivery is necessary. Chlamydia is not a virus. Antiviral medication is not indicated. A cesarean birth may be indicated following a discussion between the provider and the patient.

Epidural anesthesia is not indicated based upon the information provided in the question. Oxytocin is not indicated based upon the information provided in the question.

Which action would the nurse take for an older resident in a nursing home with Alzheimer disease who hoards leftover food and other seemingly valueless articles and stuffs them into pockets "so the others won’t steal them"?

Remove the resident’s unsafe and soiled articles during the night.

Give the resident a small bag in which to place selected personal articles and food.

Explain to the resident why the nursing home’s policy for cleanliness and safety must be followed.

Tell the resident that the staff is required to keep harmful objects out of reach in the resident’s closet.

Rationale The nurse would give the resident a small bag in which to place selected personal articles and food. This action allows the client to exercise the right to decide which articles to keep and helps ensure safety and cleanliness. Removing the resident’s unsafe and soiled articles during the night deceives the client and will create mistrust toward the staff. Because of the client’s decreased attention span and memory, explanations alone will not help ensure safety or meet this client’s needs.

Telling the resident that the staff is required to keep harmful objects out of reach in the resident’s closet does not address the client’s needs and with the loss of shortterm memory, this may be futile; no data indicate that the resident is hoarding harmful objects.

Applying the emergency severity index (ESI) criteria, which client condition would the nurse consider least severe?

Cardiac arrest Abdominal pain Multiple trauma Closed extremity trauma

Rationale Care for a client with closed extremity trauma could be delayed because it is considered less severe when compared with other client conditions and triaged in emergency severity index (ESI-4). This client is given least priority. The client with cardiac arrest is triaged under ESI-1 and should be seen immediately because the

condition is more severe. The client with abdominal pain is triaged under ESI-3 and should be seen within 1 hour. The client with multiple trauma should be seen within 1 hour and is triaged under ESI-2.

Based on their condition, which client would be triaged first according to the 3-tiered triage system?

Client A Client B Client C Client D

Rationale Client A reporting chest pain is considered to have a life-threatening condition and is triaged as emergent. Clients B and C having displaced or multiple fractures and renal colic need quick treatment but are not considered to have immediately lifethreatening conditions, particularly when compared with client A’s condition. They are triaged in the urgent tier level. Client D with strains and sprains is triaged as nonurgent because this client can wait for treatment.

Which client would be triaged under emergency severity index (ESI)-1 based on threat to life and stability of vital functions?

A B C D

Rationale Client B in cardiac arrest will have unstable vital functions of the ABCs (airwaybreathing-circulation) and a threat to life exists. The client should be triaged under the ESI-1 level and should be seen immediately by the primary health care provider.

Client A with chest pain has threatened vital functions but is not unstable and should be seen within 1 hour. This type of client is categorized as ESI-2. Client C

who has a simple laceration is categorized as ESI-4, which indicates that the vital functions are stable and the client has no immediate threat to life. Client D who has a hip fracture is triaged as ESI-3, which indicates that the vital function is stable and a threat to life is unlikely.

Test-Taking Tip: Recall the conditions that are generally triaged by the emergency severity index based on the vitality function or threat to life to choose the correct answer.

Which condition would the nurse triage as urgent among these client conditions?

A B C D

Rationale Client A with displaced or multiple fractures does not have an immediately lifethreatening condition, but needs immediate treatment when compared with other clients, so is considered urgent and triaged under urgent. Client B with a skin rash, client C with strains and sprains, and client D with a simple fracture could wait several hours and are triaged as nonurgent.

Which client would be treated immediately according to the disaster triage tag system?

Client A Client B Client C Client D

Rationale According to the disaster triage tag system, the red tag is used to label the clients who require immediate treatment; therefore client A should be seen immediately.

The yellow tag is applied to clients who can wait for a short time for the treatment. A black tag is issued to the clients who are dead or expected to die. Green tags are issued to clients who can ambulate on their own.

Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly because there usually is no pattern to the answers.

Which client would the triage nurse provide care to first based on condition?

A B C D

Rationale Client A with severe respiratory distress is triaged under emergency severity index 1 (ESI-1) and should be seen immediately because their condition is most severe.

Client B with chest pain resulting from trauma is triaged under ESI-2 and is seen within 1 hour. Client C with a hip fracture could be delayed treatment because the condition is less severe and is prioritized as ESI-3. Client D with cystitis is triaged as ESI-4, and the client could receive delayed treatment.

The client with which core body temperature would require priority critical care?

30°C

27°C 32°C 29°C

Rationale Severe hypothermia, or a core body temperature below 82.4°F (28°C), can cause cardiac arrest. The client with a core body temperature of 27°C should be treated first to ensure safety. Clients with moderate hypothermia (82.4°F-90°F [28°C-32°C]) are at lesser risk for cardiac arrest than clients with severe hypothermia. Clients with core body temperatures of 30°C, 32°C, and 29°C can be treated after treating the client with a core body temperature of 27°C. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

Which client condition would be prioritized by the nurse under the emergent classification? Select all that apply. One, some, or all responses may be correct.

Shock Contusion Open fracture Airway obstruction High cervical spinal cord injury

Rationale Clients with shock and airway obstruction have immediate threat to life and are

triaged under the emergent class, or class 1. The client with contusion is triaged under the nonurgent, or class 3, category because a contusion is a minor injury and the client is ambulatory. The client with an open fracture has a major injury and is triaged under urgent, or class 2, but not the emergent class. The client with a high cervical spinal cord injury may be classified as expectant, or class 4, which means the client is deceased or likely to die before medical intervention can be mobilized.

Which staff member would be the first to manage the care of victims from an accident at a nuclear power plant?

Emergency medicine health care provider Emergency medical technicians Paramedics Prehospital care providers

Rationale Prehospital care providers are the first caregivers before clients are transported to the emergency department by ambulance or helicopter. Paramedics are the advanced life support (ALS) providers who generally perform advanced techniques.

These staff members provide advanced care but are not given priority to help in providing transport. Emergency medicine health care providers are professionals with specialized education and training in emergency client management.

Emergency medical technicians render basic life support (BLS) interventions to clients.

A client who has syphilis tells the nurse that it must have been contracted from a toilet seat. The nurse knows that this cannot be true because of which property of the causative agent of syphilis?

It is immobilized by body contact.

It is chelated by wood and plastic.

It is inactivated when exposed to a dry environment.

It is destroyed when exposed to a warm environment.

Rationale A dry environment inactivates Treponema pallidum, making it incapable of causing disease. The organism is transferred by warm, moist, sexual body contact, which supports growth of the organism. Nothing chelates this organism.

A client with which condition would the nurse treat first according to a three-tiered triage system?

Respiratory distress Simple lower limb fracture Multiple soft tissue injuries New onset of respiratory tract infection

Rationale According to a three-tiered triage system, respiratory distress is categorized as an emergent or life-threatening condition. Clients with respiratory distress should be treated first. A simple leg fracture is considered a nonurgent condition, and the client can wait for hours to receive treatment. Multiple soft tissue injuries are categorized as urgent but not life-threatening according to a three-tiered triage system. Clients with multiple soft injuries and new onset of respiratory tract infection can be treated after treating the client with respiratory depression.

Which nursing intervention would be the priority for a client with multiple injuries from an accident?

multiple injuries from an accident?

Establishing a patent airway in the client Cleaning injuries with an antiseptic solution Administering blood of appropriate blood type Administering intravenous (IV) fluids and electrolytes

Rationale A client who could have a brain injury can progress rapidly to anoxic brain death without an adequate oxygen (O 2) supply. The priority nursing intervention in a client in the ED is to establish a patent airway to ensure adequate O 2 supply. The nurse can clean the injuries with an antiseptic solution after establishing a patent airway. The nurse can administer blood and IV fluids and electrolytes to the client after establishing a patent airway.

Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

Which action would the nurse take when a client with tuberculosis (TB) is admitted to the nursing unit?

Put on a gown when entering the room.

Place the client with another client who has TB. Wear a particulate respirator when caring for the client.

Don a surgical mask with a face shield when entering the room.

Rationale Centers for Disease Control (Canada: Public Health Agency of Canada) guidelines recommend use of a high-particulate filtration mask to protect health care workers from exposure to the Mycobacterium tuberculosis organism. Airborne transmissionbased precautions do not require a gown unless contact with respiratory secretions is anticipated. The client should be placed in a private room with negative pressure and multiple full air exchanges per hour vented to the outside environment. A surgical mask with a face shield is inadequate to prevent transmission of the tuberculosis microorganism.

During the hourly assessment of client’s intravenous (IV) line, the nurse discovers that the prescribed amount of solution was not delivered during the past hour. Which action would the nurse take?

Increase the flow rate.

Inspect the infusion setup.

Provide the client a glass of juice.

Notify the health care provider.

Rationale Assessment is the first step in the nursing process. Before the problem is diagnosed and nursing care is planned and implemented, data must be collected to determine the cause of the problem. Increasing the flow rate is unsafe without a health care provider’s prescription. Assessment may indicate that an independent nursing intervention is required, or it may provide significant information that should be communicated to the health care provider. Oral intake is not related to IV intake.

Also, the health care provider may have prescribed nothing-by-mouth status.

Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel

insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point.

Which parent education would the nurse include about the cause of most cases of otitis media?

A virus Bacteria A fungus Rickettsia

Rationale Otitis media, one of the most prevalent illnesses in toddlers, is caused by a bacterial infection. The causative agent is not a fungus, virus, or rickettsial organism.

Which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place?

"The restraints will be removed once the client is extubated."

"We are required to restrain all clients with breathing tubes."

"Restraints are a last resort to prevent accidental extubation."

"It is routine procedure for us to restrain all intubated clients."

Rationale Restraints are a last resort to protect the airway and are only used as long as necessary. The need for restraints is evaluated frequently, and restraints are discontinued as soon as the client is able to understand and comply with the need to not pull or attempt to reposition the endotracheal tube. The need for restraints will be reassessed at least every 24 hours and a new prescription obtained if restraints are still needed. It is not a requirement to restrain all clients who have breathing tubes. Restraints are never considered routine practice for intubated clients.

Which action will the nurse take to support safe oral intake after tracheostomy?

Include thin liquids.

Provide large meals.

Inflate the tracheostomy cuff fully.

Position client as upright as possible.

Rationale After tracheostomy, positioning the client as upright as possible supports safe eating by preventing aspiration. Thin liquids are more difficult to swallow and increase the risk for aspiration. Large meals may cause overdistention of the stomach and lead to regurgitation and aspiration; meals should be small and frequent. The tracheostomy cuff should be deflated to decrease interference with swallowing.

A client with a chest tube is to be transported via a stretcher. When

transporting the client, what would the nurse do?

Keep collection device attached to mechanical suction Keep chest tube clamped distal to the water-seal chamber Keep collection device below the level of the client's chest Keep chest tube end covered with sterile gauze pads taped to the client

Rationale The collection device must be kept below the level of the chest to prevent backflow of fluid into the pleural space. A chest tube clamped distal to the water-seal chamber is contraindicated. The chest tube should not be clamped because it may precipitate a tension pneumothorax. A chest tube end covered with sterile gauze pads taped to the client is contraindicated. There is no reason to disconnect the chest tube from the water-seal system; this will allow atmospheric air to enter the pleural space, causing a pneumothorax.

Which statement by the wife of a client receiving hemodialysis who undergoes surgery to create an arteriovenous fistula indicates that further teaching is required?

"I must touch the shunt several times a day to feel for the bruit."

"I have to take his blood pressure every day in the arm with the fistula."

"He will have to be very careful at night not to lie on the arm with the fistula."

"We really should check the fistula every day for signs of redness and swelling."

Rationale Taking the blood pressure in the affected arm may injure the fistula. The presence of a bruit indicates that the circulation is not obstructed by a thrombus.

Hemorrhage can occur in a matter of minutes if the cannula is dislodged. It is correct that the patient should not lie on the arm with the fistula.Redness and swelling are signs of infection, which is a complication of cannulization.

Which suggestion will the nurse make to minimize orthostatic hypotension when teaching a client who has a new prescription for antihypertensive medication?

Wear support hose continuously.

Lie down for 30 minutes after taking medication.

Avoid tasks that require high-energy expenditure.

Change position slowly when going from lying to standing.

Rationale Changing position slowly when going from lying to sitting to standing gives the body a chance to adjust to the effects of gravity on circulation in the upright position. Support hose may help prevent orthostatic hypotension by increasing venous return. However, they must be applied before getting out of bed and should not be worn continuously. Lying down for 30 minutes after taking medication will not prevent episodes of orthostatic hypotension. Energetic tasks, once standing and acclimated, do not increase hypotension.

Which intervention would help facilitate communication and coordination during a mass casualty event in a hospital using the Hospital Incident Command System? Select all that apply. One, some, or all responses may be correct.

Activate communication equipment.

Establish a command center in a designated location.

Provide key personnel with distinctive clothing identifying their role.

Ensure key personnel are properly immunized and have a personal emergency plan.

Distribute job action sheets identifying reporting relationships, tasks, and responsibilities.

Rationale To facilitate communication and coordination during a mass casualty event in a hospital using the Hospital Incident Command System, communication equipment needs to be activated. In addition, a command center needs to be created in a designated location. Key personnel need to be easily identified, which can be done by providing distinctive clothing that identifies their role. Job action sheets that identify reporting relationships, tasks, and responsibilities will also help facilitate communication and coordination at this time. Key personnel do not need to be immunized or have a personal emergency plan when handling a disaster within an organization.

Which type of event can often be handled by an individual hospital disaster plan without collaboration with other systems?

A motor vehicle accident involving five cars A tornado destroying 50 homes and businesses An act of terrorism injuring and killing hundreds of people A hurricane causing flooding and displacing thousands of people

Rationale A multicasualty event, such as a motor vehicle accident involving five cars, is an event that can often be handled with the implementation of an individual hospital disaster plan without collaboration with other systems. Any mass casualty event, such as a tornado, an act of terrorism, or a hurricane, often requires not only the implementation of the hospital disaster plan but collaboration with other systems.

STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress.

Which injuries would likely be given a green tag after a disaster?

Select all that apply. One, some, or all responses may be correct.

Shock Strains Sprains Abrasions Airway obstruction

Rationale According to the disaster triage tag system, green tags are applied to clients with strains, sprains, and abrasions. Clients with shock and airway obstruction are marked with red tags according to the disaster triage tag system.

Which groups may be activated by state and federal government

authorities to assist during a flooding situation that results from a hurricane? Select all that apply. One, some, or all responses may be correct.

National Guard American Red Cross Medical Reserve Corps Public health departments Local emergency departments

Rationale During catastrophic mass casualty events, such as flooding that can occur with a hurricane, the National Guard, the American Red Cross, the public health department, various military units, a Medical Reserve Corps (MRC), or a Disaster Medical Assistance Team (DMAT) can be activated by state and federal government authorities. Although authorities may contact local emergency departments for notification purposes, they do not have the authority to activate a disaster preparedness plan for individual emergency departments.

Which unit in the hospital would be the priority for implementation and evaluation of a workplace violence protection plan as one component of a hospital disaster plan?

Medical unit Surgical unit Emergency department Maternity department

Rationale The Emergency Nursing Association (ENA) supports comprehensive workplace violence prevention plans to be included as a component of the organizational disaster plan. The ENA recommends that the comprehensive workplace violence prevention plan be implemented and evaluated in every emergency department.

Medical units, surgical units, and maternity departments may also require such plans; however, these units have system barriers that decrease the risk for violence when compared with emergency departments.

Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

Which nursing actions contribute to a health care facility’s emergency preparedness and response before a natural disaster? Select all that apply. One, some, or all responses may be correct.

Participating in drills Evaluating outcomes Activating a telephone tree Performing a triage assessment Discharging clients who no longer require acute care

Rationale Nursing actions that contribute to a health care facility’s emergency preparedness and response include participating in drills and evaluating outcomes. Activating a

telephone tree, performing a triage assessment, and discharging clients who no longer require acute care are nursing actions that occur during a health care facility’s response to an actual natural disaster.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

The nurse is changing the soiled bed linens of a client with a wound that is draining serosanguinous exudate. Which personal protective equipment (PPE) would the nurse wear?

Mask Clean gloves Sterile gloves Shoe covers

Rationale Clean gloves protect the hands and wrists from microorganisms in the linens. Clean gloves are the first line of defense in preventing the spread of infection. Mask, sterile gloves, and shoe covers are not required for this situation.

Which resource can the staff educators use to assist with the education of health care providers who work within the system when implementing a Hospital Incident Command System (HICS) for a disaster preparedness plan for the entire health system?

National Incident Management System (NIMS)

Centers for Medicare and Medicaid Services (CMS) Occupational Safety and Health Administration (OSHA) Federal Emergency Management Administration (FEMA)

Rationale FEMA offers free courses on the NIMS model and HICS structure through their website (www.training.fema.gov/IS/). CMS requires a certain number of drills per year to be in compliance with their disaster preparedness mandates. OSHA does not provide education for the implementation of a disaster preparedness plan at the hospital level.

Which emergency response team is involved in emotional recovery of victims after a disaster?

American Red Cross Disaster Medical Assistance Team (DMAT) Community Emergency Response Team Federal Emergency Management Agency

Rationale The American Red Cross has a critical incident stress management unit. This unit arranges group discussions to allow participants to share and validate their feelings and emotions about the experience. DMAT is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours, and they are part of the National Disaster Medical System (NDMS) in the United States. A community emergency response team and the Federal Emergency

Management Agency train citizens to understand their personal responsibility in preparing for a natural or man-made disaster.

STUDY TIP: Focus your study time on the common health problems that nurses most frequently encounter.

Which nursing intervention would prevent septic shock in the hospitalized client?

Maintain the client in a normothermic state.

Administer blood products to replace fluid losses.

Use aseptic technique during all invasive procedures.

Keep the critically ill client immobilized to reduce metabolic demands.

Rationale Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.

Which disaster triage tag would the nurse apply to the group of clients who have extensive full-thickness body burns and severe head trauma after an apartment building fire and clients who require mechanical ventilation for survival?

Red Black Green

Yellow

Rationale Clients with extensive full-thickness body burns, severe head trauma, and high cervical spinal cord injury requiring mechanical ventilation are given black tags because they are expected to die. Clients with airway obstruction or shock are given red tags because they require immediate attention. Clients with open fractures with a distal pulse and large wounds that need treatment within 30 minutes to 2 hours are given yellow tags. Green tags are issued to clients with minor injuries.

Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

Which agents of bioterrorism can be treated effectively with antibiotics? Select all that apply. One, some, or all responses may be correct.

Plague Anthrax Botulism Tularemia Hemorrhagic fever

Rationale

Bioterrorism agents such as plague, anthrax, and tularemia are caused by bacterial species and are treated effectively by antibiotics. Botulism is treated with antitoxin though several vaccines are being studied. There are no established antiviral medications for most viruses causing hemorrhagic fever.

The nurse is working with a child who was physically abused by a parent. Which is the most important goal for this family?

The child will live in a safe environment.

The parents will use verbal discipline effectively.

The family will feel comfortable in its relationship with the counselor.

The parents will gain an understanding of their abusive behavior patterns.

Rationale The most important goal and top priority is to ensure the safety of the child. Once this is ensured, other goals can be identified and fulfilled, including the parents using verbal discipline effectively, the family feeling comfortable in its relationship with the counselor, and the parents gaining an understanding of their abusive behavior patterns.

After a bomb blast in a city, why would the federal government send the Medical Reserve Corps (MRC) to the site?

To provide advanced Disaster Life Support training To establish first aid stations or special-needs shelters To establish fully functional field surgical facilities to victims To provide medical equipment sufficient for 72 hours to victims

Rationale The MRC helps establish first aid stations or special-needs shelters to victims of a disaster. The National Disaster Life Support Foundation renders core, basic, and advanced disaster life support training courses. International Medical-Surgical Response Teams (IMSRTs) establish fully functional field surgical facilities. A Disaster Medical Assistance Team (DMAT) is a medical relief team that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

Which additional assessments should be conducted on an 18-year-old woman who was confused when found on the bathroom floor and her urinalysis tested positive for flunitrazepam?

Assess for signs of sexual assault.

Observe for hallucinations or delusions.

Directly ask about suicidal intentions.

Monitor for renal failure.

Rationale Flunitrazepam, illegal in the United States, has been used in date rapes; the side effects include sedation, muscle relaxation, confusion, memory loss, dizziness, and impaired coordination. Flunitrazepam is not used to treat psychosis or depression, or hangover symptoms.

Which type of natural disaster will the nurse manager recommend be included in the emergency response plan for a hospital located in the Rocky Mountains?

Rocky Mountains?

Tornado Hurricane Avalanche Earthquake

Rationale Disaster drills are ideally planned based on a risk assessment or vulnerability analysis that identifies the events most likely to occur in a particular community. For a hospital in the Rocky Mountains there is a significant risk for an avalanche; meanwhile, there is not a significant risk for tornados, hurricanes, or earthquakes.

The nurse manager will, therefore, recommend that avalanche planning be included in the hospital disaster plan.

Which statement regarding the role of the community emergency response teams (CERTs) would the nurse include in a presentation to the community regarding the need for volunteers?

"You will learn triage skills during the training process."

"You will need to report to your nearest hospital in the event of a natural disaster."

"You will learn decision-making and rescuer safety skills during the training process."

"You will be required to submit your name as a first responder in the event of a natural disaster."

Rationale

CERTs are recognized by the Federal Emergency Management Agency (FEMA) as important partners in emergency preparedness. As part of the CERT team, members learn decision-making and rescuer safety skills. CERTs are an extension of the first responder services. They can offer immediate help to victims and organize untrained volunteers to assist until professional services arrive. CERT team members are not taught triage skills; they are not required to report to the nearest hospital in the event of a natural disaster; they are not required to submit their names as first responders.

Which internal disaster may create a need for evacuation or relocation of clients?

Hurricane Earthquake Gas explosion Terrorism with explosive devices

Rationale A gas explosion is an internal disaster that creates a need for evacuation or relocation. A hurricane or earthquake are natural disasters and are external. The use of explosive devices for a terrorist attack is also an external disaster.

Which role is a function of the Hospital Incident Command System (HICS) in disaster management? Select all that apply. One, some, or all responses may be correct.

To manage mass fatalities To provide first aid stations To standardize disaster operations

To establish emergency animal care To establish an emergency operations center (EOC)

Rationale The HICS is the facility-level organizational model for disaster management. It functions to standardize disaster operations. HICS personnel establish an EOC or command center. Disaster Mortuary Operational Response Teams (DMORTs) manage mass facilities. A Disaster Medical Assistance Team (DMAT) is a medical relief team that provides first aid stations. A National Veterinary Response Team (NVRT) is a health care service that establishes emergency animal care.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which finding is an effect of long-term exposure to mustard gas?

Select all that apply. One, some, or all responses may be correct.

Skin burns Skin blisters Irritation of eyes Pulmonary edema Respiratory depression

Rationale Mustard gas may be used as a chemical weapon in a terror attack. It causes skin

burns, skin blisters, and irritation to the eyes upon prolonged exposure. Pulmonary edema and respiratory depression may occur with exposure to phosgene gas.

STUDY TIP: Enhance your organizational skills by developing a checklist and creating ways to improve your ability to retain information, such as using index cards with essential data, which are easy to carry and review whenever you have a spare moment.

Which nursing intervention made by the nurse caring for a client who survived an earthquake indicates a need for correction?

Avoiding stereotypical talk Making prejudicial remarks Maintaining situational awareness Isolating the client in case of airborne disease

Rationale The nurse would avoid prejudicial remarks to develop trust in the client. The nurse would avoid stereotypical talk and should speak calmly. The nurse would maintain situational awareness while caring for clients in emergency department. The nurse would assess the need to isolate the client in case of airborne diseases.

Which action, if performed by the nurse, is inappropriate while caring for different clients after a disaster?

Teaching and supervising volunteers Providing on-site first aid and emergency care Evacuating injured and uninjured people from a danger area Teaching clients about procedures that are needed for safety

Rationale After a disaster, evacuating the injured and uninjured people from the danger area and placing them in a safer place is done by firefighters and other disaster-trained emergency personnel. The nurse would not perform this action because they are not provided with specific rescue training. The nurse would teach and supervise volunteers to effectively perform during disasters. The nurse would provide on-site first aid treatment to the clients. The nurse would also perform the emergency care at the disaster site. Teaching the client about safety measures at home is appropriate.

Which practical response would the nurse provide a sexually active female client who is upset with her diagnosis of gonorrhea and asks the nurse, "What can I do to prevent getting another infection like this?"

"Douche after every sexual intercourse."

"Avoid engaging in sexual behaviors."

"Insist that your partner uses a condom."

"Use a spermicidal cream with sexual intercourse."

Rationale Once people become sexually active, they usually remain sexually active; a condom, although not 100% effective, is the best protection against gonorrhea in a sexually active person. The response, "Douche after every intercourse," has no proven protective effect against sexually transmitted infections; excessive douching can alter the vaginal environment and may promote an ascending infection. The response, "Avoid engaging in sexual behavior," is not a realistic response to a sexually active person. Spermicidal cream has no protective effect against sexually transmitted

infections.

Why would the nurse claim class III clients are of major concern in the hospital environment after a nuclear accident?

They are emergency cases.

They are extremely injured.

Their life can be easily saved.

They often come to the hospital on their own.

Rationale Green-tagged or class III clients may evacuate themselves from the disaster and are able to reach the hospital on their own. They may unknowingly carry contaminants from a nuclear, biological, or chemical disaster into the hospital environment, with potentially disastrous consequences. Clients considered class III are less injured and can be managed later. They are not emergency cases. Clients in the class III category are nonurgent and do not require immediate treatment. Clients with green tags have fewer injuries and their lives can be saved, and this may not be a major concern in the hospital environment after a nuclear explosion disaster.

When the emergency department nurse expects death in a client critically injured in a bomb blast, which would be the appropriate triage categorization for the client?

Urgent Emergent Expectant Nonurgent

Rationale Clients who are expected to die or are dead are categorized under class IV triage level or as expectant. Urgent or class II clients are those who require immediate treatment, but can wait for a short period. Emergent or class I clients are those who have an immediate threat to life and require immediate treatment. Nonurgent or class III clients are those who have minor injuries and do not require immediate treatment.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which behavior is most important to prevent for clients with mental health disorders?

Breaking contracts Ruminating over losses Harming themselves or others Attending to hallucinations

Rationale The physical safety of the client and others is the priority. Although it is important for clients to avoid breaking contracts, this cannot always be prevented. The nurse can teach clients to use distraction and interruption to decrease rumination and hallucinations, but this is learning process that takes time.

Which trauma center level is appropriate for the client who survived

Which trauma center level is appropriate for the client who survived an earthquake and is found to have multiple injuries and requiring stabilization?

Level I Level II Level III Level IV

Rationale A level III trauma center provides stabilization to a client with multiple injuries. A level I trauma center provides a full continuum of trauma services for all clients.

Level II trauma centers provide care to the most injured clients. Level IV provides advanced life support and basic trauma client stabilization.

The nurse finds that the surgical mask being worn has become moist before going into a surgery. Which would the nurse do?

Dispose of the mask and put on a new one.

Wait until the mask gets dry and then enter the operating room.

Do not cough or sneeze while wearing the mask.

Talk less after wearing the mask to minimize respiratory airflow.

Rationale The nurse would dispose of a mask if it gets moist or wet because the mask might have been contaminated. The nurse would not wait until the mask gets dry; instead, the mask should be changed. Coughing or sneezing should be avoided when the

nurse is in a sterile area. The nurse would talk less after wearing a dry or sterile mask to minimize respiratory airflow.

Which casualty condition would be present for a client who survived a tornado and is assigned a red tag?

No treatment, expected to die Treatment can be delayed, minor injuries Requires emergent treatment, threat to life Require immediate treatment, major injuries

Rationale The disaster triage tag system categorizes triage priority by color and number.

Under mass casualty conditions, a red tag indicates that there is an immediate threat to life that requires emergent treatment. A black tag represents that the client is expected to die and no treatment will be provided. A green tag indicates that there can be delayed treatment due to minor injuries. Major injuries that require immediate treatment are indicated by a yellow tag.

Which intervention will the nurse manager and the critical incident stress management team encourage when debriefing nurses after a mass casualty incident (MCI)?

Sharing feelings Discussing errors Providing respite Organizing volunteers

Rationale The critical incident stress management unit works with employees after a disaster to allow members to share and validate feelings. This allows staff to process the incident and begin to heal, as well as minimize the incidence of posttraumatic stress disorder. Errors are not discussed, and respite is not provided during these meetings. Volunteers are organized during the disaster.

Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

A client with Laënnec cirrhosis experiences ascites, jaundice, and confusion. Which is a nursing priority when caring for this client?

Correcting nutritional deficiencies Measuring abdominal girth every day Providing for the client’s physical safety Placing the client in the high-Fowler position

Rationale Hepatic encephalopathy, related to high ammonia levels, results in central nervous system derangement; physical safety is the priority. Although correcting nutritional deficiencies is important, it is not the priority. Although measuring abdominal girth is important, it is not the priority. The high-Fowler position will be uncomfortable because of the pressure of the distended abdomen against the legs. The semiFowler position is more appropriate, and it promotes respiration.

Which factor puts the nurse at highest risk for developing acute stress disorder after working during a mass casualty event?

Took breaks Talked to clergy Contacted family Worked for 24 hours

Rationale To decrease the risk of acute stress disorder during a mass casualty event, nurses would not work more than 12 hours per day. The nurse that has worked 24 hours is at highest risk for acute stress disorder. Using available counseling, taking regular breaks, and keeping in contact with family and friends decrease the risk of acute stress disorder.

A client with a methicillin-resistant Staphylococcus aureus (MRSA) infected wound is scheduled for a computed tomography (CT) scan.

To ensure client and visitor safety during transport, the nurse would implement which precaution?

No special precautions are required.

Cover the infected site with a dressing.

Drape the client with a covering labeled biohazardous.

Place a surgical mask on the client.

Rationale

Covering the infected site with a dressing will contain secretions and set up a barrier, thus decreasing the risk for transmission to others. Contact precautions must be used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment. Draping the client with a sheet marked biohazardous does not protect the client’s privacy. A wound infected with MRSA can be transmitted to others via contact, not through the airborne route; thus a mask is unnecessary.

Which response would the nurse give to a client with tuberculosis who asks about the communicability of the disease?

"Tuberculosis is not communicable at this time."

"Untreated active tuberculosis is communicable."

"Tuberculosis is communicable during the primary stage."

"With the newer long-term therapies, tuberculosis is not communicable."

Rationale The statement that untreated active tuberculosis is communicable is an accurate statement; treatment is necessary to stop communicability. The statement that tuberculosis is not communicable at this time is false reassurance; untreated active tuberculosis is communicable. Tuberculosis is not communicable when there is no active infection; the primary complex refers to the presence of a primary (Ghon) tubercle and enlarged lymph nodes and is the initial response to exposure; active disease may or may not occur. Tuberculosis is a communicable disease; close contacts would be screened via a skin test.

Which responsibility would the registered nurse appointed as a triage officer of the disaster management team have?

To decide the resources needed for the clients

To determine the priority of treatment for clients To act as leader in implementing the emergency plan To serve as a liaison between the hospital and the media

Rationale The role of the triage officer in disaster management is to evaluate each client and to determine the priority of treatment based on the severity of the client’s condition.

Deciding the resource needs of clients is the responsibility of the medical command physician. The role of the hospital incident commander is to act as a leader in overall implementation of the emergency plan. Serving as a liaison between the health care facility and the media is the responsibility of the public information officer.

Which basic professional certification is most desirable in the nurse who wants to join a team sent to care for earthquake victims?

Certification in Emergency Care Certification in Basic Life Support Certification in Advanced Cardiac Life Support Certification in Pediatric Advanced Life Support

Rationale The Certified Emergency Nurse possesses a certification in core emergency nursing knowledge, which is useful at an emergency disaster site. To perform cardiopulmonary resuscitation in clients with cardiac arrest, the nurse would possess a Certification in Basic Life Support. If the nurse has to perform any invasive airway management, pharmacology, or electrical therapies, an Advanced Cardiac

Life Support certification is desired. If the nurse has to perform any neonatal and pediatric resuscitation, the nurse would possess a Pediatric Advanced Life Support certification.

Which statement by the registered nurse is true regarding the mitigation phase of disaster management?

It is a phase of identifying the potential risks due to the disaster.

It is a process of assisting clients to regain a normal level of functioning.

It is a process of combating a disaster event and providing assistance to victims.

It is a process of minimizing the disaster’s influence on human health and community.

Rationale The process of minimizing the disaster’s influence on human health and community is the mitigation phase. Identifying potential risks due to the disaster is the preparedness phase of disaster management. The process of assisting clients to regain a normal level of functioning is the response phase. The process of combating a disaster event and providing assistance to victims is the recovery phase.

Which step is the first in the disposal of sharp wastes after use on a client with acquired immunodeficiency syndrome (AIDS)?

Place tape over the container.

Place the container in a paper bag.

Place the waste in a puncture-resistant container.

Pour a 1:10 bleach solution in the container.

Rationale The sharp wastes of a client with AIDS should first be placed in a puncture-resistant container and labeled. Then a 1:10 bleach solution should be poured into the container for disinfection. Next the container should be taped to prevent leakage.

The container should then be placed into a paper bag and subsequently disposed of in the regular trash.

Which factors would the nurse educator emphasize when teaching about mass casualty incidents (MCIs)? Select all that apply. One, some, or all responses may be correct.

Involves large numbers of victims Can be from man-made or natural causes Causes permanent changes in a community Requires minimal assistance from outside resources Overwhelms a community’s ability to respond with resources

Rationale MCIs involve large numbers of victims. An MCI is a man-made or natural event or disaster that causes permanent changes within a community. It overwhelms a community’s ability to respond with existing resources. MCIs always require significant assistance from resources outside the affected community.

The nurse is preparing discharge instructions for a client who acquired a nosocomial Clostridium difficile infection. Which would the nurse include in the instructions?

Anticipate that nausea and vomiting will continue until the infection is no longer present.

The infection causes diarrhea accompanied by flatus and abdominal discomfort.

Consume a diet that is high in fiber and low in fat.

Other than routine hand washing, it is not necessary to perform special disinfection procedures.

Rationale The main clinical manifestation of C. difficile is diarrhea accompanied by excessive flatus and abdominal discomfort. Nausea and vomiting are not typically associated with this infectious disease. Clients should follow a nutritionally balanced diet with no specific restrictions. Cleaning and disinfection of items in the home is key to preventing spread of the infection because the C. difficile spore is relatively resistant.

Which action do the employees of a hospital with an organizational goal to participate in emergency management of disasters need to do before being recognized by the National Incident Management System (NIMS)?

Learn basic electrocardiogram interpretation.

Attend training on the incident command system.

Become certified in advanced cardiac life support.

Participate in basic cardiac life support recertification.

Rationale NIMS requires that all emergency services–related disciplines wishing to participate in the emergency management of disasters be incident command system trained.

Basic electrocardiogram interpretation, certification in advanced cardiac life support, and basic cardiac life system recertification are not identified as being NIMS requirements.

Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

A hospital in an urban setting is located on two rivers, which are spanned by several bridges. Resources arrive to this community via commercial trains or airplanes. Which credible threats should this hospital prepare for when constructing the emergency preparedness plan? Select all that apply. One, some, or all responses may be correct.

Floods Landslides Bridge collapses Boating accidents Train derailments

Rationale Preparedness activities must address all credible threats to the safety of the community that could result in a disaster situation. For this community, the rivers

could cause flooding. The bridges that span the rivers could collapse. Community members who use boats on the rivers could have accidents. And the trains that service the community could derail. There is no information to support the potential for landslides.

Which parental statement indicates accurate understanding of bicycle safety for the school-age client?

"My child should ride opposite of traffic."

"My child should ride the bicycle through crosswalks."

"My child should avoid hand signals in advance of stopping."

"My child should keep as close to the curb as possible when in the street."

Rationale The parental statement indicating the school-age child should ride as close to the curb as possible when riding a bicycle in the street indicates accurate understanding of bicycle safety. The child should ride with the traffic, not opposite of traffic. The child should walk, not ride, the bicycle through crosswalks. The child should be taught to use, not avoid, hand signals in advance of stopping.

Wrist restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. Which nursing intervention is correct regarding restraints?

Have the prescription renewed every 48 hours.

Assess the client’s condition per hospital protocol.

Provide range-of-motion exercises to the client’s wrists every shift.

Document output from the nasogastric tube and catheter every 2 hours.

Rationale A restraint impedes the movement of a client; therefore a client’s condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours.

Restraints should be removed and activity and skin care provided at least every 2 hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally does not need to be documented as frequently as every 2 hours. Generally, output from tubes is emptied, measured, and documented at the end of each shift.

Which action is required before several disaster medical assistance team (DMAT) nurses from Pennsylvania can provide health care to hurricane victims in South Carolina?

Applying for licensure in South Carolina Showing Pennsylvania state nursing license None because the nurses are acting as federal employees Calling the National Council for the State Boards of Nursing and request licensure

Rationale Because licensed health care providers such as nurses act as federal employees when they are deployed, their professional licenses are recognized and valid in all states. There is no need for the nurses to apply for licensure in South Carolina, show Pennsylvania license, or call the National Council for the State Board of Nursing to request licensure.

The nurse is reviewing discharge plans with a client who is

The nurse is reviewing discharge plans with a client who is hospitalized with hepatitis A. The nurse concludes that the client understands preventive measures to reduce the risk of spreading the disease when the client makes which statement?

"I should wash my hands frequently."

"I should launder my clothes separately."

"I should put used tissues in the garbage."

"I should wear a mask when leaving the house."

Rationale Hepatitis A microorganisms are transmitted via the anal-oral route; hand washing, particularly after toileting, is the most important precaution. The response "I should launder my clothes separately" will not deter the spread of the virus; hand washing is necessary. Putting used tissue in the garbage is important, but hand washing is the most important precaution. Hepatitis A microorganisms exit through the rectum, not the respiratory tract.

Which item would the nurse need when caring for a client undergoing treatment from an internal radiation implant that has become dislodged? Select all that apply. One, some, or all responses may be correct.

Mask Latex gloves Biohazard bag Lead-lined container

Long-handled forceps

Rationale To decrease risk of radiation exposure to the nurse and others from the radiation implant, the nurse will obtain a pair of long-handled forceps to pick up the implant and a lead-lined container in which to place the implant. A mask and latex gloves do not guard against radiation exposure. Biohazard bags do not provide enough protection from the radiation source; lead-lined containers are necessary to reduce exposure.

Which statement would indicate to the nurse that the parents of an infant admitted with gastroenteritis understand contact precautions when they note that after washing their hands they need to do which?

Put on a mask when holding the baby.

Weigh the diaper each time they change the baby.

Keep the door to the baby’s room closed most of the time.

Change their gloves each time they change the baby’s diaper.

Rationale The organisms causing gastroenteritis are eliminated in the feces. The gloves should be removed and the hands washed after giving direct care. New gloves should be donned if the parents are to remain with the child. A mask is required for airborne precautions. Weighing diapers is not a requirement of contact precautions; this technique may be used to measure intake and output. The door to the baby’s room should be closed if airborne precautions are necessary.

How long would the nurse maintain isolation of a child with bacterial

meningitis?

For 12 hours after admission Until the cultures are negative Until antibiotic therapy is completed For 48 hours after antibiotic therapy begins

Rationale Most children are no longer contagious after 24 to 48 hours of intravenous antibiotics. Twelve hours after admission is inadequate, even if antibiotics are started immediately. Keeping the child isolated until cultures are negative or antibiotic therapy is complete is an excessively long period and is unnecessary.

STUDY TIP: When forming a study group, carefully select members for your group.

Choose students who have abilities and motivation similar to your own. Look for students who have a different learning style than you. Exchange names, email addresses, and phone numbers. Plan a schedule for when and how often you will meet. Plan an agenda for each meeting. You may exchange lecture notes and discuss content for clarity or quiz one another on the material. You could also create your own practice tests or make flash cards that review key vocabulary terms.

The nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos would the nurse include in the teaching plan?

Hepatitis A Hepatitis C Hepatitis D

Hepatitis E

Rationale Hepatitis C is a blood-borne pathogen that can be transmitted via contaminated tattoo needles. Hepatitis A is not a blood-borne pathogen; it is spread through contaminated food or water. Although hepatitis D is a blood-borne pathogen, it can be produced only when the hepatitis B virus is present. Also, hepatitis D is not the main virus associated with contaminated tattoo needles. Hepatitis E is believed to be transmitted via the fecal-oral route; it is spread through contaminated food or water.

The nurse would include which instruction to the parents of a child being treated with oral ampicillin for otitis media?

Complete the entire course of antibiotic therapy.

Herbal fever remedies are highly discouraged.

Administer the medication with meals.

Stop the antibiotic therapy when the child no longer has a fever.

Rationale Once antibiotic therapy is initiated, the antibiotics start to destroy specific bacterial infections that the health care provider is trying to treat. Antibiotic therapy takes a specific dose and number of days to completely eliminate the bacteria. If the caregivers start a dose and stop it before the course is complete, the remaining bacteria have a chance to grow again, become resistant to antibiotic treatment, and multiply. The nurse would not discourage use of herbal fever remedies; however, the herbal treatment would be reviewed to see if it is contraindicated. Ampicillin would be taken 1 to 2 hours after meals. Antibiotic therapy would be completed as

prescribed.

The nurse should seek clarification by the practitioner for which order?

Discharge in AM Blood glucose monitoring ac and bedtime Erythromycin 250 mg TIW Dalteparin 5000 international units Sub-Q BID

Rationale TIW, indicating three times a week, is an unacceptable abbreviation. It may be mistaken for "three times a day" or "twice weekly." The abbreviation AM for in the morning is an acceptable abbreviation. The word "discharge" must be completely spelled out instead of just "D/C" because this may be confused with "discontinue."

The use of ac (before meals) is an acceptable abbreviation. Bedtime must be completely spelled out instead of "hs" because "hs" may be confused with "half strength" or "every hour." The abbreviation Sub-Q, indicating the subcutaneous route, is an acceptable abbreviation. BID, indicating twice a day, is an acceptable abbreviation. International units must be completely spelled out instead of "IU" because it may be mistaken as a roman numeral four (IV).

Which reason would the nurse document as "nonadherence" for the client not adhering to the prescribed antibiotic therapy?

"I skipped some doses because I just don’t like to take pills."

"I left my pills in the bedroom and I forgot to take them with breakfast."

"I saw all the side effects on television and decided to not take the pills."

"I had to choose between getting my prescription filled and paying the heating bill."

Rationale Nonadherence is accidental failure to take a medication. Noncompliance is deliberately failing to take a medication as might be done when skipping doses because of not liking to take pills, choosing to not take a medication because of information seen on television, or not being able to afford medication.

Which nursing intervention would the nurse implement when providing care for pediatric clients with leukemia on chemotherapeutic protocols?

Prevention of physical activity during this time Checking the clients’ vital signs every 2 hours Having them avoid contact with infected persons Reducing unnecessary stimuli in their environment

Rationale Chemotherapy and acute lymphoblastic leukemia (ALL) cause immunosuppression (low white blood cells), thus increasing the risk for infection. Avoiding contact with infected persons is a necessary precaution. The client should maintain tolerated physical activity. Although checking vital signs to assess for changes in pulse or blood pressure is important data, unless there is clinical evidence of bleeding, obtaining vital signs every 2 hours is not necessary. Except when acutely ill, children need stimulation appropriate for their developmental level.

Which intervention would the nurse implement to prevent cross-

contamination of herpes genitalis from one client to another?

Institute droplet precautions with this client.

Arrange transfer of the client to a private room.

Wear a gown and gloves when providing direct care.

Close the door and wear a mask when in the room.

Rationale The exudate from herpes virus type 2 is highly contagious; gown and gloves should be worn. A face shield should be worn if there is a potential for splashing of body fluids. The organism is not in respiratory tract secretions; the organism is present in the exudate from active lesions. Arranging transfer to a private room is unnecessary.

Closing the door and wearing a mask when in the room is not necessary because herpes genitalis is not an airborne infectious disease.

Which statement indicates effective discharge teaching for a client with osteomyelitis? Select all that apply. One, some, or all responses may be correct.

"I will take the antibiotic at the same time every day."

"I will take the antibiotic regularly until my symptoms subside."

"I will take the antibiotic with food if I develop gastric distress when on the antibiotic."

"I will notify my health care provider and stop taking the medication if I develop a rash or shortness of breath."

"I will need to change my diet to avoid milk and milk products while on these antibiotics."

Rationale The antibiotic should be taken as prescribed for the full length of treatment. The statements, "I will take the antibiotic at the same time every day," "I will take the antibiotic with food if I develop gastric distress when on the antibiotic," and "I will notify my health care provider and stop taking the medication if I develop a rash or shortness of breath," demonstrate understanding of the discharge instructions. The client should not discontinue the medication when symptoms subside. The client does not need to avoid milk and milk products because the class of antibiotics typically prescribed for osteomyelitis is the quinolone class. Quinolones do not have any adverse food interactions.

Which parental statement would the nurse recognize as requiring additional education about drowning prevention?

"My baby likes to take a bath in the kitchen sink."

"My baby loves to watch the birds play in the birdbath."

"Our pool is surrounded by a fence and has a locked gate."

"Any time my baby is in the pool, I make sure I am in there as well."

Rationale An infant can drown in as little as 2 inches of water. The birdbath is accessible and contains water, placing the infant at the most significant risk for drowning. There is no indication the child is left unattended in the sink during her or his bath. The pool is less of a risk because a fence surrounds it and it has a locked gate. The parent is in the pool with the infant, and there is no indication the infant is out of the parent’s sight.

Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good

night’s sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.

Which parental statement would the nurse recognize as a car seat safety concern?

"I place padding between my baby’s legs."

"I place an extra blanket under my baby to pad the seat."

"I make sure my baby is dressed with sleeves and long pants."

"I rolled up small blankets to place on each side of my baby’s head."

Rationale Placing an extra blanket to pad a car seat is a safety risk because during the impact of an accident the padding will compress, leaving the harness straps loose. Placing padding between the baby’s legs, dressing the baby in clothing with sleeves and pant legs, or rolling up small blankets to put on either side of the baby’s head to minimize movement are not safety concerns.

Which recommendation would the nurse make to parents when selecting a childcare setting?

"Choose a childcare facility that is conveniently located."

"Choose a facility in which there is a lower child-to-caregiver ratio."

"Choose your childcare facility based on what is affordable for you."

"Choose the childcare after you have contacted the state licensing agency."

Rationale State licensing agencies can help parents identify childcare centers that accept children of specific age-groups. Their records are available to the public and provide reports from the health, safety, and fire departments; periodic evaluations from the licensing agency; complaints filed against the center; and qualification of the center’s employees. Choosing a childcare facility based on its location or the fact that it holds a state license does not provide any further information about the facility. Choosing a facility for childcare for which there is a lower child-to-caregiver ratio or what is affordable does not imply the facility is licensed or is compliant with the minimum requirements and safeguards.

Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds.

Continue to analyze the options. If you can eliminate one more choice in a fouroption question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

During disaster response, which task is the responsibility of the medical command physician?

Determine client acuity.

Assist in discharging stable clients.

Communicate with the media.

Implement the emergency plan.

Rationale One responsibility of the medical command physician includes determining acuity

of clients. General staff can assist with discharging stable clients. The public information officer is the media liaison. The hospital incident commander implements the emergency plan.

Which parental statement would the nurse recognize as indicating an understanding of caring for an infant prescribed an orthotic helmet?

"I will remove the helmet during feedings."

"I will inspect my baby’s scalp for flat spots."

"I will inspect my baby’s scalp for skin irritation."

"I will rotate my baby’s sleeping position when wearing the helmet."

Rationale An orthotic helmet is used to treat plagiocephaly, usually a result of positional flattening of the skull. Specifically, the helmets are used to promote growth in the flat areas of the skull and inhibit growth in prominent areas of the skull. The parent should be instructed to inspect the infant’s scalp for any skin irritation, which includes redness, rashes, and pressure sores. The helmet does not interfere with feedings. Flattened areas of the skull are expected. The infant should be placed in a supine position to sleep to decrease the risk of sudden infant death syndrome (SIDS).

Which parental statement would the nurse recognize as indicating a need for further education about infant drowning prevention?

"I have signed my infant up for swimming lessons."

"My infant is never left alone in the water."

"I make sure I am at the poolside when my infant is in his or her floating device."

"Even though my child is still an infant, I still lock the gate to the swimming pool."

Rationale An infant should never be more than an arm’s length away at all times when swimming in the pool. Swimming lessons are encouraged. Infants should never be left alone in the water, because they can drown in as little as 2 inches of water. The gate to the swimming pool should be locked at all times when the pool is not being used, and the latch should be up high, out of reach for small children.

Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for keywords; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

Which statement would the nurse include when educating parents on the prevention of sudden infant death syndrome (SIDS)?

"Do not prop your infant’s bottle."

"Place an infant monitor where your baby sleeps."

"Place your infant in an appropriately sized, rear-facing car seat."

"Encourage your infant to use a pacifier for the first 6 months of life."

Rationale The American Academy of Pediatrics recommends the use of a pacifier in the first 6 months of life to help prevent SIDS. Propping a bottle places the infant at risk for dental caries. An infant monitor will not prevent SIDs. Using the appropriate size of

car seat positioned correctly in a vehicle prevents motor vehicle injuries.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which statement made by the parent would prompt the nurse to provide education?

"I wash my hands after changing the diaper."

"I rinse the changing table with warm, soapy water."

"I try to change my baby’s diaper as soon as it is soiled."

"I bring the soiled reusable diapers home in a plastic bag to wash."

Rationale Diaper-changing areas should be cleaned with a fresh solution of 1:64 dilution of household bleach (1 quarter cup of bleach diluted in 1 gallon of water), applied for 2 minutes then rinsed. Parents should wash their hands after changing a diaper.

Diapers should be changed as soon as possible after the child soils. Soiled reusable diapers or clothes should be sealed in a plastic bag during the transport home.

A parent of a newborn states to the nurse, "My baby is constantly crying and irritable. I just cannot take this much longer." Which information would the nurse discuss with the parent?

Limit setting Shaken baby syndrome

Developmental milestones Sudden infant death syndrome

Rationale The parent is expressing frustration and verbalizes the inability to tolerate the crying. For the infant’s safety, it is important to recognize the baby is at risk for shaken baby syndrome. Limit setting does not apply to an infant that is crying and irritable. This is not an appropriate time to discuss developmental milestones or sudden infant death syndrome.

Which rationale would the nurse provide the parent of an 8-monthold infant for removing small objects from the play environment?

Sharp objects can injure the fragile skin of an infant.

Eight-month-old infants hide small objects, making them difficult to locate.

Floors may cause infections in infants when they pick up and mouth objects.

Eight-month-old infants pick up small objects and place them in their mouths.

Rationale Eight-month-old infants have the ability to use their fingers and thumbs in opposition (pincer grasp); this enables them to pick up small objects and put them in their mouths, where they may be aspirated. Although an infant’s skin is fragile, damage to the skin is not the major concern. The danger is not that the items may be hidden but that they may be put into the mouth. The floor is not an infectious health hazard if it is clean.

The nurse recognizes that belly binding is a common cultural practice

The nurse recognizes that belly binding is a common cultural practice for the mother of a 9-month-old infant with extrusion of the umbilicus. Which variation of belly binding would the nurse discourage?

Coin in the umbilicus Tight diaper over the umbilicus Binder that encircles the umbilicus Adhesive tape across the umbilicus

Rationale A coin may be dislodged, allowing the infant to put it in his or her mouth, resulting in a safety issue. A diaper fastened tightly around the waist, a binder, or adhesive tape over the umbilicus will not endanger the infant. Cultural beliefs that do not place the infant at risk should not be discouraged.

Which covering would the nurse use over the exposed area of an infant admitted with exstrophy of the bladder?

Loose diaper Dry gauze dressing Moist sterile dressing Petroleum jelly gauze pad

Rationale The bladder membrane is exposed; it must remain moist and, as much as possible, sterile. A loose diaper and a dry gauze dressing will each allow the exposed

membrane to dry out, increasing the risk for infection. Petroleum jelly will adhere to the membrane, resulting in trauma.

Which information would the nurse include in a teaching plan for a client whose burns are being treated with the exposure (open) method?

Aseptic techniques are required.

Plants, but not flowers, are allowed.

Equipment will be shared with others.

Dressings will be changed every 3 days.

Rationale Medical asepsis and surgical asepsis are essential for prevention of infection with the exposure method, because only antimicrobials are used with no dressing.

Neither plants nor flowers can be present. Equipment is not shared on the burn unit. Dressings are not used with the exposure method.

Which information would be included when teaching the parent of a newborn about automobile infant restraint systems? Select all that apply. One, some, or all responses may be correct.

Use a forward-facing infant car seat.

Secure the infant seat so that it faces the rear.

Position the seat between the driver’s and passenger’s seats in the front seat.

Follow the manufacturer’s directions to secure the infant seat in the back seat.

Be sure to follow weight guidelines set forth in the manufacturer’s instructions.

Rationale An infant seat should face the rear, not the front, of the automobile, because the head and neck are better protected from a whiplash injury in the event of an accident. Research demonstrates that passengers in the front seat sustain more serious injuries than do individuals in the rear seat in most accidents. Using a forward-facing infant car seat and positioning the seat between the driver’s and passenger’s seats in the front seat is dangerous for the infant and not recommended by the infant car seat safety information guidelines.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which statement made by the client indicates the need for further teaching about strategies to reduce burn injuries?

"I should never smoke in bed."

"I should never use gasoline to start a fire."

"I should never leave hot oil unattended while cooking."

"I should never have candles near open curtains."

Rationale Candles can be left unattended near open curtains if they are not burning. The client should never smoke in bed, use gasoline to start a fire, or leave hot oil

unattended while cooking.

Which parental statement would the nurse recognize as a knowledge deficit when discussing the care of an infant with a severe diaper rash?

"I expose the buttocks to the air."

"I direct a heat lamp at the buttocks."

"I don’t use soap to clean the diaper area."

"I apply a medicated ointment to the diaper area."

Rationale Heat lamps are not used because of the potential for burns. Exposing the diaper area to air will promote drying and healing. Soap may irritate excoriated skin.

Ointment protects the buttocks from the irritating contents of stool.

Which postoperative nursing care would the nurse provide to a 3week-old infant after surgery to repair a cleft lip?

Using a spoon to administer oral feedings Cleansing the suture line to prevent infection Offering a pacifier for sucking to prevent crying Using wrist restraints to keep the infant’s hands away from the face

Rationale Meticulous care of the suture line is necessary to prevent infection and to help ensure the best cosmetic outcome. Using a spoon is contraindicated, because it

could disrupt the suture line; the infant may be fed with a device designed especially for this purpose. Offering a pacifier is contraindicated, because sucking will put tension on the suture line and may result in disruption of the sutures. Elbow restraints are used; this allows the infant to move the arms without bending the elbows and thus prevents the infant from touching the face.

Which developmental milestone would the nurse emphasize while providing safety education to the parents of a 6-month-old infant?

Sits up Rolls over Crawls short distances Stands while holding on to furniture

Rationale Muscle coordination and perception are developed enough at 6 months for the infant to roll over. If unaware of this ability, the parent may leave the infant unattended for a moment to reach for something, making it possible for the infant to roll off an elevated surface. Most infants accomplish sitting up unsupported at 7 to 8 months. Crawling takes place around 9 months of age. Standing by holding on to furniture is accomplished by most infants between 8 and 10 months of age.

STUDY TIP: Rest is essential to the body and brain for good performance; think of it as recharging the battery. A run-down battery provides only substandard performance. For most students, it is better to spend 7 hours sleeping and 3 hours studying than to cut sleep to 6 hours and study 4 hours. The improvement in the rested mind’s efficiency will balance out the difference in the time spent studying.

Knowing your natural body rhythms is necessary when it comes to determining the amount of sleep needed for personal learning efficiency.

Which rationale would lead the nurse to question an order for a tap water enema for a 6-month-old infant with suspected Hirschsprung disease?

Necessary nutrients could be lost.

It could cause a fluid and electrolyte imbalance.

It could increase the fear of intrusive procedures.

The result could cause shock from a sudden drop in temperature.

Rationale Tap water enemas are hypotonic and are contraindicated; they may cause increased absorption of fluid through the bowel and may upset the balance of fluid in the body. Such enemas also interfere with the potassium ion balance; this electrolyte can be lost by way of the large intestine. The enema removes waste products from the bowel, not nutrients. Fear of intrusive procedures is typical of preschoolers, not infants. The temperature of the water is regulated, so shock from a temperature drop is not a concern.

Which rationale explains the nurse using the term iatrogenic when describing an infection at a catheter insertion site that developed in a hospitalized client?

Poor personal hygiene is the cause.

Inadequate dietary intake is the cause.

The client’s developmental level is the cause.

A procedure performed at the hospital is the cause.

Rationale An iatrogenic infection is one caused by health care providers or therapy. Poor personal hygiene, inadequate dietary intake, and the client’s developmental level are not the causes of an iatrogenic infection.

Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses.

Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.

After an above-the-knee amputation for bone cancer, an adolescent male is returned to his room. Which item would the nurse plan to keep at the bedside?

Hemostat Vitamin K Protamine sulfate Pressure dressing

Rationale A pressure dressing will control hemorrhage until surgical intervention can be instituted. A hemostat is not practical because bleeding may be internal. Vitamin K is the antidote for warfarin. There is no indication that the client is taking warfarin.

Protamine sulfate is the antidote for an excessive amount of heparin; the client is not receiving heparin.

Test-Taking Tip: Do not read too much into the question or worry that it is a "trick."

If you have nursing experience, ask yourself how a classmate who is inexperienced would answer this question from only the information provided in the textbooks or given in the lectures.

Which information is important for the nurse to include in a teaching program for a client admitted to the hospital after having a tonicclonic seizure and being diagnosed with a seizure disorder?

Explain strategies a client may use to prevent physical trauma from occurring during a seizure.

Teach the client to take anticonvulsant medications on an empty stomach.

Teach the client that the symptoms and treatment of seizure disorders are similar, regardless of the cause.

Explain that sharing the knowledge of their illness with others is not necessary, because medications will control the seizures.

Rationale Injuries occur in many ways during a seizure, and trauma prevention is a priority with these clients. Anticonvulsants can cause gastrointestinal disturbances, especially early in therapy, and the client should take them with food. Seizures and seizure disorders are not similar; they vary greatly. Other individuals around the client should understand the condition and be taught how to help in case of a seizure.

Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night’s sleep the night before your exam. Cramming is not smart and is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere

with your sleep. Your brain needs sleep to function at its best.

Which nursing action is appropriate for a patient during the tonicclonic stage of a seizure?

Go for additional help Establish a patent airway Restrain the client to prevent injury Protect the client’s head from injury

Rationale Protecting the client’s head from injury is an appropriate nursing action for a client experiencing a tonic-clonic seizure. The client should not be left unattended.

Establishing a patent airway is done after the seizure; the mouth should not be pried open to insert an airway during a seizure because injury may occur.

Restraining a client will increase the risk for injury so is an unsafe action during a seizure.

Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds.

Continue to analyze the options. If you can eliminate one more choice in a fouroption question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

Which nursing action is appropriate when caring for a client who is legally blind and has been admitted to the hospital for surgery?

Enter the room while speaking softly.

Touch the client gently before speaking.

Hold the client by the elbow when ambulating.

Keep the furniture in the same location in the room.

Rationale Placing furniture and objects in the same location in the room promotes safety and independence. Entering a room while speaking softly can increase anxiety because the client may not be able to identify what is happening. Touching the client gently before speaking can startle the client and increase anxiety; speak to the client before touching. The blind client should hold the nurse’s elbow when ambulating.

Which would the nurse include in the plan of care to decrease the risk for injury related to motor vehicle accidents for a school-age client?

Securing seat belts properly Using a low heat setting when cooking Recommending enrollment in swimming lessons Making sure smoke detectors are installed in the home

Rationale Properly securing seat belts is appropriate for the nurse to include in the plan of care to decrease the risk for injury related to motor vehicle accidents for school-age clients. Using a low heat setting when cooking decreases the risk for burn injury.

Recommending enrollment in swimming lessons decreases the risk for drown injury. Making sure smoke detectors are installed in the home is appropriate to decrease the risk for burn injury.

Which intervention would the nurse anticipate for a toddler

Which intervention would the nurse anticipate for a toddler experiencing moderate gastroenteritis related to iron toxicity?

Gastric lavage Induced emesis Bowel irrigation Chelation therapy

Rationale Emesis empties the stomach more effectively than gastric lavage. Whole bowel irrigation is used if radiopaque tablets are viewed on abdominal x-ray. Chelation therapy is used for severe toxicity.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

For which condition are pregnant women at a five- to sixfold increased risk?

Bradycardia Hypertension Thromboembolic disease Decreased cardiac output

Rationale

Pregnancy is considered a hypercoagulable state, which places pregnant women at a five- to sixfold increased risk of thromboembolic disease. Heart rate increases 10 to 15 beats/minute during pregnancy. Systolic blood pressure increases only slightly or decreases during pregnancy, and diastolic blood pressure slightly decreases by midpregnancy and returns to prepregnancy levels by the end of pregnancy. Cardiac output increases, not decreases 30% to 50% during pregnancy.

Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for keywords; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

Which parental statement would concern the nurse during a toddler’s wellness visit?

"My child loves to eat popcorn."

"My child loves our family pets."

"My child likes to play with gardening toys."

"My child loves to play with a fork and spoon."

Rationale Popcorn kernels pose a choking risk to a toddler. The statement about the child who loves the family pet does not indicate there is any risk of injury. There is no risk of injury if a toddler has age-appropriate gardening toys. The statement about the child playing with a fork and spoon does not pose a danger unless the child is ambulating with utensils.

Which response would the nurse have when a parent expresses concern that their toddler loves to play dress-up with jewelry?

concern that their toddler loves to play dress-up with jewelry?

"Make sure you supervise your child during play."

"Jewelry poses a choking risk to your child."

"You may want to buy play jewelry made for children."

"The necklaces or the larger pieces are okay to play with."

Rationale Jewelry is a choking hazard for a toddler and should be kept out of reach.

Supervising the child playing with jewelry, buying jewelry for a toddler, or allowing the toddler to play with the necklaces places the child at risk for choking.

Which parental statement would the nurse recognize as indicative of understanding strategies to prevent burn injuries in toddlers?

"I never leave the stove unattended."

"I keep the glass doors of the fireplace closed."

"I have placed furniture in front of the electrical outlets."

"I have made sure the temperature on the water heater is 130°F (54°C)."

Rationale Electrical outlets should have furniture placed in front of them or, if accessible, protective guards plugged into them. Whether the parent leaves the stove attended or not, toddlers still are at risk for grabbing pot handles and/or touching a hot stove; a stove guard is recommended. The fireplace should have a guard placed in front of it. The water heater should be set at no higher than 120°F (48.9°C).

Which explanation would the nurse provide a parent regarding their

toddler’s higher risk of falling from heights?

Sensory perception Cognitive perception Lack of motor coordination Immature visual depth perception

Rationale A lack of motor coordination places a toddler at risk of falling from heights. The toddler’s cognitive and sensory perception are not the primary factors that place the toddler at risk of falling from heights. Although the toddler’s visual depth perception continues to develop, this is not the primary factor that places the toddler at risk of falling from heights.

Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.

Which recommendation would the nurse provide a parent who asks when it is safe to transition a toddler from a crib to a bed?

"Children can sleep in a bed safely when their height reaches 35 inches (89 cm)."

"Children are safe to sleep in a bed when they reach a weight of 25 pounds."

"Children can sleep in a bed safely around the time they begin toilet training."

"Children are safe to sleep in a bed when they are no longer waking up at night."

Rationale When children reach a height of 89 cm (35 inches), they should sleep in a bed rather than a crib. Weight, toilet training, or no longer waking at night are not determining factors for the safe transition from sleeping in the crib to a bed.

Which consideration would the nurse emphasize to the parent of a toddler-age client when selecting toys?

Cost Safety Creativity Appropriateness

Rationale Although all of these considerations are factors when choosing an age-appropriate toy for a toddler-age client, the priority is safety, especially in regard to size and sturdiness. Cost, creativity, and appropriateness are also factors; however, these are not the priority when using Maslow’s hierarchy of needs to plan client care.

Which medication therapy lowers a child’s resistance to varicella?

Anticonvulsant Systemic steroid Antihypertensive

Topical antibiotic

Rationale Individuals who are taking steroids have lowered resistance and may become fatally ill if exposed to the varicella virus. Anticonvulsants and antihypertensives do not lower body resistance; therefore, they do not increase susceptibility. Topical antibiotics do not affect body resistance because topical antibiotics do not have systemic effects.

For which reason would an adolescent client be prescribed an adult dose of acetaminophen?

The prescription is weight-based.

The dose is adjusted based on outcome.

The prescription can be metabolized at the adult dose.

Renal metabolism of acetaminophen is at its peak.

Rationale Medication-metabolizing capacity declines at puberty, becoming that of an adult.

Therefore, an adolescent client would be prescribed an adult dose of acetaminophen. An acetaminophen prescription is not weight-based. The dosing for some medications may need to be adjusted; however, acetaminophen has a maximum 24-hour dosage of 3000 mg/day. Acetaminophen is metabolized in the liver, not the kidneys. The renal system excretes, rather than metabolizes, the medication.

Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices

that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

Which would the nurse assess for in a male child prescribed an androgen?

Tendon rupture Delayed puberty Cartilage erosion Decreased height

Rationale Reduced adult height can occur due to premature epiphyseal closure in males taking androgens. Tendon rupture is associated with fluoroquinolones. Premature puberty, rather than delayed puberty, can occur in males taking androgens.

Cartilage erosion is associated with nalidixic acid.

Which statement would the nurse make when providing information to the parent of a child who calls the pediatric clinic after dropping a mercury thermometer at home?

"Hang up and call 9-1-1 for further treatment."

"Contact the poison control center immediately."

"Clean up the spill using paper towels and disposable gloves."

"Bring your child to the clinic immediately for further assessment."

Rationale

The nurse would tell the parent to clean up the spill using paper towels and disposable gloves to avoid the risk of inhalation injury for the toddler-age client.

There is no reason to activate emergency medical services, contact the poison control center, or to bring the child to the clinic for further assessment based on the current data.

Which recommendation from the school nurse to the parent of an older child reflects the safest plan for managing the child’s asthma in the school setting?

"Your child’s inhaler will be kept locked in the health center."

"I will provide all supervision when your child uses the inhaler."

"Your child’s teacher will supervise your child’s use of the inhaler."

"I need your permission for your child to carry the inhaler at all times."

Rationale With parental permission, older children with asthma can carry their inhalers with them at all times in case of an emergency. Locking the inhaler in the health center or telling a parent that a nurse or teacher will always be available to supervise the child may not be realistic, because they may not be immediately present if the child requires the inhaler, which would delay treatment and risk an asthma exacerbation.

Which parental statement would the nurse recognize as placing the children at risk for injury?

"I take my children to the hill at the park to sled."

"I watch my children sled in the backyard of our home."

"My children like to pull each other down the street on the sled."

"The children both sit together and slide down the hill on the sled."

Rationale Sledding accidents are more likely to occur when children ride sleds without adult supervision and in streets, as opposed to parks. Riding a sled down the hill at the park, sledding supervised in the backyard, or sledding together down a hill does not necessarily place children at risk for injury.

Which intervention would the nurse recommend to the parents of a latchkey child?

Leave a list of chores for the child to do upon getting home.

Encourage the child to check in whenever he or she feels lonely.

Emphasize the positive aspects of independence and resourcefulness.

Allow the child to stop at the park and play on the way home from school.

Rationale Emphasizing the positive aspects of independence and resourcefulness will help increase the child’s self-esteem and promote acceptance of the situation. It is not necessary to leave a list of chores for the child to do. A list of activities will be better received and less demanding on the child. Checking in with a parent may not be feasible every time the child feels lonely. The child should not be allowed to stop at a park and play unsupervised.

Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each

question before the computer will present the next question, and you cannot go back to any previously answered questions. Remember that you do not have to answer all of the questions correctly to pass.

Which parental statement indicates an understanding of the prevention of motor vehicle injury for a 5-year-old child?

"My child is not able to cross the street safely."

"My child is old enough that a booster seat is not required."

"I no longer have to worry about my child darting into the street."

"It is no longer necessary for my child to remain in the backseat."

Rationale The developmental skills for a child 5 to 6 years of age can be overestimated.

Misinterpretation of the traffic signs or disobeying common traffic safety regulations, and darting out into the street can contribute to the injury of a child.

The use of restraint systems and appropriate passenger seating are simple but effective measures for eliminating noncrash injuries and reducing the severity of crash injuries.

Test-Taking Tip: What happens if you find yourself in a slump over the examination?

Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.

Which guidance would the nurse provide to the parent of an 8-yearold child?

Expect an increase in minor injuries.

The child may need more rest during this period.

Strong food preferences and frequent food refusals are common.

Support the child’s desire to "grow up," but allow regressive behavior when needed.

Rationale Guidance for an 8-year-old child includes the expectation for an increase in minor injuries. Children ages 11 to 12 years of age require more rest and have a strong desire to "grow up." However, the parent should be encouraged to allow regressive behavior when needed. Children 6 years of age have strong food preferences and frequent food refusals are common.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which guidance would the nurse provide to the parent of a 6-year-old child?

Use caution in selecting and maintaining sports equipment.

Prepare parents for an increasing interest in activities outside the home.

Prepare fathers to expect an increasing admiration and encourage father– child activities.

Emphasize the need to encourage independence while maintaining limit setting and discipline.

Rationale A 6-year-old child will display an increased interest in activities outside the home.

For a child 7 to 10 years of age, the nurse will emphasize caution in selecting and maintaining sports equipment, prepare fathers to expect an increasing admiration at around 10 years and encourage father–child activities, and emphasize the need to encourage independence while maintaining limit setting and discipline.

Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.

Which is the most common cause of vehicle injuries in children?

Inappropriate seat belt restraints Sitting in the front seat of the car Disobeying common traffic safety regulations Walking in the opposite direction of the traffic

Rationale Most injuries occur when children disobey common traffic safety regulations or misinterpret traffic signs. Inappropriate seat belt restraints, sitting in the front seat of the car, and walking in the opposite direction of the traffic are not the most common cause of motor vehicle injuries in children.

Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A child undergoes tonsillectomy and adenoidectomy for numerous recurrent respiratory tract infections. After the surgery, which

recurrent respiratory tract infections. After the surgery, which education would the nurse provide the parent?

Offer crushed ice chips.

Encourage the intake of ice cream.

Keep the child in the supine position.

Gargle with a diluted mouthwash solution.

Rationale Ice chips are soothing and promote vasoconstriction. Cool water, flavored ice pops, or diluted fruit juice may be given, but fluids with a red or brown color should be avoided to distinguish fresh or old blood in emesis from the ingested liquid. Milk and milk products coat the mouth, causing the child to clear the throat, which may precipitate bleeding. The supine position promotes edema and does not allow oral secretions to drain from the mouth. The head of the bed should be elevated, and the child should be positioned on the side. Mouthwash solution is too caustic; a warm saltwater solution is preferred.

Which is the priority teaching point at discharge of a child who just completed a cycle of chemotherapy?

Purchasing a wig Ensuring adequate rest Offering sufficient fluids Performing thorough hand washing

Rationale Effective hand washing helps prevent infection, and this is the most important

intervention in the care of a child with a suppressed immune system. Although purchasing a wig may be important for the child’s self-image, it is not the priority.

Although providing rest and offering sufficient fluids are also important, neither is the priority.

Which statement helps the nurse determine that a woman with genital herpes (HSV-2) infection understands her self-care?

"When I have a baby, I don’t want a cesarean."

"I can have sex as soon as the herpes sores have healed."

"When I finish the acyclovir prescription I will be cured."

"I must be careful when I have sex because herpes is a lifelong problem."

Rationale HSV-2 infection is characterized by remissions and exacerbations; it cannot be cured and is a lifelong infection. Some pregnant women with HSV-2 need cesarean deliveries, which are indicated if there is an outbreak of HSV-2 near the time of birth to prevent their newborns from contracting the disease while passing through the vagina. Herpes is most contagious when active lesions are present; however, the virus can still be shed after the lesions have healed. Use of a condom can reduce the risk of transmission. Herpes can be controlled but not cured.

Which intervention is the nurse’s priority when caring for a child with human immunodeficiency virus (HIV)?

Maintaining optimal hydration Protecting the child from infection Promoting growth and development Ensuring adequate and balanced nutrition

Rationale Children with HIV have a dysfunction of the immune system (depressed or ineffective T cells, B cells, and immunoglobulins) and are susceptible to opportunistic infections; infection can result in death. Although optimal hydration is important, insufficient hydration is not as potentially life threatening as an infection. Although children with HIV are most likely small for their age, and it is important to promote growth and development, inability to do so is not as potentially life threatening as an infection. Although adequate and balanced nutritional intake is important, it is not the priority because it is not as potentially life threatening as an infection.

Which consideration is most important when counseling the family of a child with human immunodeficiency virus (HIV)?

Risk for injury Susceptibility to infection Inadequate nutritional intake Altered growth and development

Rationale Children with HIV have a dysfunction of the immune system (depressed or ineffective T lymphocytes, B lymphocytes, and immunoglobulins) and are susceptible to opportunistic infections. All children are subject to injury because of their curiosity, inexperience, and lack of judgment. Although inadequate nutrition can be a problem for children with HIV, the prevention of infection is the priority.

Although children with HIV are usually small for their age, altered growth and development is not as life threatening as an infection.

Which consideration is most important when formulating a plan of

Which consideration is most important when formulating a plan of care for a child undergoing chemotherapy?

Preventing infection Increasing caloric intake Limiting nausea and vomiting Monitoring hematoma formation

Rationale Chemotherapy suppresses the immune system; the child is in danger of contracting an overwhelming infection. Although increasing caloric intake is important, it is not the priority. Although nausea and vomiting are side effects of chemotherapy, they can be minimized with appropriate pharmacological therapy. Although it is important to check for hematomas, it is not as important as preventing infection; gentle handling helps prevent hematomas.

Which education would the nurse provide the parent of a preschool child with atopic dermatitis?

"Scratching causes lesions to become more contagious."

"Scratching spreads dermatitis to other areas of the body."

"Scratching results in skin breaks that can lead to infection."

"Scratching produces changes that are precursors to skin cancer."

Rationale Scratching can compromise the integrity of the skin, leaving it vulnerable to infection. Dermatitis is a response to an allergen; it is not contagious. Scratching will not cause the dermatitis to spread. There are no data to indicate that scratching

or dermatitis is a precursor to skin cancer.

Which client statement confirms that the client who is being treated for a sexually transmitted infection (STI) has understood the nurse’s instruction regarding future sexual contacts?

"If I have sex, nothing I do will really prevent me from getting another STI." "If I get another STI, I can take any antibiotic, because I’m not allergic to any of them."

"I won’t have unprotected sex again, and I’ll tell my partners to be tested for STIs." "I have to ask my partners if they have an STI, and if they say no I’ll know that I can have sex."

Rationale The most effective strategies for preventing sexually transmitted infections-contracting them or spreading them to sex partners--are the use of condoms and having sex partners tested to determine their status and get treatment if necessary.

There are protective measures that can be used to help prevent the transmission of STIs. The emphasis should be on prevention, not treatment; some STIs have no cure. Asking partners whether they have an STI does not always elicit a truthful answer; protection is necessary to help prevent the transmission of STIs.

Which information would the nurse include in a discussion of anticipatory guidance for adolescents with staff at a local teen center to support prevention efforts?

They more consciously take risks.

They have difficulty judging speed and distance.

Peer pressure starts to influence behaviors.

They lack understanding of cause and effect.

Rationale Anticipatory guidance for adolescents needs to include understanding of an increase in conscious risk-taking behaviors, which lead to more injuries and deaths caused by motor-vehicle accidents and violence. School-age children have difficulty judging speed and distance and are beginning to be influenced by peers placing them at risk for pedestrian and bicycle accidents. Toddlers and preschoolers lack understanding of cause and effect.

Which term would the nurse use to describe the ability of an organism to enter, multiply, and spread from one host to another?

Infectivity Virulence Invasiveness Pathogenicity

Rationale Infectivity is the ability of an organism to enter, multiply, and spread from one host to another. Virulence refers to the ability to produce a severe pathologic reaction.

Invasiveness describes the ability to penetrate and spread throughout tissue.

Pathogenicity is the ability to produce a specific clinical reaction after infection.

Which term would the nurse use when discussing the persistent prevalence of low to moderate cases of dengue fever in most of the islands in the Caribbean?

islands in the Caribbean?

Endemic Pandemic Epidemic Holoendemic

Rationale When low to moderate cases of an infectious disease consistently persist in a population, it is considered endemic. Pandemic refers to the epidemic spread of an infectious disease or problem over several countries or continents. Epidemic is used when the number of cases of a disease exceed what would be expected over a given period of time. If a disease or issue is holoendemic in a population, it indicates a highly prevalent problem that is commonly acquired early in life, with prevalence decreasing as age increases.

Which term describes a disease outbreak that spreads gradually from person to person over more than one incubation period and for which a common source cannot be determined?

Propagated outbreak Point source outbreak Common source outbreak Intermittent source outbreak

Rationale A propagated outbreak has no identifiable common source and spreads gradually from person to person over more than one incubation period. In a point source

outbreak, all persons are exposed and become ill at the same time. A common source outbreak refers to a group exposed to common noxious influences such as ricin in the water system. When exposure occurs over time such as with food poisoning, it is referred to as intermittent or continuous.

For which condition is a pregnant client who takes levothyroxine at increased risk?

Anemia Infection Preeclampsia Thyroid storm

Rationale Levothyroxine is prescribed for hypothyroidism. Ferrous sulfate should be taken at least 4 hours apart from levothyroxine. When taken together, the ferrous sulfate decreases the absorption of T 4, increasing the client’s risk for inadequately treated hypothyroidism. Pregnant women with untreated or inadequately treated hypothyroidism are at risk for preeclampsia. The risks for anemia and infection are not increased. A thyroid storm is associated with hyperthyroidism.

Which is the nurse’s priority action when caring for an obstetrical client experiencing eclampsia?

Turn the head to one side.

Obtain the fetal heart rate.

Administer intravenous analgesia.

Place an oral airway.

Rationale The airway should be kept patent by turning the client’s head to one side or placing a pillow under the back or one shoulder if possible. Nothing should be placed in the client's mouth, including an oral airway during a seizure. Maternal safety is a priority. During eclampsia administering analgesia is not a priority intervention. If possible, the fetal heart rate may be obtained after ensuring maternal safety.

Which finding would the nurse be most concerned about in the client receiving a bolus of magnesium sulfate intravenously for the treatment of preeclampsia?

Flushing Diaphoresis Nausea and vomiting Burning at the intravenous (IV) site

Rationale Nausea and vomiting are symptoms of magnesium toxicity and can also be symptoms of worsening preeclampsia. Flushing, diaphoresis, and burning at the IV site are common side effects of the magnesium sulfate.

For which reason is a client with worsening preeclampsia placed in a nonstimulating environment?

To limit respiratory effort To decrease severity of frontal headaches To reduce the probability of tonic-clonic seizures

To prolong the action of hypotensive medications

Rationale Even minimal sensory stimuli can trigger an exaggerated cerebral response such as seizures; therefore, a nonstimulating environment is most therapeutic. Women with preeclampsia do not have respiratory problems. Although respiration may become depressed with magnesium sulfate therapy, a quiet environment will have no effect on respiration. A nonstimulating environment does not reduce the severity of headaches resulting from hypertension and has no relationship to the effects of antihypertensive medications.

Which intervention would the nurse question when caring for a client who has tested positive for human immunodeficiency virus (HIV)?

Sonogram Nonstress test Sterile vaginal examination Internal fetal scalp electrode

Rationale The electrode used for internal fetal monitoring pierces the fetal scalp; fetal exposure to maternal blood increases the risk of the fetus contracting HIV. Sonograms and nonstress tests are noninvasive tests that pose no risk to the fetus.

Sterile vaginal examination is necessary to determine progression of labor; although invasive, it poses no risk to the fetus if standard precautions are used.

For a client receiving intravenous morhine supfate, which action would the nurse immediately take when noting a client's respiratory

rate is 8 breaths per minute?

Measure other vital signs.

Stop administering the medication.

Elevate the head of the client’s bed.

Report to the primary health care provider.

Rationale Morphine sulfate is an opioid analgesic and can depress the central nervous system, which results in respiratory depression. A respiratory rate of 8 breaths per minute indicates respiratory depression, and the nurse would stop the medication immediately. The nurse can measure the other vital signs after discontinuing the medication administration. Elevating the head of the client’s bed ensures proper breathing. The nurse would elevate the client’s bed after discontinuing the medication. The nurse would report to the primary health care provider for an appropriate antidote after stopping the medication administration.

Which action would the nurse take first for a client who is experiencing an anaphylactic reaction secondary to drug hypersensitivity?

Administer oxygen.

Insert an intravenous (IV) catheter.

Ask about exposure to allergens.

Obtain an arterial blood gas analysis.

Rationale

Administering oxygen should be the first action of the nurse for this client. With anaphylaxis, there is bronchial constriction and subsequent vascular collapse; therefore the airway is of primary concern. At this point, it would be appropriate to insert an IV catheter to administer emergency medications and possibly obtain an arterial blood sample to determine oxygenation status. Asking about exposure to allergens is part of the later assessment and is appropriate once the client is stabilized.

Which action would the nurse take first for a client on intravenous medication who experiences an anaphylactic reaction?

Stop the intravenous medication.

Administer epinephrine (adrenaline).

Start a normal saline infusion immediately.

Report to the primary health care provider immediately.

Rationale Intravenous medications can cause an anaphylactic reaction. During anaphylactic reactions, the nurse would immediately stop the intravenous medication and administer epinephrine (adrenaline). The nurse can start a normal saline infusion and report to the primary health care provider, but only after stopping the intravenous medication and administering epinephrine (adrenaline).

Test-Taking Tip: Multiple-choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

According to triage based on tier levels, which client condition would

According to triage based on tier levels, which client condition would receive a higher priority? Select all that apply. One, some, or all responses may be correct.

Stroke Skin rash Active hemorrhage Respiratory distress Chest pain with diaphoresis Displaced or multiple fractures

Rationale Clients presenting with signs of a stroke, active hemorrhage, respiratory distress, or chest pain with diaphoresis should be triaged under the emergent tier level because the conditions are life-threatening. Clients with a skin rash are categorized as nonurgent because treatment can be delayed. Displaced or multiple fractures are triaged as urgent, which needs quick treatment but is not immediately lifethreatening.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which intervention would the nurse recommend to decrease tuberculosis (TB) in the community? Select all that apply. One, some, or all responses may be correct.

Improving financial resources

Eliminating overcrowded housing Initiating needle-sharing programs Improving access for food pantries Providing barrier contraceptive devices

Rationale Factors that increase the incidence of TB in communities include HIV infection, poverty, overcrowded living conditions, malnutrition, smoking, and drug and alcohol use. Improving financial resources would benefit clients living in poverty.

Addressing the overcrowded housing situation would help decrease the transmission of TB. The nurse would need to address HIV transmission. This would be by implementing needle sharing programs and providing barrier contraceptive devices as these can decrease the incidence of HIV. Improving access to food pantries can improve nutrition.

After donning gloves, which action would the nurse take first after discovering a large amount of blood under the buttocks of a client who had a cardiac catheterization through the femoral artery?

Apply pressure to the site.

Obtain vital signs.

Change the client’s gown and bed linens.

Assess the catheterization site.

Rationale

Observing standard precautions is the first priority when dealing with any body fluid, followed by assessment of the catheterization site as the second priority. This action establishes the source of the blood and determines how much blood has been lost. Once the source of the bleeding is determined, the priority goal for this client is to stop the bleeding and ensure stability of the client by monitoring the vital signs. Changing the client’s gown and bed linens is not necessary until the bleeding is controlled and the client is stabilized.

Which topic would the nurse include when teaching a client who is being treated for active tuberculosis and has a productive cough?

Reasons to avoid going outside Need for continued hospitalization Use of disposable tissues when coughing Benefits of attending community events

Rationale Sputum can be contained within disposable paper tissues that can then be discarded in fluid-impervious bags. Clients with tuberculosis are encouraged to go outside where there is less risk of transmission of tuberculosis to others. Continued hospitalization is not needed for clients who have active tuberculosis if they are taking antituberculosis medications and can take precautions to avoid spread of disease to household members. Until clients with active tuberculosis have effective treatment, they should be discouraged from spending time in crowded situations where others may be exposed to the disease.

Which statement by a client who is being discharged with a new prescription for home oxygen therapy indicates the need for further instruction by the nurse?

"I will use only grounded electrical equipment."

"I have a new woolen blanket to keep me warm."

"I have told my family they cannot smoke in the house."

"I will keep a pitcher of water near me so I drink enough."

Rationale An open flame or a spark from static electricity (generated by such items as leathersoled shoes; wool, silk, and nylon blankets; or ungrounded electrical appliances) can initiate an explosion and fire in the presence of higher-than-environmental oxygen levels. Grounded electrical equipment helps prevent sparks. When combined with oxygen, heat from lit cigarettes can ignite flammable material. Oxygen is drying; increased fluid intake is advisable.

Which client would be treated first according to a three-tiered triage system?

A B C D

Rationale A three-tiered triage system categorizes clients into emergent, urgent, and nonurgent categories based on the severity of their conditions. Client A, with an active hemorrhage, has an emergent or life-threatening condition requiring immediate treatment. Clients B and C, with renal colic and severe abdominal pain, have urgent conditions and need quick treatment, but their conditions are not immediately life threatening. Strains and sprains are considered nonurgent conditions, and client D can wait several hours to receive treatment.

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele. Which action is the priority nursing intervention

during the first 24 hours?

Using only disposable diapers for perineal care Placing the infant in a prone or side-lying position Washing the infant’s genital area with an anti-infective wipe Performing neurological checks above or at the site of the lesion

Rationale A prone or side-lying position will prevent pressure on the sac; if the sac ruptures, infection may occur. Diapers should not be applied, because they may irritate or contaminate the sac. Anti-infective wipes are too caustic. Assessment of the area below, not at or above, the defect is essential for determination of motor, urinary, and bowel function.

When a client in the clinic is offered the influenza vaccine and states, "I had the vaccination already last year, so I won’t need it now," which response will the nurse give?

"The flu vaccine is recommended for everyone."

"You only need 1 flu shot in your lifetime to achieve immunity."

"As long as you are younger than 50 years old, you will not really need vaccination."

"The immunization changes, so you need to get vaccine annually to stay protected."

Rationale The influenza vaccine changes to best suit the strains circulating during a particular

flu season. Therefore, people need to be vaccinated annually. The flu vaccine is safe for most adults, but some people with allergies to components of the vaccine cannot receive it. One influenza vaccination is not adequate for lifetime immunity; an annual vaccination is recommended. Although it is especially important that higher-risk individuals such as adults older than 50 are vaccinated, annual influenza vaccination is recommended for all individuals older than 6 months.

The nurse is administering a prescribed antidepressant medication to a client in an inpatient mental health facility. Which action would the nurse perform to ensure the client is not stashing doses of medication?

Provide a 1:1 sitter for the client.

Observe the client swallowing the medication.

Ask a client’s family member to ensure the dose is taken.

Set the correct medication dose on the client’s meal tray.

Rationale Clients in inpatient mental health facilities may attempt to stash doses of prescribed medication for use in a suicide attempt. The nurse will need to watch the client to ensure the medication is swallowed and not "cheeked." It is the nurse’s responsibility to oversee medication administration, not a sitter or family member. A client will never be left to take medication unsupervised; therefore, the nurse would not leave the dose in a client’s room or on a meal tray.

After the nurse receives a report from the unlicensed assistive personnel (UAP) who completed routine vital signs, which client condition or situation would the nurse address first?

Ready for discharge Slurred speech Beeping intravenous (IV) pump Pain medication request

Rationale The client with slurred speech is experiencing a symptom of stroke and should be seen immediately. The client ready for discharge, the client with a beeping IV pump, and the client requesting pain medication all require attention but are not a priority over the client with symptoms aligning with the life-threatening condition of stroke.

Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

Which question would the nurse ask first of the witnesses who accompanied a rescued drowning victim to the emergency department?

"How long was the client underwater?"

"Was the client drinking alcohol today?"

"What is the client’s name and date of birth?"

"Did the client dive head first into the water?"

Rationale Establishing how long the client was without oxygen and the type of water (fresh or salted) in which the drowning occurred is the priority in care of the drowning victim because these factors affect the treatment of hypoxia. Contributing factors such as alcohol would be investigated but not before investigating the duration of hypoxia.

Establishing the client’s identity would be investigated but not before investigating the duration of hypoxia. Investigating causes such as head and cervical spine trauma from diving would be completed but not before investigating the duration of hypoxia.

Which action by the nurse is the priority for a client with heat stroke?

Assess the airway and breathing.

Administer diazepam to prevent shivering.

Apply ice packs to the axilla, groin, head, and neck.

Ask the client to state their name and date of birth.

Rationale Assessment and establishment of airway-breathing-circulation are the priority in the heat stroke client because absence of airway-breathing-circulation is an immediate threat to life. Diazepam may be used to treat shivering if it occurs during the cooling process but is not a priority over airway and breathing. Applying ice packs to the axilla, groin, head, and neck begins the process of external cooling but is not a priority over airway and breathing. Asking the client's identity and assessing for confusion are eventually completed, but this is not a priority over airway and breathing.

The nurse discovers a client experiencing a seizure on the floor by their bed. Which action would the nurse take?

Protect the head.

Restrain movement.

Place an oral airway.

Move the client to the bed.

Rationale Safety is a priority for the client experiencing a seizure. The nurse would protect the head through cradling or using a pad. Movement should not be retrained because that can lead to musculoskeletal injury. An airway should not be placed until the mouth is relaxed because it can chip teeth that can then be aspirated. The body should remain protected where it is while convulsing, not moved.

Upon entering a client's room, the nurse notices the trash is on fire.

In which order would the nurse perform the following interventions?

1.

Rescue clients in immediate danger.

2.

Activate the fire alarm.

3.

Close doors and windows.

4.

Extinguish the fire.

Rationale The nurse uses the mnemonic RACE to address a fire. R, rescuing the client in danger, is the first priority. A, activating the fire alarm, is the second priority. C, closing the doors and windows to the fire for containment is the third priority. E, extinguishing the fire, is the fourth priority.

A home care nurse arrives to visit a client who states they have attempted suicide by ingesting paint thinner and then collapses?

Which action would the nurse take?

Contact 911.

Induce vomiting.

Call the poison control center.

Place the client in a side-lying position.

Rationale The priority response in the poisoned client that collapses or stops breathing is to contact 911 for emergency help and begin cardiopulmonary resuscitation (CPR). Do not induce vomiting because this can cause more harm to the gastrointestinal tract.

In the alert client, call the poison control center before performing any interventions. Placing the client in a side-lying position to prevent aspiration may be indicated but not until 911 is contacted and CPR is not needed.

After an alert client reports an attempted suicide by ingesting paint thinner, which action would be the priority for the home health nurse to implement?

Induce vomiting.

Call the poison control center.

Wash the skin around the mouth.

Place the client in a side-lying position.

Rationale In the alert client, call the poison control center before performing any interventions. Do not induce vomiting because this can cause more harm to the gastrointestinal tract. Washing the skin of the poison and placing the client in a side-lying position to prevent aspiration may be indicated but not until after the poison control center is contacted.

Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.

Which action will the nurse take after noticing condensation in the tubing of humidified oxygen?

Replace the entire oxygen system.

Drain the condensation into a water trap.

Empty the condensation into the humidifier.

Reassure the client that no action is needed.

Rationale

Draining the condensation into a water trap removes the condensation from the tubing and prevents contamination of the humidifier. The system does not need to be replaced when the water can be safely drained into a water trap or other container. The condensation should not be returned to the humidifier because it can contaminate the water for humidification. Although condensation is expected, action is needed because condensation in the tubing may change the FiO 2 being delivered or be inadvertently drained into the client respiratory system.

Which question will the nurse ask to assess a client’s potential exposure to inhaled environmental irritants or toxic gases?

"Do you garden?"

"Are there ashtrays in your home?"

"How much water or fluids do you drink daily?"

"What type of work have you done in the past?"

Rationale The nurse will ask about a client’s occupation to obtain history of exposure to occupational irritants like chemicals, fumes, or fine particles. Asking about hobbies may help in obtaining information about exposure to some irritants, but gardening does not increase risk for inhaled irritants or toxic gases. Asking about ashtrays in the home will help determine if the client is exposed to secondhand smoke but will not address exposure to environmental irritants or toxic gases. Asking about fluid intake may be helpful in developing a plan of care for a client but does not assess for toxic gas exposure or environmental irritants.

Which action will the nurse include in the plan for care for a client after a bronchoscopy examination?

Check for the gag reflex.

Send the client for a chest x-ray examination.

Assess breathing every 30 minutes.

Have the client avoid the Valsalva maneuver.

Rationale After bronchoscopy, the nurse will assess for return of the gag reflex before providing anything by mouth. A chest x-ray examination is not needed after bronchoscopy but would be prescribed after diagnostic procedures such as thoracentesis. Breathing should be assessed at least every 15 minutes for 2 hours after bronchoscopy. The Valsalva maneuver is safe to perform after bronchoscopy.

When a client is taking varenicline for smoking cessation, which symptom reported by the client is most important for the nurse to communicate to the health care provider?

Headache Productive cough Strong desire to smoke Changes in behavior or thought processes

Rationale Varenicline can bring on or worsen serious mental health issues, including

depression, paranoia, hallucinations, delusions, and suicidal ideation. The nurse will immediately report any changes in a client’s behavior or thought processes to the health care provider and anticipate that the medication will be discontinued.

Headache is a potential adverse effect but does not require discontinuation of the medication. Upper respiratory symptoms may occur but are not an indication that the medication should be immediately discontinued. When treatment begins, it is expected that the client will have the desire to smoke. As treatment continues, the desire should lessen if the medication is effective.

Which action would the nurse take to avoid red man syndrome when preparing to administer a vancomycin infusion?

Infuse slowly.

Change the intravenous (IV) site.

Reduce the dosage.

Administer vitamin K.

Rationale Vancomycin should be infused slowly to avoid the occurrence of the reaction known as "red man syndrome." Changing the IV site reduces the incidence of thrombophlebitis. Reducing the dosage is done in the setting of renal dysfunction.

Administration of vitamin K is done to correct an elevated prothrombin time.

Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

Which substance history of a severe allergic reaction results in avoidance of the cephalosporins such as cefazolin, cefditoren,

avoidance of the cephalosporins such as cefazolin, cefditoren, cefotetan, and ceftriaxone? Select all that apply. One, some, or all responses may be correct.

Milk Aspirin Calcium Penicillin Strawberries

Rationale Use of cephalosporins like cefazolin should be avoided in the client with a history of severe allergic reaction to penicillin because of the potential of cross-sensitivity. The cephalosporin cefditoren should not be administered to the client with a milk allergy because it contains the milk protein caseinate. Bleeding can be magnified with the use of aspirin and the use of the cephalosporins cefotetan or ceftriaxone.

The cephalosporin ceftriaxone and calcium should not be administered together because they cause the formation of precipitates. Strawberry allergies do not prohibit the use of these medications.

Which instruction would the nurse include when teaching a female client with a new infant who is prescribed amoxicillin for a urinary tract infection?

"Take this medication on an empty stomach."

"Report signs of allergic reaction such as skin rash or itching."

"Stop taking the medication as soon as you void without burning."

"Breast-feeding should stop until you have finished with this medication."

Rationale Penicillin class medications have a high incidence of allergic reaction, so the client should monitor for allergy and report symptoms of an allergic reaction. Amoxicillin may be taken with food. The entire course of treatment should be completed, not stopped when symptoms are absent. It is safe to breast-feed with amoxicillin.

The nurse is caring for a client who underwent a total thyroidectomy.

Which assessment finding would lead the nurse to notify the rapid response team?

Stridor Hoarseness Bradycardia Hypocalcemia

Rationale Stridor is an indication of respiratory distress, which would require immediate intervention from the rapid response team. Hoarseness is a normal postoperative finding. Tachycardia, not bradycardia, is a sign of respiratory distress. Hypocalcemia can be corrected with intravenous (IV) calcium gluconate or calcium chloride.

The nurse is caring for a client with type 2 diabetes mellitus and renal insufficiency. The client is scheduled for a computerized tomography (CT) scan with contrast. Which medication would the nurse withhold to prevent lactic acidosis?

Pioglitazone Insulin

Glyburide Metformin

Rationale The metformin would be held in clients with renal impairment, as this medication along with contrast dye can cause lactic acidosis. Pioglitazone, insulin, and glyburide do not cause lactic acidosis.

The nurse is planning care for a client with hyperparathyroidism and subsequent hypocalcemia and low bone density. Which information would the nurse provide the unlicensed assistive personnel (UAP) to prevent injury?

Record urinary output.

Document respirations.

Initiate cardiac monitoring.

Use a lift sheet for transfers.

Rationale Hypocalcemia leads to low bone density, which places the client at risk for pathological bone fractures. Therefore the nurse would instruct the UAP to be careful when moving the client and use a lift sheet for repositioning. Urinary output, respirations, and cardiac monitoring are important interventions, but not for preventing injury.

The nurse is educating a client with hypothyroidism about the use of levothyroxine. Which information would the nurse provide? Select all

that apply. One, some, or all responses may be correct.

Take dose same time each day.

Refrain from switching brands.

Have regular bloodwork drawn.

Hold medication for pulse >60 beats per minute.

Report weight loss more than 3 pounds.

Rationale Clients taking levothyroxine should take the same dose the same time each day and should not switch medication brands. The client should have regular thyroid levels drawn to ensure accurate dosage. The medication should be held if the client is experiencing tachycardia, or a heart rate greater than 100 beats per minute. The client with hypothyroidism will begin to lose weight with medication as thyroid levels stabilize.

The nurse is admitting a client with severe myxedema coma. Which interventions would the nurse include in the plan of care? Select all that apply. One, some, or all responses may be correct.

Administer intravenous (IV) levothyroxine.

Avoid use of corticosteroids.

Give IV normal saline.

Wait for laboratory results before treating.

Monitor blood pressure every 4 hours.

Rationale Myxedema coma is a major complication of poorly treated hypothyroidism.

Interventions include administering IV levothyroxine. This promotes the return to normal thyroid hormone levels. IV normal saline corrects dehydration.

Corticosteroids are administered as part of the treatment. Levothyroxine is initiated before obtaining laboratory results because waiting can cause death. The blood pressure should be monitored hourly.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

Which topic will the school nurse include in adolescent education on sexually transmitted infections (STIs)? Select all that apply. One, some, or all responses may be correct.

Condom use Sexual identity Types of contraception Number of sexual partners Alcohol and drug consumption

Rationale Condom use, other types of contraception, and the importance of limiting the number of sexual partners should be included in discussions of STI transmission, because these practices decrease risk of developing STIs in adolescents. Sexual identity and alcohol and drug consumption are important issues to address with

adolescents but do not relate to STI transmission.

Which factor will the home health nurse use to assess an adolescent’s safety in the home environment? Select all that apply. One, some, or all responses may be correct.

Use of helmets Drug and alcohol use Presence of weapons Vehicle safety restraints Number of people in home Nutrition and food consumption

Rationale The nurse will assess the following safety factors in the home environment: use of helmets and vehicle safety restraints, drug and alcohol use, and presence of weapons. The number of people residing in the home and nutrition are included in other areas of the assessment but are not specific to evaluating safety.

Which topic will the nurse include when educating adolescents about injury prevention? Select all that apply. One, some, or all responses may be correct.

Suicide Depression Seat belt use Contraception

Firearm safety

Rationale Education about injury prevention for adolescents will include suicide, seat belt use, and firearm safety. Depression should be addressed when assessing mental health.

Contraception should be included in discussions about sexuality.

Which information will the nurse document to prevent injury when an adolescent is admitted to the hospital for a surgical procedure?

Allergies Pain level Grade in school Emergency contact

Rationale To prevent injury from exposure to allergens, the nurse will document all allergies in the medical record. Pain level, current grade in school, and emergency contact information do not need to be included in the record to prevent injury.

Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

Which information would the nurse include when educating an adolescent about herpes simplex virus 2 (HSV-2)? Select all that apply.

One, some, or all responses may be correct.

Illness or stress can result in outbreaks.

Use lubricant during sexual encounters.

Treatment is intended to prevent outbreaks.

A one-time dose of oral azithromycin is curative.

Condoms should be used to decrease transmission.

Rationale Clients will be made aware of factors that cause outbreaks, including stress, illness, trauma, and ultraviolet light. Advise clients to use lubricant during sexual encounters to decrease friction and reduce the risk of opening lesions. Treatment is aimed at preventing outbreaks and may include antibiotics, but there is no cure for HSV-2. Using condoms decreases the risk of transmission.

Which intervention will the nurse perform before delivery to decrease perinatal exposure when caring for an adolescent who is pregnant and reports a past history of gonorrhea? Select all that apply. One, some, or all responses may be correct.

Screen at 36 weeks’ gestation Plan to use standard precautions Administer intramuscular ceftriaxone Recommend bottle feeding after birth Report any greenish-yellow purulent discharge

Rationale To decrease risk of perinatal exposure, the nurse will screen clients for gonorrhea at 36 weeks’ gestation to determine the presence of infection. The nurse also will administer intramuscular ceftriaxone to treat the infection. Standard precautions protect the nurse, not the newborn. The infection is passed vaginally; clients with gonorrhea do not need to avoid breast-feeding. Female clients frequently do not display symptoms, but the presence of purulent discharge indicates infection, which could be transmissible.

Which issue will the public health nurse discuss when addressing safety and infection control in adolescents, according to the Healthy People 2020 initiative?

Safe sex practices Alcohol use and binge drinking Testing all adolescents for human immunodeficiency virus (HIV) before adulthood Performing Papanicolaou (Pap) smears by age 16

Rationale The Healthy People 2020 initiative includes the goal of testing all adolescents for HIV infection before adulthood. Safe sex, alcohol use, and binge drinking are important topics to discuss with adolescents but are not part of the Healthy People 2020 initiative. Pap smears are obtained beginning at age 21, not 16, and are performed annually thereafter.

Which anticipatory guidance is most important when a client comes to the health care provider’s office for a 14-year-old wellness visit?

Abstinence Healthy diet Ways to prevent accidents Correct handwashing technique

Rationale The biggest health risk for adolescents is accidents (the number-one cause of death in this age group), so anticipatory guidance during interactions with adolescents should be directed at accident prevention. Adolescents have a thought process that allows them to participate in risky behaviors because they feel as though nothing bad will ever happen to them. All adolescents are at risk for accidents, but not all 14year-olds are sexually active. Although dietary issues and hygiene issues are important, they are not as important as accident prevention.

Which response would the nurse give when a client with syncope from a vagal response asks why it is important to avoid bearing down during a bowel movement?

"Straining can decrease blood flow to your brain because it is filling hemorrhoids."

"Trouble moving your bowels is stressing your heart and may lead to a heart attack."

"Bearing down stimulates a nerve response that decreases your heart rate and blood pressure."

"Difficulty with a bowel movement means you are dehydrated, which causes low blood pressure."

Rationale Bearing down stimulates a vagal nerve response that results in a decrease in heart rate and blood pressure leading to syncope (loss of consciousness). Blood flow to hemorrhoids is not the cause of syncope. Bearing down decreases the heart rate through a vagal response, not ischemic disease leading to myocardial infarction (heart attack). Straining, not dehydration, is a direct cause of vagal stimulation.

Which response would a nurse give when a client with a prosthetic heart valve asks why it is important to take antibiotics before a dental procedure?

"The antibiotic is taken to prevent infection around your artificial heart valve."

"Valvular heart disease increases the risk for dental caries and gum disease."

"All clients with murmurs need prophylactic antibiotics before dental procedures."

"You only need to take the antibiotic if you have a fever before your dental procedure."

Rationale An antibiotic is taken prophylactically to prevent infection of the heart if bacteria from the mouth enter the bloodstream. The risk for valvular heart disease (e.g., endocarditis)after invasive dental procedures is increased in clients with artificial heart valves, but the risk for dental infections such as caries or inflammatory gum disease is not increased by artificial heart valves. Current recommendations are that clients with artificial heart valves, a history of endocarditis, or uncorrected congenital heart disease should receive prophylactic antibiotics, but most clients with murmurs do not need antibiotic prophylaxis before invasive procedures. The prophylactic antibiotics should be taken as prescribed before the dental procedure

to prevent endocarditis. If the client experiences fever, it should be reported to the dentist and health care provider and may require further evaluation and treatment.

Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for keywords; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

Which food would the nurse teach a client who has a prescription for warfarin to limit? Select all that apply. One, some, or all responses may be correct.

Spinach Oranges Broccoli Chicken breast Sweet potatoes

Rationale Because the effectiveness of warfarin is decreased by vitamin K, the nurse will teach the client to limit foods high in vitamin K such as spinach or broccoli. Oranges contain minimal vitamin K. Chicken breast is low in vitamin K. Sweet potatoes are high in vitamin A and potassium, but they are low in vitamin K. Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question.

Which response would the nurse give to a menstruating female client

Which response would the nurse give to a menstruating female client who asks how to avoid toxic shock syndrome with tampon use?

"Change the tampon every 8 hours."

"Force the tampon up as far as it will go."

"Wash your hands before inserting the tampon."

"Use the strongest absorbency tampon that you need."

Rationale Washing the hands before inserting the tampon is an intervention to reduce introducing organisms to the vagina and causing toxic shock syndrome. Tampons should be changed every 3 to 6 hours. Tampons should be inserted gently and with care, and not forced into the vagina in order to avoid damaging the tissue. Super absorbent tampons should be avoided.

Which action by a client with peripheral arterial disease indicates that more teaching about how to manage the disease is needed?

Applying a hot water bottle to the abdomen Using a heating pad to warm the extremities Drinking a warm cup of tea when feeling chilly Turning the room thermostat above 72°F (23.3°C)

Rationale The client’s extremities are less able to respond to thermal stress because of peripheral vascular problems, and burns may occur with the application of a heating pad to the extremities. Applying heat to the abdomen causes reflex dilation of the

arteries in the extremities and increases blood flow without untoward effects.

Raising the internal temperature by drinking warm fluid prevents vascular constriction and warms the extremities. Increasing heat of the external environment will safely help prevent arterial constriction and improve client’s peripheral circulation.

Which action would the nurse take regarding the new prescription of a client who is receiving methotrexate for acute lymphocytic leukemia (ALL) and develops a temperature of 101°F (38.3°C) after the health care provider prescribes aspirin 650 mg every 4 hours as needed?

Express concern about the dosage prescribed.

Request a prescription for an antacid.

Express concern about the type of antipyretic prescribed.

Ask if the frequency should be every 6 hours instead.

Rationale Both ALL and methotrexate may cause thrombocytopenia, with resulting bleeding risk. Aspirin is contraindicated with thrombocytopenia because of its inhibitory effect on platelet aggregation, so the nurse should express concern about the type of antipyretic prescribed. The dosage of aspirin prescribed is within the normal range for a client with a normal platelet count. In clients who need to take nonsteroidal anti-inflammatory drugs like aspirin, an antacid may be appropriate, but aspirin should not be administered to this client. Although the frequency is within acceptable limits, aspirin is contraindicated.

Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for keywords or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical

experiences. Think of each question as being an ideal, yet realistic, situation.

Which statement from a pregnant client with premature rupture of membranes (PROM) demonstrates an understanding of the infection risk? Select all that apply. One, some, or all responses may be correct.

"I will report a fever to my doctor."

"I will wipe from front to back when using the bathroom."

"If I have contractions, medications will be administered."

"If I develop chorioamnionitis, my doctor will induce labor."

"I will let my doctor know if I experience foul-smelling vaginal discharge."

Rationale The nurse would provide thorough education on signs of infection, infection prevention, and possible outcomes of infection for pregnant clients with PROM. The client would be instructed on how to keep the genital area clean and advised that nothing is to be introduced into the vagina. The client would be made aware of the importance of being vigilant for signs of infection, such as fever and foulsmelling vaginal discharge, and that these signs would be reported immediately.

Clients would be made aware that labor will need to be induced if chorioamnionitis develops. If preterm labor occurs, tocolytic medications can be administered to "buy time" enough for transporting the client to a hospital capable of providing preterm infant care. The additional time also allows antenatal corticosteroids or antibiotics to reach effective levels.

Which finding would the nurse be most concerned about when reviewing the chart of a client scheduled for an amniocentesis?

Hepatitis B Prior uterine surgery Active genital herpes B negative blood type

Rationale Because of the possibility of fetomaternal hemorrhage, administering Rho D immune globulin to the woman who is Rh negative is standard practice after an amniocentesis. Hepatitis B, prior uterine surgery, or active genital herpes do not increase the risk for maternal or neonatal complications of amniocentesis.

Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

The nurse caring for a client receiving magnesium sulfate observes respirations of 10 breaths/minute, heart rate of 68 beats/minute, and blood pressure of 88/50 mm Hg. After discontinuing the magnesium sulfate, which priority action would the nurse take?

Administer oxygen.

Initiate rescue breathing.

Initiate a bolus of intravenous (IV) fluid.

Administer calcium gluconate.

Rationale The client is experiencing magnesium sulfate toxicity, which can be reversed with calcium gluconate. If left untreated, magnesium sulfate toxicity can result in respiratory or cardiac arrest. Oxygen, rescue breathing, and an IV fluid bolus will not reverse the effects of the magnesium sulfate.

Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for keywords; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

Which clinical condition concerns the nurse the most for an obstetrical client with heart disease? Select all that apply. One, some, or all responses may be correct.

Obesity Anemia Hypertension Hypothyroidism Emotional distress

Rationale The effects of factors that increase the workload of the cardiovascular system can be reduced by appropriate treatment of coexisting conditions that increase the risk of cardiac decompensation. Conditions such as obesity, anemia, hypertension, and emotional stress should be reduced. Hypothyroidism is not a condition that increases the workload of the cardiovascular system; however, hyperthyroidism

does.

Which are risk factors of diabetes in pregnancy? Select all that apply.

One, some, or all responses may be correct.

Preterm birth Hypertension Cesarean birth Placenta previa Placental abruption

Rationale Maternal complications associated with diabetes include preterm birth, hypertension, and cesarean birth. Placenta previa and placental abruption are not directly associated with diabetes.

Which information would the nurse include in the teaching for a client who received methotrexate? Select all that apply. One, some, or all responses may be correct.

Urine is considered toxic for 48 hours.

Avoid sexual intercourse for 72 hours.

Gastric distress is a possible side effect.

Stools will contain some residual methotrexate for 7 days.

Double flush the toilet with the lid down after urinating.

Rationale Gastric distress is a possible side effect. Stools may contain some residual methotrexate for up to 7 days. The client should double flush the toilet with the lid down to prevent the splashing of contaminated urine. Urine is considered toxic for 72 hours. The client should be instructed to avoid intercourse until the beta-human chorionic gonadotropin level is undetectable.

A woman who is admitted to the labor suite has herpes simplex virus type 2 (HSV-2) with active lesions in the perineal area. Which action would the nurse’s plan of care include?

Withholding oral fluid intake Discussing the need for formula feeding Obtaining permission for a paracervical block Applying moist compresses to the perineal area

Rationale Withholding oral intake of fluids is part of the preparation for a cesarean birth. This client has active herpes, which can be transmitted to the infant during a vaginal birth. A client with herpes may breast-feed. A paracervical block is not used for a planned cesarean birth. Herpes lesions should be kept as dry as possible.

A primary health care provider prescribes carboprost tromethamine (Hemabate) to be administered to a postpartum client with intractable vaginal bleeding. The nurse should notify the provider of which current condition in the client’s medical history?

History of asthma Negative Homan sign

Increased blood pressure Absence of the Babinski reflex

Rationale Carboprost is contraindicated in clients with asthma because of its respiratory side effects of coughing and dyspnea. The Homan sign is thought to be suggestive of thrombophlebitis and is not related to carboprost. Carboprost does not affect blood pressure. Absence of the Babinski reflex is an expected adult finding.

Which intervention would the nurse follow to prevent future falls in an older adult experiencing delirium who sustained a leg fracture caused by a fall? Select all that apply. One, some, or all responses may be correct.

Minimizing sedating medications Modifying the home environment Teaching clients about the safe use of the Internet Manage foot and footwear problems Providing information about the effects of using alcohol

Rationale The nursing interventions followed to prevent falls are minimizing medications, modifying the home environment, and managing foot and footwear problems.

Teaching clients about the safe use of the Internet may be an effective intervention for preventing delirium. Providing information about the effects of using alcohol is not an intervention for older adults; this action is more beneficial for adolescents.

Which medication is most beneficial to the client with sickle cell anemia receiving a blood transfusion regimen and experiencing cardiac dysrhythmias due to iron overdose toxicity?

Deferasirox Deferiprone Deferoxamine Ferrous gluconate

Rationale A client with sickle cell anemia requires frequent blood transfusions and is at an increased risk for iron toxicity. Deferoxamine is an intravenous medication that chelates with the iron and reduces iron overload or hemochromatosis in the client in less time. Deferoxamine is the most beneficial medication in this situation.

Deferasirox and deferiprone are oral chelating agents and therefore show delayed action compared with deferoxamine. Iron supplements such as ferrous gluconate should not be administered to the client, because they further increase the risk of iron overload.

Which priority emergency assessment would the nurse perform on a client with bomb blast injuries? Select all that apply. One, some, or all responses may be correct.

Airway Breathing Circulation Provide comfort measures Facilitate family presence

Exposure or environmental control

Rationale The primary survey focuses on airway-breathing-circulation (ABC) and environmental control. These are surveyed during emergency assessments in a primary survey to identify life-threatening conditions and to analyze the appropriate interventions. Giving comfort measures and facilitating family presence are performed in a secondary survey of emergency assessment followed by a primary survey.

Test-Taking Tip: Key words or phrases in the question stem such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. No real absolutes exist in life; however, every rule has its exceptions, so answer with care.

When initiating continuous cardiac monitoring, the nurse maintains oxygen saturation and end-tidal carbon dioxide on a client who survived a fire. Which type of emergency assessment is the nurse performing?

Focused adjuncts Full set of vital signs Comfort measures Family presence

Rationale Emergency assessment of focused adjuncts is used to determine the need for additional procedures in a secondary survey. Initiating a continuous

electrocardiogram, maintaining oxygen saturation and end-tidal carbon dioxide, inserting a gastric tube, and obtaining blood for laboratory studies are some of the interventions performed during emergency assessment of focused adjuncts.

Emergency assessment of the full set of vital signs is performed to obtain temperature, heart rate, and blood pressure. The nurse gives comfort measures to assess, treat, and reassess for pain and anxiety. Facilitating family presence involves determining the caregiver’s desire to be present during invasive procedures and/or cardiopulmonary resuscitation.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

Which action would the nurse instruct an older client to implement to ensure antibody-mediated immunity? Select all that apply. One, some, or all responses may be correct.

Obtain a shingles vaccination.

Receive a tetanus booster injection.

Obtain the pneumococcal vaccination.

Receive annual testing for tuberculosis.

Receive an annual influenza vaccination.

Avoid obtaining the pertussis vaccination.

Rationale Because older adults are less able to make new antibodies in response to the presence of new antigens, they should receive the shingles vaccination. Because

older adults may not have sufficient antibodies present to provide protection when they are reexposed to microorganisms they have already generated antibodies against, booster shots are encouraged. The pneumococcal and influenza vaccinations help create antibodies in response to new antigens. Testing for tuberculosis addresses cell-mediated immunity for the older client. Avoiding the pertussis vaccine would not ensure antibody-mediated immunity.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which action would the nurse take to decrease the risk of ventilatorassociated pneumonia (VAP) for a client receiving mechanical ventilation?

Suction the client on a regular schedule.

Elevate the head of the bed to at least 30 degrees.

Schedule daily changes of the ventilator tubing.

Maintain continuous sedation during ventilator use.

Rationale Elevating the head of the bed to 30 to 45 degrees helps reduce aspiration and decreases incidence of VAP. Suctioning is done only when assessment data indicate that it is necessary. Changes of ventilator tubing increase the risk for VAP, and tubing changes are recommended only when there is visible soiling of the tubing.

Sedation should be interrupted at least daily to allow evaluation of client respiratory effort and possible readiness for extubation.

In which order would the four clients with various conditions admitted to an emergency department after a bus accident be seen by the nurse?

1.

Cardiac arrest

2.

Chest pain resulting from ischemia

3.

Abdominal pain

4.

Closed extremity trauma

Rationale The client in cardiac arrest is triaged under emergency severity index 1 (ESI-1) and should be seen immediately because the condition is severe. The client with abdominal pain is triaged as ESI-3 and is seen within up to 1 hour. The client with closed extremity trauma could be delayed and is assigned ESI-4. The client with chest pain resulting from ischemia is triaged as ESI-2. This client should be seen by the health care provider within 10 minutes, but not immediately as should the client with cardiac arrest.

Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

The client with which change in vital signs measurements would be treated first to ensure safety?

A B C D

Rationale According to a 3-tiered triage system, the client with unstable vital signs is categorized under the emergent tier level. Normal respiratory rates and heart rates

are in the range of 12 to 20 breaths per minute and 70 to 100 beats per minute, respectively. Client B first has normal values for respiratory rate and heart rate and then shows markedly elevated values for respiratory and heart rates. Client B should be treated first. Clients A, C, and D do not have any fluctuations from normal values for respiratory and heart rates. Clients A, C, and D can be treated after client B is treated.

A client with acquired immunodeficiency syndrome (AIDS) and cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment would the nurse use? Select all that apply. One, some, or all responses may be correct.

Goggles Surgical mask Shoe covers Gown Gloves N95 HEPA mask

Rationale A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other body fluids during intimate body care. Goggles would be important only if the client was on mechanical ventilation to avoid contact with sputum. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving client care at the bedside. An N95 HEPA mask would be necessary if the client had tuberculosis, but not for cryptococcal pneumonia alone.

Which action would the nurse take first after learning that sputum cultures for a client with a chronic cough were positive for tuberculosis?

Place the client on airborne precautions.

Notify the client’s health care provider.

Auscultate the client’s breath sounds.

Notify the public health department.

Rationale The initial action by the nurse after learning that a client has active tuberculosis would be to assure the safety of other clients, visitors, and staff by implementing airborne precautions. The health care provider would be notified, but this can be done after airborne precautions are started because implementation of infection control measures does not require a prescription by the health care provider. The nurse would plan to check the client’s lung sounds, but this can be done after airborne precautions, including the use of an N95 mask by the nurse when assessing the client. The public health department will need to be notified so that contacts of the client can be tested and treated, but this can be done any time during the client’s hospitalization.

The nurse is educating a client on a new antidepressant prescription.

Which statement by the client indicates the need for further teaching?

"This medication will cure my depression."

"I should never double the dose to feel better."

"I will see my health care provider every month."

"It may take several weeks for the medication to take effect."

Rationale Antidepressants manage depression but do not cure the condition. Clients will be instructed never to double the dose and to see their health care provider every month. Clients will also be made aware that the effects of many medications used to treat mental illness can take several weeks, if not months, to take effect.

Which medication can place the breast-fed infant at risk?

Sertraline Fluoxetine Desipramine Nortriptyline

Rationale Fluoxetine can be passed to infants through breast-feeding. The medication’s presence in breast milk can cause colic and inadequate weight gain. Sertraline, desipramine, and nortriptyline are all considered safe for clients to take while breast-feeding.

Which information would the nurse provide a client beginning treatment with haloperidol to prevent injury?

Monitor temperature.

Wear a mask when out.

Change positions slowly.

Report pacing and squirming.

Rationale Antipsychotic medications can cause orthostatic hypotension through their mechanism of action—blocking alpha 1-adrenergic receptors in blood vessels. To prevent injury, the nurse will instruct clients to change positions slowly to help prevent light-headedness and subsequent injury from falls. Temperature would be monitored with neuroleptic malignant syndrome. Agranulocytosis can occur with certain antipsychotics and increases the risk of infection. Pacing and squirming, or akathisia, can be disturbing for clients but does not place them at risk for injury.

Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question.

Which would the nurse use to monitor for torsades de pointes in a client with schizophrenia being treated with chlorpromazine?

Electrocardiogram (ECG) Weight Serum sodium Orthostatic blood pressures

Rationale Chlorpromazine is one of four first-generation antipsychotic medications that can cause life-threatening ventricular fibrillation. The nurse will obtain an ECG and serum potassium level before and during treatment. Weight gain can be a complication of antipsychotics, but is not a fatal complication. Serum potassium, not sodium, will be monitored in clients taking chlorpromazine. Orthostatic hypotension can result in clients taking chlorpromazine, but is generally not a fatal complication and is not related to monitoring for torsades de pointes.

Which nursing intervention is priority when caring for a client with schizophrenia who begins to have difficulty breathing and whose eyes begin to roll up after receiving the first dose of chlorpromazine?

Administer intravenous (IV) benztropine.

Reduce chlorpromazine dosage.

Administer oral benzodiazepine.

Obtain serum liver function tests.

Rationale When taking first-generation antipsychotics such as chlorpromazine, clients may experience extrapyramidal symptoms including acute dystonia. This reaction requires immediate intervention with administration of IV or intramuscular (IM) anticholinergic medication such as benztropine. Once the immediate crisis is resolved, the health care provider may lower the dosage or discontinue chlorpromazine. Oral benzodiazepines are used to treat neuroleptic-induced parkinsonism. Liver function tests and any other laboratory work would be obtained after the client has been stabilized.

Which action would the nurse implement for a client who has overdosed on barbiturates? Select all that apply. One, some, or all responses may be correct.

Apply ice packs.

Maintain airway.

Administer naloxone.

Give activated charcoal.

Give intravenous fluids.

Rationale Due to the adverse effect of respiratory depression, the nurse will administer oxygen and maintain the airway. Any unabsorbed medication can be removed by giving the client activated charcoal. To eliminate any barbiturate that has been absorbed, the nurse would administer intravenous fluids to alkalinize the urine. Naloxone is given to reverse the effects of opioid overdoses. The nurse will provide warm blankets, not ice packs, to clients who have overdosed.

When caring for a sedated client who is being mechanically ventilated, which action will the nurse take first when the low flow alarm is persistently sounding?

Adjust the alarm settings.

Notify the respiratory therapist.

Ventilate manually and call for assistance.

Check all connections and ventilator tubing.

Rationale If an alarm is persistently sounding, the nurse would mechanically ventilate the client and ask another member of the health care team to take actions such as notifying the respiratory therapist, checking ventilator connections, or assessing the endotracheal tube cuff pressure. The alarm settings may be adjusted in consultation with the health care provider and respiratory therapist, but further assessment is needed first. The respiratory therapist would be notified, but the nurse would need to manually ventilate the client until the respiratory therapist has arrived and checked the ventilator. The connections and ventilator tubing would be assessed for leaks, but a sedated client will need to be manually ventilated until the low pressure situation has been addressed.

Test-Taking Tip: What happens if you find yourself in a slump over the examination?

Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.

Which information will the nurse plan to include in the discharge teaching plan for a client who has been admitted for a pulmonary embolism and has a new prescription for an oral anticoagulant?

Select all that apply. One, some, or all responses may be correct.

Floss twice daily to prevent the need for dental work.

Avoid eating hot food or liquid that can burn the mouth.

Use an electric shaver instead of a straight-bladed razor.

Apply ice to any areas of trauma like bumps and scrapes.

Use enemas to prevent straining during bowel movements.

Rationale The goal of self-care for clients on anticoagulation therapy is to prevent bleeding.

Clients should avoid eating hot food or liquid, which can burn the mouth, disrupt the mucous membrane, and encourage bleeding. Clients should use an electric shaver instead of a straight-bladed razor to avoid cuts. Clients should be instructed to apply ice to any areas of trauma, such as bumps and scrapes, to slow blood flow and minimize bleeding. Clients on anticoagulation therapy should not floss because this can cause the gums to bleed; however, they should be encouraged to brush their teeth with a soft tooth brush and make sure their dentist knows they are on anticoagulants. Stool softeners, rather than enemas, should be used to prevent straining because enemas can cause rectal bleeding.

Which information will the employee health nurse include when teaching about ways to prevent transmission of influenza in the workplace? Select all that apply. One, some, or all responses may be correct.

Sneeze or cough into the upper sleeve.

Avoid use of over-the-counter antihistamines.

Use alcohol-based hand sanitizers after blowing the nose.

Turn the head away from others when coughing or sneezing.

Antiviral medications are the most effective means of transmission prevention.

Rationale Sneezing or coughing into the upper sleeve is recommended because it minimizes droplet spread and prevents the influenza virus from getting on the hands, where it can easily be spread to environmental surfaces. Alcohol-based hand sanitizer use after blowing the nose will reduce transmission of influenza virus to environmental surfaces. Turning the head away from others when coughing or sneezing decreases droplet spread. Over-the-counter antihistamines are recommended for control of rhinitis and nasal congestion. Although antiviral medications may help reduce symptoms and transmission if they are started within the first 2 days after symptoms develop, the most effective means to reduce influenza transmission is annual vaccination.

After the nurse has instructed a client with active tuberculosis (TB) on self-care at home, which client statement indicates understanding of the teaching?

"I will plan to stop drinking alcohol during treatment."

"Once the cough and fever go away, I can stop the medication."

"While taking this medication I will stop all my other medications.

"I will make sure no visitors enter my home until I have finished treatment."

Rationale The medications used for treatment of TB can be toxic to the liver, and other substances that are hepatotoxic (such as alcohol) should be avoided during TB treatment to decrease the risk for liver damage. The medications must be taken for 6 months or longer to complete therapy; treatment should not be discontinued when symptoms subside. A client’s health care provider will review current medications and let the client know if any should be stopped while being treated for TB, although most medications are safe to take with the medications used to treat TB. Most clients who are taking medications are not contagious after several weeks of treatment. A client who has started TB treatment and has had negative sputum cultures is not contagious and may return to usual activities such as having visitors, although the client will need to continue treatment for at least 6 months.

Which information would the nurse educator include in a presentation on how to care for clients with a chest tube drainage system? Select all that apply. One, some, or all responses may be correct.

Ensure the chest tube dressing is tight and intact.

Palpate the skin to detect subcutaneous emphysema.

Place the chest tube drainage system below the chest.

Quickly attempt to reinsert the chest tube if it falls out.

Strip the chest tube with long strokes to promote drainage.

Rationale Care of clients with chest tubes includes ensuring the chest tube dressing is tight and intact to prevent tube dislodgement and air leak. The nurse will palpate the skin to detect subcutaneous emphysema. The chest tube drainage system is placed below the chest. If a chest tube falls out, the nurse will cover the site with sterile gauze and immediately notify the health care provider. The chest tube should not be stripped because this causes negative pressure that can cause trauma to the pleura.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

When the nurse is assessing a client after tracheostomy placement, which finding requires immediate action by the nurse?

Crackling of the skin on palpation Small amount of blood at the surgical site Client reports the area around incision is tender The client is unable to speak with a cuffed tube

Rationale Crackling of the skin on palpation indicates the presence of subcutaneous emphysema, which the nurse will immediately report to the health care provider. A small amount of blood at the surgical site is expected and will be monitored for signs of hemorrhage. Tenderness after the surgical procedure would be expected.

Inability of the client to speak with a cuffed tube is expected because airflow prevents use of the vocal cords.

Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.

When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicates a need for more staff education about oxygen therapy?

Oxygen flow rate is set to 8 L/min.

There is bubbling present in the humidifier.

Pressure areas of tubing along the ears are padded.

Smoking and open flame prohibited signs are clearly posted.

Rationale Flow rates for nasal cannulas should be set no higher than 6 L/min, higher flows do not lead to an increase in FIO 2, and high oxygen flow increases drying and irritation of mucous membranes. Bubbling of oxygen through the humidifier indicates that humidification of oxygen is occurring. Padding of pressure areas on the oxygen tubing decreases skin irritation and breakdown. Smoking and open flame prohibition signs are posted in places where oxygen is used to decrease the risk for fire.

Which personal protective equipment would the nurse use when giving a bath to a client with acquired immunodeficiency syndrome (AIDS), pneumonia, and AIDS wasting syndrome with fecal incontinence? Select all that apply. One, some, or all responses may

be correct.

Goggles Surgical mask Shoe covers Gown Gloves N95 hepa mask

Rationale Evidence-based guidelines indicate the need to use standard and contact precautions (consisting of a gown and gloves) in clients who have fecal incontinence to avoid possible transmission of gastrointestinal infection. Standard precautions are used for clients with AIDS, but the client’s pneumonia diagnosis indicates the need for droplet precautions with eye protection and a surgical mask, because the client may be coughing during the bath. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving patient care at the bedside. An N95 hepa mask would be necessary if the client had tuberculosis, but not for pneumonia.

Which adverse effect would prompt the nurse administering a course of aminoglycoside treatment to a client with Klebsiella infection to hold treatment and contact the health care provider? Select all that apply. One, some, or all responses may be correct.

Vertigo Tinnitus Dizziness

Heartburn Persistent headache

Rationale The nurse monitors the client administered aminoglycosides for signs of ototoxicity, which include vertigo, tinnitus, dizziness, and persistent headache. Any sign of ototoxicity should result in holding the treatment and contacting the health care provider. Heartburn is not associated with ototoxicity.

Which statement by the client indicates to the nurse a need for further teaching on rifampin therapy?

"I can expect my skin to turn yellow."

"I can expect my sweat to change color."

"I can expect my urine to turn red-orange."

"I can expect my contact lenses to stain orange."

Rationale The skin turning yellow indicates jaundice, a serious unexpected adverse effect of rifampin therapy that needs to be reported to the prescriber. Sweat, urine, saliva, and tears (which may stain contact lenses) may turn to a red-orange color during rifampin therapy, which is expected.

Which statement by the client indicates to the nurse a need for further teaching on isoniazid therapy?

"I will avoid alcohol during treatment."

"I will take the medication on an empty stomach."

"I will stop treatment once my fever has subsided."

"I will contact my doctor if I notice tingling in my feet."

Rationale Treatment for tuberculosis lasts at least 6 months and should not be stopped with the decrease of symptoms. Alcohol should be avoided because treatment can injure the liver. Isoniazid should be taken on an empty stomach unless stomach upset occurs. Symptoms of peripheral neuropathy, such as tingling, should be reported to the health care provider.

Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.

Which statement by a client about sulfonamide use for a urinary tract infection would the nurse review for correction?

"I will avoid the sunlight."

"I will increase my fluid intake."

"I will let my doctor know if I develop a rash."

"I will stop taking the medication when my symptoms subside."

Rationale

The nurse instructs the client to complete the entire course of treatment, not stop when symptoms subside. The client on sulfonamide therapy should avoid prolonged exposure to the sun, increase fluid intake to support the kidneys, and report a rash to investigate possible hypersensitivity.

Which assessment finding during the administration of intravenous penicillin would prompt the nurse to stop the infusion? Select all that apply. One, some, or all responses may be correct.

Hives Itching Nausea Skin rash Shortness of breath

Rationale Penicillin administration carries a high rate of allergic reaction, so the nurse monitors the client for signs of allergy. Hives, itching, skin rash, and shortness of breath are all indications of allergic reaction and warrant cessation of the infusion and contact with the health care provider. Nausea is not an indication of allergic reaction.

Which client would benefit from the administration of prophylactic antibiotics? Select all that apply. One, some, or all responses may be correct.

Chickenpox infection Fever of unknown origin

Preoperative hip replacement Congenital bicuspid aortic valve Current chemotherapy treatment

Rationale Prophylactic antibiotics are indicated in the preoperative hip replacement client because this decreases the occurrence of infection postoperatively. Prophylactic antibiotics are indicated for the client with congenital bicuspid aortic valve disease because this decreases the risk of endocarditis with an invasive procedure.

Prophylactic antibiotics are indicated for the current chemotherapy treatment client because this decreases the risk of infection due to neutropenia. A client with the chickenpox infection has a viral infection for which antibiotics are ineffective. A fever of unknown origin should not be treated with antibiotics because that may eliminate the ability to discover the causative organism, and a virus could be the cause of the fever.

Which medication would the nurse question when reviewing the home medication list for a client admitted with peptic ulcer disease (PUD)?

Iron Ibuprofen Famotidine Acetaminophen

Rationale Clients with PUD should refrain from taking aspirin or nonsteroidal anti-

inflammatory drug (NSAID) products as this can cause gastrointestinal (GI) bleeding. This includes ibuprofen. Iron helps with the production of more red blood cells, and famotidine is an H2 blocker that decreases gastric acid secretion.

Acetaminophen does not irritate the GI mucosa and is safe for clients with PUD.

The nurse is providing discharge instructions for a client receiving unsealed radioactive isotope. Which actions made by the client indicate an understanding of the instructions provided? Select all that apply. One, some, or all responses may be correct.

Uses dishwasher for all utensils Flushes toilet twice after each use Avoids contact with pregnant women Takes a laxative 3 days after treatment Washes clothes separately from others

Rationale A client who received an unsealed radioactive isotope should avoid contact with pregnant women, take a laxative 2 to 3 days after treatment to facilitate excretion of contaminated stool, and wash all clothes separately from the clothing of other household members to avoid contamination. The client should use disposable utensils, not those shared with other family members. The client should flush the toilet three, not two, times after use.

The home health nurse is educating a client with adrenal insufficiency regarding the disease process and medication safety. Which statement made by the client indicates a need for further education?

"I should not skip any doses of my medication."

"It is important to never switch brands of medication."

"I should weigh myself every day and report weight gain."

"I only need a medical alert bracelet when in the hospital."

Rationale A client with adrenal insufficiency must take adrenal hormone replacement medication for life and must always wear a medical alert bracelet with the name of the condition and the medication. Therefore the statement about needing to wear the bracelet only in the hospital requires further education. The client is correct to avoid skipping any medication doses, to avoid switching brands of medication, and to perform daily weight checks and report weight gain.

The nurse is reviewing the electronic health record of a client admitted with syndrome of inappropriate antidiuretic hormone (SIADH). Which medication order would the nurse question?

Furosemide (Lasix) Tolvaptan (Aquaretic) Intravenous (IV) 0.9% sodium chloride Demeclocycline (Declomycin)

Rationale IV 0.9% sodium chloride should be administered cautiously in clients with SIADH, as it can further potentiate fluid volume overload. Instead, a 3% sodium chloride is hypertonic and can be used to treat severe hyponatremia related to SIADH. Diuretics such as furosemide (Lasix) can be used to treat heart failure if the sodium level is normal. Tolvaptan (Aquaretic) and demeclocycline (Declomycin) are both

medications used to treat SIADH. Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.

The nurse is planning care for a client with diabetes insipidus (DI).

Which intervention made by the nurse requires correction?

Assessing sodium levels Measuring urine output Restricting fluids at night Changing positions slowly

Rationale A client with DI is at risk for severe fluid volume deficit due to increased urination.

Therefore the nurse would never restrict fluids for longer than 4 hours, because it can lead to severe dehydration. The nurse would assess sodium levels, measure urine output, and have the client change positions slowly.

The nurse is caring for a client who underwent a transsphenoidal hypophysectomy and notices clear nasal drainage. Which intervention would the nurse perform first to prevent complications?

Test fluid for glucose.

Place client on bed rest.

Document the findings.

Administer glucocorticoids.

Rationale To determine the source of the fluid draining from the nose, the nurse would first test the fluid for glucose. Other interventions are based on knowing the source of the fluid. If the fluid is cerebrospinal fluid, the client would be placed on bed rest.

After all interventions are performed, the nurse would document the findings.

Glucocorticoids are given to treat a client who underwent pituitary gland removal.

The nurse is educating a client on postoperative care after a transsphenoidal hypophysectomy. Which action made by the client is incorrect?

Performing deep-breathing exercises Bending at the knees to pick up objects Coughing to clear pulmonary secretions Taking stool softeners to prevent straining

Rationale A client who underwent a transsphenoidal hypophysectomy should avoid coughing after surgery as it increases incisional pressure and can, in turn, cause a cerebrospinal fluid leak. Therefore this action indicates a need for further teaching.

The client should perform deep-breathing exercises, bend at the knees to pick up objects, and take stool softeners to prevent straining with bowel movements.

Which statement by a client with chlamydia about medication

compliance and preventing recurrence indicates the need for further instruction?

"If there is more drainage or I have pain, I will call the office."

"The full regimen of prescribed oral antibiotics needs to be taken."

"Sexual intercourse should be avoided for 3 days after treatment."

"I will notify all my sexual partners of the infection so they can get treated."

Rationale Clients should refrain from sexual intercourse for 7 days after treatment. Having sex before that time can lead to reinfection or continued transmission to partners.

Clients will be instructed to report any further drainage or pain, complete the full course of oral antibiotics, and inform all sexual partners of infection and the need for treatment.

Which statement by an adolescent indicates the need for additional teaching regarding sexually transmitted infections (STIs)?

"We use condoms with nonoxynol-9."

"I use spermicide as contraception."

"My partner uses a female condom."

"I have never used drugs or alcohol."

Rationale Use of spermicide only protects against pregnancy, not STIs. Nonoxynol-9 lubricated condoms and female condoms both decrease the risk of STI transmission. Drug and alcohol use is not directly related to STI transmission.

Test-Taking Tip: The presence of absolute words and phrases can also help you determine the correct answer to a multiple-choice item. If answer choices contain an absolute (e.g., none, never, must, cannot), be very cautious. Remember that there are not many things in the world that are absolute, and in an area as complex as nursing, an absolute may be a reason to eliminate it from consideration as the best choice. This is only a guideline and should not be taken to be true 100% of the time; however, it can help you reduce the number of choices.

Which statement by an adolescent during an annual physical examination indicates the need for human immunodeficiency virus (HIV) testing?

"I only have sex with one partner."

"I always use barrier contraception."

"I occasionally smoke pot with friends."

"I have shared needles when using drugs."

Rationale Risk factors for HIV infection include sharing intravenous drug needles. Therefore, this statement indicates a need for HIV testing. Monogamous sex, use of barrier contraception, and smoking pot are not high-risk behaviors.

Which statement by an adolescent on using sunscreen to reduce skin cancer risk requires correction by the nurse?

"I’ll use sunscreen without lanolin."

"Sunscreen will be applied every 2 hours."

"I can use sunscreen with an alcohol-free base."

"I will use sunscreen with a sun protective factor (SPF) of 10."

Rationale The nurse will recommend using sunscreen with an SPF of at least 15, not 10.

Adolescents using sunscreen without lanolin, applying it every 2 hours, and with an alcohol-free base do not need correction by the nurse.

Which action by a parent of an adolescent indicates understanding of the vaccination protocol to prevent cervical cancer?

Had bloodwork obtained for titers Client received first vaccination at 8 years of age Client received booster dose at 16 years of age All three vaccinations were received at intervals

Rationale The human papillomavirus (HPV) vaccination is administered as a three-dose series.

Clients do not need to obtain bloodwork for titers before receiving the HPV vaccine.

HPV vaccinations can begin as early as 9 years of age, not 8 years. Boosters are received at 16 years for meningococcal vaccine, not HPV vaccine.

Which statement would most concern the nurse performing a mental health depression screen to determine an adolescent’s risk of suicide?

"I have a plan for taking my life."

"Lately I have felt down and sad."

"I don’t have any close friends at school."

"Several people in my family have been depressed."

Rationale The nurse will be most concerned if a client reports having a plan for committing suicide. In this situation, the nurse seeks immediate intervention. When obtaining a health history, the nurse will assess a client for reports of feeling down, having no close friends, and a family history of depression. These factors will be further assessed to determine a client’s risk for committing suicide, but do not represent immediate danger.

Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

Which complication is of most concern when the nurse is caring for a client with chronic lymphocytic leukemia (CLL)?

Bleeding Fatigue Infection Cachexia

Rationale In CLL, defects in humoral and cellular immunity increase the risk for infection, which can be life threatening. The other complications are also of concern but are not as dangerous as infection. Bleeding is possible because of thrombocytopenia associated with CLL, but the platelet count must drop to around 10,000 mm 3 (10 × 10 9/L) before spontaneous bleeding occurs. Fatigue caused by CLL related anemia

is also common, but not life threatening. Although excessive weight loss is a concern, it does not pose the same threat as infection for clients with CLL.

Which information about a client who has heart failure would the nurse communicate to the health care provider before administration of the prescribed digoxin?

Apical pulse rate 96 beats/minute Bilateral foot and ankle pitting edema Crackles heard at the base of both lungs Potassium level of 2.3 mEq/L (2.3 mmol/L)

Rationale Symptoms of digoxin toxicity, including life-threatening dysrhythmias, can occur when digoxin is administered to a client with hypokalemia. The nurse would hold the digoxin and notify the health care provider, anticipating that potassium supplements would be prescribed before administration of digoxin. An apical pulse of 96 beats per minute is at the upper end of normal and would not be a reason to hold digoxin. Lower extremity edema is a sign of heart failure, which would be improved with administration of digoxin. Crackles at the lung bases are common in clients with heart failure and not a reason to hold digoxin.

Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to 2 minutes.

Which intervention would the nurse use for a client taking quetiapine for acute psychosis who develops lead-pipe rigidity, trismus, and tachycardia? Select all that apply. One, some, or all responses may be correct.

Perianal care Fall precautions Use of a cooling blanket Monitoring of intake and output Discontinuation of the medication Administration of bromocriptine as prescribed

Rationale The client is demonstrating symptoms of neuroleptic malignant syndrome (NMS).

Perianal care would be needed for incontinence. Fall precautions would be instituted for alterations in consciousness. Cooling blankets would be used for pyrexia. Intake and output would be monitored to assess for dehydration caused by diaphoresis, fever, and reduced oral intake because of a change in consciousness.

The medication would be discontinued as NMS is a potentially fatal adverse effect of antipsychotic therapy. Symptoms usually last for 5 to 10 days after discontinuation of oral medications and 13 to 30 days with depot antipsychotic medicine.

Bromocriptine is a dopamine agonist used to treat NMS.

Which nursing intervention will be implemented when the health care provider prescribes verapamil to be administered intravenously to a 70-year-old client with hypertension?

Monitor the electrocardiogram for reflex tachycardia.

Keep the client in bed for an hour after giving the medication.

Dilute the dose in 50 mL of normal saline and administer it over 15 minutes.

Assess the client for wheezes and history of asthma before administering the medication.

Rationale Hypotension is a common side effect of intravenously administered verapamil.

Keeping the client in bed for an hour after administration provides for the safety of the client. Verapamil slows cardiac conduction as well as causing arterial dilation, so reflex tachycardia does not occur. Reflex tachycardia does occur with the dihydropyridine calcium channel blockers such as nifedipine. Verapamil should be administered undiluted when given intravenously. It is administered over 2 minutes for adults and over 3 minutes for older adults. Asthma history and wheezing would be assessed before administration of beta-receptor blockers, whereas heart rate and blood pressure would be checked before giving calcium channel blockers.

Which action would the nurse take next after cardiopulmonary resuscitation has been started by the code team for an unresponsive hospitalized client?

Contact the client’s primary health care provider.

Move any other clients or visitors out of the room.

Get the client’s record and have it available in the room.

Obtain the defibrillator and place paddles on the client’s chest.

Rationale Ventricular fibrillation is the most common cause of sudden death in adults, and research shows that rapid defibrillation is needed for successful resuscitation. After placement of the paddles on the client’s chest, the nurse will be able to detect and treat ventricular fibrillation or other dysrhythmias. The other actions are also

important once the defibrillator is available and any needed treatment has been initiated. The primary health care provider would be notified about the client’s status. Other clients and visitors may be moved out of the room to allow room for resuscitation efforts. The nurse would obtain the client’s record and be available to update the code team about the client’s status preceding the cardiac arrest.

Which results are the benefits of providing culturally competent care?

Select all that apply. One, some, or all responses may be correct.

Increased client safety Limits number of visitors Reduced health disparities Increased client satisfaction Ensures adequate interpreters

Rationale Cultural competence is the ability to understand, appreciate, and work with individuals from cultures other than one’s own and involves awareness and acceptance of differences. Cultural competence leads to increased client safety, reduced health disparities, and increased client satisfaction. Cultural competence does not limit the number of visitors that clients receive. Cultural competence does not ensure adequate interpreters; however, there are other means of facilitating communication, such as translation devices, that can be useful.

Which strategies will promote safety and quality of client care on the unit? Select all that apply. One, some, or all responses may be correct.

Communicate with clarity and precision when designing multidisciplinary plans of care.

Create a safety huddle so all health care professionals are aware of the clinical objectives.

Emphasize electronic communication is quick and most effective means of sharing information in all situations.

Conduct communication simulations to increase knowledge about expertise of other health care disciplines.

Explain effective communication will take more time and effort compared with ineffective communication.

Rationale Client care is becoming increasingly complex. High-quality, safe, and effective care calls for high-functioning health care teams. Communication is key. To improve quality and safety on the client care unit, team members should be encouraged to communicate with clarity and precision when designing multidisciplinary plans of care. Creating a staff huddle ensures all staff members are aware of the clinical objectives of the day. Practicing communication in simulations can be useful to increase knowledge about the expertise of other health care disciplines on the health care team. Recognizing that electronic communication may be quick but, in some situations, may not be effective. For example, when client care issues are at stake, a focused, well-organized interdisciplinary meeting is more effective than a series of "round-robin" emails. It usually takes about the same amount of time to communicate and collaborate ineffectively as it does to do it effectively.

The nurse is working with an adolescent who reports cutting on a

regular basis. The client states, "Life is so hard; it is difficult to handle the stress." Which action made by the client indicates part of the sixstep approach to recovery?

Administering antidepressants Implementing new coping skills Encouraging support group attendance Refraining from further self-harm

Rationale The fifth step of the six-step approach to recovery is to replace self-injury with coping skills. Administering antidepressants and encouraging support group attendance are nursing interventions. Refraining from further self-harm is a nursing outcome.

Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

The nurse is assessing the hospital room for items that the client can use to inflict self-harm and commit suicide. Which finding indicates a need to modify the client’s environment for safety?

Windows cannot open Battery-operated radio Fresh flowers in glass vase Breakaway shower curtain

Rationale The nurse would remove the glass vase from the room because this can be broken and used for self-harm. The client’s room should have windows that cannot open and a breakaway shower curtain to prevent self-harm from jumping or hanging. A battery-operated radio is free of cords and would be safe.

The nurse is assessing a client with a history of depression to determine imminent risk for attempting suicide. Which statement made by the client indicates a need for immediate intervention?

"I have a strong faith in a higher power."

"My parents keep firearms in the house."

"Everyone would be better off if I wasn’t here."

"I grew up in a house where we were often abused."

Rationale Clients with depression should be assessed for suicidal ideations to determine the risk for committing suicide. The statement, "Everyone would be better off if I wasn’t here" is a warning sign that the client is at an immediate risk for suicide. The client with a strong faith in a higher power possesses the ability to adapt to stressors and is less likely to commit suicide. The presence of firearms in the house and living through abuse are risk factors for possible suicide, but do not represent an imminent risk.

The nurse manager is educating a group of nurses regarding older adults and the risk for suicide. Which factors would be included in this presentation? Select all that apply. One, some, or all responses may be correct.

Spiritual beliefs Presence of family Loss of independence Chronic health conditions Access to many medications

Rationale Older adults, especially men over the age of 65, are at increased risk for committing suicide. Risk factors include loss of independence, presence of chronic health conditions, and access to large amounts of medications. Positive factors that decrease the risk for self-harm include spiritual beliefs and presence of family in the life of the older adult.

The nursing staff used seclusion for a client due to behavior that placed other clients and staff at risk for harm. Which intervention would the nurse perform first when reintegrating the client into the unit?

Document behaviors that occurred.

Administer antipsychotic medication.

Discuss behavior that necessitated seclusion.

Plan alternative methods to respond to stress.

Rationale When a client is allowed back into the unit after a period of seclusion, the first action the nurse would perform is to discuss the behavior that led to the client being placed in seclusion. This leads the client to identify triggers that caused the behavior. The nurse would document the behaviors that occurred after the client is placed in seclusion. The nurse would administer medications as an alternative to seclusion. After discussing the behaviors that caused the seclusion, the nurse would work with the client to develop different methods to use when responding to stress in the future.

The nurse educator is presenting to a group of nurses about the use of de-escalatory techniques. Which actions would the nurse include in the presentation? Select all that apply. One, some, or all responses may be correct.

Identify client needs.

Stand close to the client.

Use a loud and commanding voice.

Determine stressors and triggers.

Refrain from arguing with the client.

Rationale De-escalatory techniques that should be included in the presentation include identifying client needs, determining stressors and triggers, and refraining from arguing with the client. These techniques can help prevent the situation from becoming worse. The nurse would keep a safe distance from the client, because getting too close to the client can increases anxiety. The nurse would use a calm, clear tone of voice when talking with the client.

When the registered nurse (RN) assigns the unlicensed assistive personnel (UAP) to obtain and record routine vital signs on all clients on the unit, what should the RN be sure to do? Select all that apply.One, some, or all responses may be correct.

Validate willingness to accept the delegated task.

Convey unique client requirements, characteristics, or concerns.

State the exact task, how it is to be accomplished, and expected outcomes.

Specify concerns or emergency conditions that warrant prompt reporting.

Allow delegated personnel to make decisions regarding times in which vital signs should be performed.

Rationale The RN would validate the delegated personnel’s willingness to accept the delegated task. The RN would also convey unique client requirements, characteristics, or concerns (i.e., the client will only drink with a straw); communicate to the UAPs the exact task to be done, how the task will be accomplished, and the expected outcomes; and specify any specific concerns or emergency conditions that warrant prompt reporting. The RN would specify the time and frequency of the task to be performed.

The nurse is caring for a client who is displaying increased agitation and anger that is not responding to de-escalatory techniques. Which interventions would the nurse perform next to maintain client and staff safety? Select all that apply. One, some, or all responses may be correct.

Apply restraints.

Place in seclusion.

Administer medication.

Notify health care provider.

Discuss situation with client.

Rationale When a client becomes increasingly agitated and does not respond to de-escalatory techniques, the nurse may have to use restraints, seclusion, or medications to prevent injury to other clients and staff. The health care provider should be notified, but this does not promote client and staff safety. De-escalatory techniques include discussing the current situation with the client through therapeutic communication.

These have failed, so the nurse would use other methods to protect the safety of the clients and staff.

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

The nurse is managing the care of several clients today. Which client poses the highest risk for harming others?

A 16-year-old female with depression who cuts A 20-year-old male who has been incarcerated A 25-year-old female with binge-eating disorder A 30-year-old male with autism spectrum disorder

Rationale

Demographic risk factors for possible anger and aggression issues include males between the ages of 14 to 24 years of age who have no support systems and have served time in prison. Therefore the 20-year-old male who has been incarcerated has the highest risk for harming others. Both the client with depression who cuts and the client with binge-eating disorder are at risk for self-harm but not at an increased risk for harming others. Because the autism spectrum is so large, more information would be needed to determine the risk of this client harming others.

The nurse is assessing a client with a history of aggression and inappropriate anger issues. Which findings indicate the client is escalating and requires immediate intervention to prevent harm to others? Select all that apply. One, some, or all responses may be correct.

Feeling depressed Mumbling to oneself Pacing back and forth Discussing issues with staff Maintaining strong eye contact

Rationale Behaviors that would require the nurse to intervene include the client mumbling to him- or herself, pacing back and forth, and maintaining strong eye contact. These are signs that precede violence. Feeling depressed may be a precursor to suicide.

Discussing issues with the staff would not indicate aggressive behavior that warrants immediate intervention.

Which beliefs or situations are barriers to effective delegation by the

registered nurse (RN)? Select all that apply.One, some, or all responses may be correct.

The nurse believes delegation is too time-consuming.

The nurse lacks confidence in the delegatee’s abilities.

The nurse overburdens the delegatee with too many tasks.

The nurse understands the delegatee’s level of competence.

The nurse determines delegation is appropriate for the situation.

Rationale Barriers to effective delegation by the RN include the belief that delegation is too time-consuming, or the nurse lacks confidence in the delegatee’s abilities and overburdens the delegatee with too many tasks. Understanding the delegatee’s level of competence is a desired skill of delegation and is not a barrier. Determining that delegation is appropriate to the situation is not a barrier to delegation.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which action by nursing staff during a facility fire drill requires correction?

Directing ambulatory clients to walk to a safe area Discontinuing oxygen for all clients able to breathe without it Closing all doors and windows after clients are safely removed Use of an ABC extinguisher to put out a small trash can fire before evacuation

Rationale All clients should be safely removed before attempting to extinguish a fire. Directing ambulatory clients to walk to a safe area, discontinuing oxygen for those who can breathe without it, and closing all doors and windows after safely removing clients are all appropriate staff responses during a fire drill.

Which feeling would the nurse be trying to prevent in other clients when setting limits on a client diagnosed with bipolar disorder, manic episode, who has a superior, authoritative, and condescending manner?

Anger Dependency Inadequacy Ambivalence

Rationale The nurse is trying to prevent anger in other clients. A person with a condescending, superior attitude typically evokes feelings of anger in others and will increase their anxiety. It is unlikely that a condescending, superior attitude will produce feelings of dependency, inadequacy, or ambivalence in others.

Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night’s sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast,

and arrive at the testing site at least 15 to 30 minutes early.

Which action by a transgender client during teach-back learning about applying an estrogen hormone patch needs review for correction?

Applies the patch over hair Rotates areas of patch application Wipes away the previous patch residue Ensures good contact between the patch and skin

Rationale Medication patches such as estrogen delivery should be applied to a hairless area.

Patch application should rotate to different areas of the body. Previous medication should be wiped away before new patch application. Good contact between the patch and skin ensures proper medication delivery.

Which intervention would the nurse include when teaching a client about self-care after mastectomy to prevent infection and lymphedema? Select all that apply.One, some, or all responses may be correct.

Wear gloves when gardening.

Apply a compression sleeve if edema occurs.

Stop all activities that involve use of the affected arm.

Consider learning exercises for manual lymph drainage.

Avoid blood draws in the arm on the side of the mastectomy.

Rationale Infection prevention and management of lymphedema are lifelong activities after mastectomy. The client should wear gloves when gardening to prevent scratches that introduce infection, apply a compression sleeve to manage edema, learn exercises to manually drain the lymph fluid, and avoid medical procedures in the affected arm like blood draws, blood pressure, and injections. The client does not need to stop all activities but should be mindful of activities that may place the arm at risk of trauma.

The nurse places a client in restraints due to violent combative behavior. Which intervention would the nurse perform next?

Offer food and drink.

Document the behavior.

Obtain a written or verbal prescription.

Provide a 1:1 attendant in the room.

Rationale The nurse can use restraint or seclusion when client behavior is violent, and it is an emergency. However, the next nursing intervention should be to obtain a verbal or written prescription for their use. Food and drink should be offered every 15 to 30 minutes. After the situation is resolved, the nurse documents the behavior. It is not necessary to have a 1:1 attendant in the room when restraints are being used because these provide the safety.

Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

Which statement made by the nurse indicates a need for further teaching when educating staff about integrating The Joint Commission’s National Patient Safety Goals (NPSG) into the behavioral health unit?

"We should screen all clients for the risk of suicidal ideations."

"It is important to perform hand hygiene for at least 15 seconds."

"It is required to obtain a current medication list upon admission."

"We should use one client identifier before giving medications."

Rationale The Joint Commission’s NPSG for safety goals include using at least two client identifiers, not one, when providing care, treatment, or services. Therefore the nurse’s statement to use only one client identifier indicates a need for further education. All clients should be screened for suicide risk, hand hygiene should be performed for at least 15 seconds, and a current medication list should be obtained upon admission.

Which activity is priority in preparing health care professionals for any type of disaster?

Identification of hazards Cooperation with state authorities Collaboration with local authorities Implementation of federal mandates

Rationale

Identification of hazards is the priority in the preparedness of health care professionals in any type of disaster plan. Although cooperation with state authorities, collaboration with local authorities, and implementation of federal mandates also play a role in being prepared for a disaster, these are not the priority because it is essential to identify the specific hazard to implement the most appropriate portion of the disaster plan.

Which client would the nurse see first after receiving reports on four clients who are postnephrostomy tube placement?

The client with tenderness at the surgical site The client with small clots in the drainage bag The client with cloudy urine in the drainage bag The client requesting the next dose of pain medication

Rationale The client with cloudy urine could have an infection that should be evaluated for accompanying symptoms like fever and back pain and reported immediately to the surgeon. Tenderness at the surgical site is expected and not a priority over cloudy urine. Small clots in the urine collection bag are expected and not a priority over cloudy urine in the bag. The client requesting pain medication should be attended to soon, but the cloudy urine must be first assessed and reported.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

The nurse is caring for a client who just returned from an

The nurse is caring for a client who just returned from an esophagogastroduodenoscopy (EGD) and directs the unlicensed assistive personnel (UAP) to get the client settled in the room. Which action made by the UAP is incorrect?

Raising the head of bed Straightening bed linens Obtaining vital signs Offering client water

Rationale After an EGD, the client should not have any food or drink until the gag reflex has returned. Therefore, the nurse would correct the UAP to not offer the client water.

Raising the head of bed, straightening bed linens and obtaining vital signs are acceptable tasks to perform.

Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely.

Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatmentspecific option.

Which intervention regarding preventing future infections are taught to a sexually active female client with a urinary tract infection? Select all that apply. One, some, or all responses may be correct.

Increase fluid intake.

Wear snug nylon underwear.

Use douche and scented lubricants.

Clean the perineum wiping front to back.

Empty the bladder before and after sexual intercourse.

Rationale Increasing fluid intake increases urine volume to flush out invading bacteria.

Cleaning the perineum front to back avoids introducing bacteria from the rectum forward. Emptying the bladder before and after intercourse flushes the urethra of bacteria. Underwear should be loose fitting and cotton to allow air flow. Douche and scented lubricants should be avoided because they disrupt the normal flora and may contain irritants.

The nurse provided education to a client with peptic ulcer disease (PUD) regarding foods and substances to avoid that would increase the secretion of gastric acid. Which food choice for breakfast selection made by the client indicates a need for further teaching?

Coffee and toast Grapes and cheese Apple juice and pancakes Cheese and crackers

Rationale Caffeine-containing drinks such as coffee, tea, and soda can increase the production of gastric acid. Therefore, this menu choice indicates a need for further education.

Grapes, apple juice, and cheese with crackers do not cause more acid to be produced.

Which response after educating a client with an overactive bladder

Which response after educating a client with an overactive bladder about starting extended release anticholinergic medication therapy requires a need for correction?

"I will use hard candy if I experience dry mouth."

"I will chew the medication to release its ingredients."

"I will increase the fiber in my diet to decrease constipation."

"I will monitor my urine output and report a noticeable decrease."

Rationale Extended release capsules should not be chewed as that results in a bolus dose instead of a slowly released dose; the medication should be swallowed whole. Hard candy can be used to increase salivation to treat dry mouth that can result from anticholinergic. Fiber and fluid intakes help prevent constipation that can result from anticholinergic use. A decrease in urine output should be reported because that may indicate urine retention.

Which client is contraindicated to receive contrast media?

The client with asthma The client with a recent creatinine level of 0.9 The client who is nothing-by-mouth (NPO) since midnight with an intravenous (IV) infusion of 0.9% normal saline (NS) The client administered a dose of metformin this morning with a sip of water

Rationale Metformin should be discontinued 24 hours before and 48 hours after contrast

media to prevent the risk of lactic acidosis. Clients with asthma should be monitored closely for reaction to the contract, and reaction could be severe but does preclude receiving contrast. A creatinine of 0.9 is normal, reflecting good kidney function to handle the contrast. NPO status with IV hydration is not a contraindication to receive contrast.

Which nursing action is correct when the state department of health recommends administering tetanus vaccine to pregnant women who have not received it previously?

Avoiding giving the vaccine to pregnant women who are in their first trimester Administering the vaccine to pregnant women at any gestational age Revaccinating pregnant women who received tetanus vaccine last year Avoiding vaccinating pregnant women who are at high risk for preterm labor

Rationale A tetanus toxoid containing vaccine might be recommended for wound management in pregnant women. This vaccine can be given at any gestational age for women who have not received it previously. The tetanus toxoid containing vaccine can be given to pregnant women at any gestational age and does not need to be avoided during the first trimester. Revaccinating can be done if a period of 5 years or more has elapsed since the last vaccination. There is no need to avoid vaccinating pregnant women who are at risk for preterm labor.

Which emergency assessment has been performed on the client when an emergency management team is removing foreign bodies and performing cricothyroidotomy on a client postburn injury?

Breathing Circulation Exposure and environmental control Airway with simultaneous cervical spine stabilization

Rationale Emergency assessment of the airway with simultaneous cervical spine stabilization involves removing foreign bodies and performing cricothyroidotomy. It is done in a primary survey to assess patency, respiratory distress, and bleeding. Assessment of breathing is done to check ventilation and respiratory rate and may require ventilating with a bag-valve-mask with 100% oxygen or using needle thoracostomy.

Circulation assessment is performed to check capillary refill or measure blood pressure and may require initiating cardiopulmonary resuscitation and advanced life-support measures. Exposure and environmental assessment is done to check the entire body for injuries; it involves removing all clothing and using warm blankets or warmed intravenous fluids to prevent hypothermia.

STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal of scoring 100% on all exams is not realistic, but scoring an 85% may be a better goal.

Which nursing action would be priority for a green-tagged client who arrives at the emergency department (ED) after a mass casualty incident (MCI) involving radiation?

Implementing decontamination measures

Performing a head to toe physical examination Placing a special bracelet with a disaster number Taking a digital photo and placing it on the medical record

Rationale The priority nursing action for a green-tagged client who arrives at the ED after exposure to radiation is implementing decontamination measures. This measure is the priority because it is essential that members of the health care team, and clients, are not exposed to the radiation while providing care. Although the other nursing actions (performing a head to toe physical examination, placing a special bracelet with a disaster number, and taking a digital photo and placing it on the medication record) should occur during the admission process to the ED, these are not the priority actions.

Which statement indicates misunderstanding of the precautions required for clients infected by the Ebola virus?

"I will isolate the infected client in a private room."

"I will use standard, contact, and droplet precautions."

"I will not touch the prepared food for the infected client."

"I will avoid direct contact with body fluids of the infected client at all times."

Rationale The Ebola virus is not spread via air, water, or food. Avoiding the touching of prepared food for the infected client may not help in preventing Ebola. The nurse should correct this misconception. Clients with Ebola should be isolated in a single

room to prevent the spread of infection. While caring for a client with Ebola, the nurse should use standard, contact, and droplet precautions to prevent Ebola infection spread. The nurse should avoid direct contact with body fluids of the infected client to prevent the spread of Ebola infection.

Which assessment finding for a client with heart failure who is taking digoxin will be most important to communicate to the health care provider?

Apical heart rate 55 beats per minute Premature ventricular contractions Serum potassium level 3.9 mEq/L (3.9 mmol/L) Bilateral swelling of the lower extremities

Rationale Digoxin toxicity can manifest with premature ventricular contractions (PVCs) or other ventricular dysrhythmias such as ventricular tachycardia or fibrillation. The nurse would communicate the presence of PVCs to the provider and anticipate collaborative actions such as checking digoxin level and potassium level. An apical heart rate of 55 would be reported, but some providers prefer a heart rate of 50 to 60 beats per minute, and no immediate change in treatment would be needed.

Hypokalemia can lead to digoxin toxicity, but a serum potassium level of 3.9 mEq/L (3.9 mmol/L) would not increase the risk for digoxin toxicity but should be monitored. Bilateral swelling of the lower extremities in a client with heart failure indicates a possible need for a change in treatment but is not life-threatening.

Which initial nursing intervention is the most appropriate for a client who survived a fire in the hospital and is found to have neck trauma, dyspnea, gasping breathing, and is unable to speak? Select all that

apply. One, some, or all responses may be correct.

Placing a nasogastric tube Performing jaw-thrust maneuver Preparing to assist in performing endotracheal intubation Monitoring respiratory rate and oxygen saturation Monitoring the heart rate and rhythm continuously

Rationale The jaw-thrust maneuver may help in opening a client’s airway. Endotracheal intubation may assist the client in obtaining proper breathing. A nasogastric tube should not be placed in the client with neck trauma because it could enter the brain.

Monitoring the respiratory rate and oxygen saturation is required after performing the jaw-thrust maneuver and endotracheal intubation may be required in this situation. Heart rate and rhythm should be monitored continuously in an emergency condition to assess the condition after the client has stabilized breathing.

Which information would the nurse include when teaching a client with coronary artery disease about aspirin therapy? Select all that apply. One, some, or all responses may be correct.

Take aspirin with food.

Report ringing in the ears.

Monitor and report excessive bleeding and bruising.

Do not mix aspirin with medications for erectile dysfunction.

Avoid over-the-counter pain medications that contain aspirin.

Rationale Aspirin is taken with food to avoid gastrointestinal upset. Ringing in the ears should be reported, because it is a sign of aspirin toxicity. Excessive bruising and bleeding should be reported, because these may be caused by decreased platelet aggregation caused by aspirin. Over-the-counter medications must be checked for aspirin.

Nitrates, not aspirin, must be avoided by those taking erectile dysfunction medications because of the risk of a dangerous drop in blood pressure.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

When teaching the parent of a newborn about skin care to prevent infections, which statement by a parent indicates the need for further education?

"It’s fine to use mild soap with a neutral pH." "I need to remove the vernix when bathing my baby."

"I will use plain warm water without any bubble bath."

"I should refrain from using talcum powder or cornstarch."

Rationale The vernix on the skin of a newborn provides protection and should not be removed. A newborn’s skin can be cleansed using mild soap with a neutral pH if needed or plain warm water without bubble baths. A newborn is at increased risk for aspirating talcum powder and cornstarch products if used too close to the face; therefore, parents should be instructed to avoid these products.

Which client statement indicates a need for further education when the nurse is reviewing statin therapy for hyperlipidemia in a female of childbearing age?

"I will report muscle aches to my primary health care provider."

"I will take my medication with grapefruit juice."

"I will avoid getting pregnant while taking this medication."

"I will need regular bloodwork to ensure my liver is OK."

Rationale Statin medication should not be taken with grapefruit juice because the furanocoumarins in grapefruit inactivate the enzyme CYP3A4, leading to metabolism issues and possible toxicity. Muscle myalgias are a side effect of statin therapy that should be reported because they may indicate medication toxicity.

Statin therapy should be avoided during pregnancy. Liver function should be monitored during statin therapy.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which assessment finding by the nurse caring for a client with newonset atrial fibrillation would be most important to communicate to the health care provider?

Irregular apical pulse Sudden vision change

Exertional dyspnea Lower extremity edema

Rationale Atrial fibrillation causes pooling of blood in the atria, leading to atrial clots and risk for stroke if clots are ejected from the left ventricle into the systemic circulation. A sudden onset change in vision may indicate stroke and would be immediately communicated to the health care provider so that actions such as rapid administration of thrombolytic medications can be considered. An irregular apical pulse is characteristic of atrial fibrillation and would not be immediately reported to the health care provider. Although exertional dyspnea would be reported to the health care provider, it is common with atrial fibrillation and does not require any immediate change in treatment. Edema may occur with atrial fibrillation because of decreased cardiac output, but it does not require an immediate change in treatment.

Which statement by a staff member after an educational session on the use of adenosine for supraventricular tachycardia indicates that the teaching has been effective?

"We will need a crash cart available at the client’s bedside."

"We will plan to schedule the anesthesiologist to be available."

"The medication should be injected over at least 1 to 2 minutes."

"Infusion of normal saline will be needed before medication injection."

Rationale Adenosine can cause significant bradycardia and short episodes of asystole along

with hypotension, so emergency equipment from the crash cart should be at the bedside. Sedation or anesthesia is not needed with adenosine administration.

Adenosine is injected over 1 to 3 seconds; slow administration prevents the medication from being effective. A bolus of normal saline is used after adenosine administration to rapidly infuse the medication, but saline is not needed before administration.

Which teaching would the nurse provide to a client with newly diagnosed pancytopenia caused by chemotherapy?

Begin a program of vigorous mouth care.

Avoid traumatic injury and exposure to infection.

Increase oral fluid intake to at least 3 L/day.

Report unusual tingling sensations in the extremities.

Rationale Reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase the susceptibility to infection. Although careful oral care may help decrease infection risk, mouth care should be done gently to avoid bleeding.

Although fluids may be increased to flush out the toxic byproducts of chemotherapy, this will have no effect on pancytopenia. Unusual tingling sensations in the extremities are not a complication of pancytopenia.

STUDY TIP: Study goals should set out exactly what you want to accomplish. Do not simply say, "I will study for the exam." Specify how many hours, what day and time, and what material you will cover.

Which long-term care facility staff member statements indicate correct understanding of a disaster response plan for staff and

residents? Select all that apply. One, some, or all responses may be correct.

"We have to implement annual drills."

"The plan must include an evacuation plan."

"Nursing homes are not required to have a plan."

"Our facility is held to the same standards as hospital facilities."

"This is an important component to receive insurance payments for care."

Rationale Hospitals are not the only health care agencies that are required to practice disaster drills. Long-term care (LTC) facilities are also mandated to have annual drills to prepare for mass casualty events. Part of the response plan must include a method for evacuation of residents from the facility in a timely and safe manner. Nursing homes are also required to have a disaster response plan. LTC facilities are not held to the same standards as hospital facilities. Insurance payment for medical care is not contingent on the implementation of a disaster response plan.

Which nursing action is the priority to include in a disaster plan for the radioactive dust and smoke that can cause illness from a radiological dispersal device?

Covering the nose Protecting the eyes Decontaminating the skin Administering prophylactic antibiotics

Rationale Radiological dispersal devices (RDDs), also known as "dirty bombs," consist of a mix of explosives and radioactive material (e.g., pellets). The priority nursing action to protect against the radioactive dust and smoke that can cause illness from an RDD is covering the nose and the mouth to decrease the risk for inhalation. Protecting the eyes is the priority if present during the explosion, but not necessarily when exposed to the subsequent dust and smoke. Decontaminating the skin is important but not the priority. Administering prophylactic antibiotics will not be effective to prevent illness related to an RDD.

The nurse is assessing a client with Crohn disease who is scheduled for an upper gastrointestinal series. Which condition would necessitate the cancellation of the procedure?

Hemorrhoids Hyperkalemia Inflamed colon Colon perforation

Rationale When a client has a perforated viscera, barium can leak out of the intestinal tract and cause inflammation or an abscess. Although hemorrhoids may be irritating, they do not contraindicate barium studies. Serum potassium is unaffected; barium is insoluble and will not affect blood content. Barium studies are not contraindicated when the bowel is inflamed. An upper gastrointestinal series is useful in diagnosing ulcerative colitis and Crohn disease.

Which action by the nurse is important when preparing for cardioversion of a client with atrial fibrillation?

Charge defibrillator to the maximum energy level.

Assure that the cardiac monitor alarm is turned on.

Set synchronizer switch on defibrillator to the "on" position.

Take client’s apical pulse for a full minute before the procedure.

Rationale Turning the synchronizer switch on ensures that the shock will not be delivered on the client’s T wave, which could cause ventricular fibrillation. The defibrillator energy level is typically set to a low level for cardioversion, although higher levels may be used if the initial cardioversion attempt is unsuccessful. The cardiac monitor alarm may be off during cardioversion because the shock is likely to set off the alarm and the cardiac rhythm and rate are being monitored during the procedure. An apical pulse for a full minute is appropriate for a client with atrial fibrillation but is not needed when the client is on a cardiac monitor.

Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point.

Which nursing action is a priority when caring for this client who came to the emergency department reporting pink-tinged urine?

Monitor the intake and output.

Take apical pulse for a full minute.

Institute measures to prevent physical injury.

Obtain stool specimen to test for occult blood.

Rationale The therapeutic International Normalized Ratio (INR) level usually is between 2 and 3; the expected range for platelets is 150,000 to 450,000/mm 3 (150 × 10 9/L to 400 × 9

10 9/L). The platelet count is significantly decreased, and the INR level of 4.5 is high.

The client is at risk for bleeding and must be protected from injury. Monitoring the intake and output is useful for clients with blood-tinged urine but not essential because there is no indication of fluid imbalance. An apical pulse for a full minute is indicated when a client has an irregular heart rhythm, but this client has been previously cardioverted and has a regular rhythm now. Obtaining a stool specimen to check for possible gastrointestinal bleeding is important, but the highest priority is to ensure client safety.

Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the hospital record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and nurse/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

Which nursing intervention would the nurse perform during resuscitation of a critically injured client in a bomb blast when the nurse finds the client is breathing spontaneously?

Inserting an endotracheal tube Applying a nonrebreather mask Providing mechanical ventilation Initiating bag-valve-mask (BVM) ventilation

Rationale A nonrebreather mask is used in spontaneously breathing clients. Providing an endotracheal tube and mechanical ventilation is beneficial in clients with

significantly impaired consciousness. A client who needs ventilatory assistance during resuscitation requires BVM ventilation with an appropriate airway adjunct and a 100% oxygen source.

After conducting a falls risk assessment education session for the staff and observing falls risk assessments on the unit, which staff action needs review for corrective action?

Using a fall risk assessment tool Assessing the environment for fall hazards Inquiring about the client’s history of falls Delegating fall assessments to assistive personnel

Rationale Falls risk cannot be delegated. The nurse needs to be the person to complete falls risk assessment, not assistive personnel. Use of a falls risk assessment tool, assessing the environment for hazards, and exploring the client’s history of falls are all appropriate actions for fall risk assessment.

Which assessment item needs to be documented on a client with restraints? Select all that apply. One, some, or all responses may be correct.

Pulse near the restrained area Temperature of the restrained area Convenience of restraining the client Skin integrity surrounding the restraint Behavior leading to the need for restraint

Rationale Restraint use requires assessment of the body area restrained, such as pulse quality and temperature for perfusion and the integrity of the skin. Behavior necessitating restraint should be assessed and documented. Restraints are used for safety only, not for convenience in care.

After presenting information about falls risk assessments to nursing staff, which participant's statement needs review for corrective action?

"We will assess every admission to the unit."

"We will implement a valid falls risk assessment tool."

"We will apply yellow wrist bands to high-risk clients."

"We will use the admission fall assessment for the entire stay."

Rationale Falls risk assessment should be updated routinely through discharge, because fall risk may change throughout the hospital stay. Falls risk assessment should be completed on every client with a valid falls risk tool. High-risk fall clients should be identified.

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

After a home assessment of an older adult's fall risk, which intervention would the nurse suggest? Select all that apply. One, some, or all responses may be correct.

Dimming lighting to avoid squinting

Secure rugs to prevent movement Remove excessive pieces of furniture Wear corrective lenses for distance vision Perform exercises to strengthen lower extremities

Rationale The home environment should be assessed by the home care nurse for risk of injury through falls. The nurse would suggest securing rugs, removing excess furniture, wearing corrective lenses, and performing exercises to strengthen the lower extremities and reduce fall risk. Lighting should be bright, not dim, to support a safe environment.

When interviewing and assessing a 17-year-old client, which finding alerts the nurse to explore substance abuse with the adolescent?

Select all that apply. One, some, or all responses may be correct.

Failing grades Blood spots on clothing Absenteeism from school Long-sleeved shirts in warm weather Separating emotionally from the family

Rationale Adolescents are developing independence and should be assessed for risk-taking behaviors such as drug abuse. Signs of drug abuse include failing grades and absenteeism because school performance is impacted, as well as blood spots on

clothing and long sleeves in warm weather, which is related to intravenous (IV) drug use. Separating emotionally from family is a normal development finding in adolescents.

After reviewing otoscope use for assessment of the ear with the nursing staff, which participant's response reflects safe follow-up care for when earwax covers the tympanic membrane?

"I will leave the wax in place."

"I will use a cotton-tipped swab to remove the wax."

"I will insert the tip of a hemostat to remove the wax."

"I will perform warm water irrigation to remove the wax."

Rationale Earwax in front of the tympanic membrane should be removed for assessment and proper hearing, and irrigation with warm water is a safe way to remove the wax. The wax should not be left in place, because the tympanic membrane cannot be seen and it may disrupt normal hearing. Cotton-tipped swabs and pointed objects like the tip of a hemostat should not be placed into the ear canal because they can cause damage.

Which parental statement indicates the need for further education related to bicycle safety for the school-aged client?

"My child should ride with the traffic."

"My child should walk the bicycle through crosswalks."

"My child should use hand signals in advance of stopping."

"My child should keep as far from the curb as possible when in the street."

Rationale The child should stay as close as possible to the curb when riding a bicycle in the street; therefore the parental statement indicating the opposite of this indicates the need for further education. The parental statements indicate that the child should ride with traffic, the bicycle should be walked through crosswalks, and the importance of using hand signals before stopping all indicate accurate understanding of the information presented.

An older client asks, "How do I know that the medications that I take are safe?" Which response by the nurse is correct? Select all that apply. One, some, or all responses may be correct.

"Ask your health care provider how and when you should be taking your medications."

"Stop taking a prescribed medication if you are not feeling better in a few days."

"Discard medications into the toilet that have exceeded the expiration date on the bottle."

"Check the name, dose, and instructions about administration of medications each time before leaving the pharmacy."

"Inform your health care provider of the over-the-counter medications, recreational drugs, and amount of alcohol you ingest."

Rationale If unsure about any information, the client should be encouraged to ask for further instructions and more information. A client needs to be proactive and should check all aspects of the prescription with the pharmacist before leaving the pharmacy. A pharmacist may have permission to substitute a generic form of the medication or may change the number of pills that deliver the prescribed dose, both of which can

confuse the client (e.g., one tablet may deliver 50 mg of a medication and be equal to two 25-mg tablets). Because of the risk of medication interactions associated with polypharmacy and altered age-related physiological functioning that can cause medication toxicity, to ensure safety the client should inform the health team about all drugs (e.g., prescription, over-the-counter, recreational), herbal preparations, and amount of alcohol ingested. A client should stop taking a prescribed medication only after consultation with the health care provider. Unused and expired medications should not be discarded into the toilet because they can contaminate groundwater.

A client with a history of angry outbursts is pacing and muttering and appears to be escalating. Which intervention would the nurse use to prevent an incident?

Set a contract with the client to verbalize frustrations before acting out.

Establish firm control and use seclusion before the client acts out impulsively.

Show the client the seclusion room as a method of deterring acting-out behavior.

Call the health care provider for a prescription for an intramuscular sedative.

Rationale While the client is still in control, the nurse would formulate a contract with the client to prevent angry outbursts. Seclusion, threats of seclusion, and sedation are violations of the client’s rights and should not be used until other, less restrictive methods are exhausted.

Which statement made by the client indicates understanding after

teaching about measures to decrease the risk for antibiotic-resistant infections? Select all that apply. One, some, or all responses may be correct.

"I should wash my hands frequently."

"I should skip doses when I am completely well."

"I should avoid taking antibiotics to treat the common cold."

"I should save unfinished antibiotics for later emergency use."

"I should avoid taking antibiotics without asking the primary health care provider."

Rationale Hand washing is necessary to prevent infections. Antibiotics are effective against bacterial infections but not viruses, which cause the common cold. Clients should take antibiotics only after asking the primary health care provider. Clients should not stop taking antibiotics even if the client is feeling better. Skipping doses may allow antibiotic-resistant bacteria to develop. Clients should not save antibiotic doses for later use because old antibiotics can lose their effectiveness, and in some cases can even be fatal if taken.

Which action by the new parent requires correction by the nurse?

Bathing the infant in warm water Sitting the infant in a rear-facing car seat Placing the infant prone on a pillow for a nap Suctioning the infant’s secretions with bulb syringe

Rationale Infants should never be placed on a pillow or in the prone position for sleep because this increases the risk for suffocation. Bathing the infant in warm water, using a rear-facing car seat, and using a bulb syringe to suction secretions are all safe practices.

Which finding would lead the nurse to postpone a newborn’s discharge from the hospital after delivery?

Lack of infant car seat Parent refuses flu vaccine Circumcision not scheduled Caregiver nervous regarding care

Rationale One of the discharge criteria after delivery is that the vehicle transporting the newborn home must have an appropriate infant car seat installed and correctly secured. The nurse will postpone discharge until a proper car seat is obtained.

Although it is highly recommended for new parents to receive the flu vaccine, it is not mandatory and will not prevent the newborn from being discharged. Parents can choose whether to have a newborn circumcised, and this decision will not delay discharge from the hospital. Many parents, especially first-time parents, are nervous about going home with their newborn. But unless the nurse or another health care provider suspects harm could come to the infant or parent upon leaving the hospital, these feelings would not prevent discharge.

Which uses of automated tracking systems with infrared and radiofrequency technology (RFT) would the nurse list for emergency departments during disaster treatment? Select all that apply. One,

some, or all responses may be correct.

To identify clients To categorize triage priority To track client’s triage priority upon arrival To track interaction of clients with caregivers To portray the overall census and acuity of clients

Rationale Emergency departments use automated tracking systems with infrared and RFT for disaster treatment. These systems track client’s triage priority upon arrival, track interaction of clients with caregivers, and portray the overall census and acuity of clients. Identification of clients is done using a special bracelet with a disaster number. Categorizing triage priority is done using a disaster triage tag system.

Which consideration would be included in the plan for deactivating the emergency plan after treating the major casualties? Select all that apply. One, some, or all responses may be correct.

Providing adequate rest periods to nurses Providing sleeping quarters only to clients Washing, packing, and resterilizing the instrument trays Allowing nurses to drive home after deactivating the plan Reordering depleted supplies after the termination of the plan

Rationale

When the treatment for the last major casualties is done and no more clients arrive, the emergency incident commander calls for deactivating the emergency plan. The nurses involved in emergency care after a disaster should be provided adequate rest.

The instrument trays should be washed, packed, and resterilized at the conclusion of deactivating the emergency plan. Depleted supplies should be reordered and delivered quickly to the hospital. Sleeping quarters should be provided both to nurses and clients. The nurse would not drive home because it may pose risk to their safety.

Which component of hand washing would the nurse include that is most effective for removing microorganisms?

Soap Time Water Friction

Rationale Friction is necessary for the removal of microorganisms. Although soap reduces surface tension, which helps remove debris, without friction it has minimal value.

Although the length of time the hands are washed is important, without friction it has minimal value. Although water flushes some microorganisms from the skin, without friction it has minimal value.

If the military system of triage is being used to triage victims of a manufacturing plant explosion, the client with which condition would be identified as class IV? Obvious fractured arm and leg

Bleeding from facial wounds and coughing sputum containing soot Walking across the parking lot to increase distance from the explosion site Bleeding from a jugular vein wound with a respiratory rate of 6 breaths per minute

Rationale The military form of triage has the overall desired outcome of doing the greatest good for the greatest number of people. The victim who should be identified as class IV or who is expected to die would be the one with a jugular vein wound and a respiratory rate of 6 breaths per minute. The client with an obvious fractured arm and leg and the victim with facial wounds coughing sputum could either be class I or II. The victim who is walking would be class III or the walking wounded.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which risk factors are associated with adolescent suicide? Select all that apply. One, some, or all responses may be correct.

Victim of family violence Limited or strained family finances Member of a single-parent household Dependence on alcohol, drugs, or both Uncertainty related to sexual orientation Repeated demonstration of poor impulse control

Rationale Being a victim of family violence of any kind increases the risk of suicide. Alcohol or drug abuse is a significant factor in adolescent suicide. A concern about sexual orientation or acceptance as a homosexual is a risk factor for suicide, especially among adolescents. Poor impulse control contributes to risk taking, which is a factor for suicide, especially among adolescents. Although economic problems and absence of a parent can cause stress, there is no research to support that either is a major factor in adolescent suicide.

For clients who have risk for impending violence, list assessments in order of escalating aggression, from the lowest risk to the highest.

1.

Increasing tension in facial expression

2.

Having difficulty waiting to take turns during a group project

3.

Pacing in the hall

4.

Engaging in verbal abuse toward the nurse

5.

Pushing another client while waiting in line to the dining room

Rationale Increasing tension in facial expression indicates increasing anxiety, but the client is still maintaining self-control. Impulsivity, as demonstrated by the inability to take

turns with others, indicates that the client is having some difficulty setting limits on their own behavior. When anxiety escalates to the point of hyperactivity and pacing behaviors, the client is attempting to cope with the anxiety and to discharge physical and psychic energy. Engaging in verbal abuse may precipitate physical abuse and is a sign that the client is not able to maintain self-control. The laying on of the hands in an offensive manner is a physical act of aggression.

Which action would be priority to maintain the hospital environment when a large number of clients walk into the emergency department (ED) asking to be treated for minor injuries sustained from the detonation of a car bomb?

Triage the injuries.

Initiate a decontamination process.

Document each name and address.

Direct to have a seat in the waiting area.

Rationale Green-tagged clients or the walking wounded who self-transport to a health care facility may unknowingly carry contaminants from a nuclear, biological, or chemical incident into the hospital environment. These issues must be anticipated and appropriate decontamination measures implemented. Triaging the injuries would not be needed because the clients walked into the ED. Documenting each name and address is essential; however, this is not the priority. Directing clients to sit in the waiting area encourages potential contamination of the hospital environment.

The nurse is working with victims who were exposed to mustard gas.

Which action by the nurse requires correction?

Administers antidote

Brushes dry substances from skin Rinses exposed areas with water Uses personal protective equipment

Rationale When a victim is exposed to mustard gas, the nurse will refrain from rinsing exposed areas with water. Water combined with mustard gas causes the release of chlorine gas. Antidotes can be administered, dry substances can be brushed off the skin, and the nurse must put on appropriate personal protective equipment before treating clients.

The nurse is working triage during a mass casualty incident (MCI).

Which victim will the nurse identify with a red tag? Select all that apply. One, some, or all responses may be correct.

Shock Sprains Open fracture Radiation exposure Burns over 50% of body

Rationale Victims who require a red tag are those with life-threatening injuries who need immediate intervention, including clients in shock, those who have radiation exposure, and those with severe burns. A victim with sprains would receive a green tag because this is a minor injury. A victim with an open fracture would receive a yellow tag because it is an urgent, but not life-threatening, injury.

Which instruction would the nurse provide to a client who is concerned about contracting amebic dysentery during foreign travel?

Apply insect repellent.

Drink only bottled water.

Avoid drinking pasteurized milk.

Obtain vaccines before foreign travel.

Rationale Entamoeba histolytica, the organism that causes amebic dysentery, is transmitted through excreta; bottled water prevents consumption of water that may be contaminated by the causative microorganism. Amebic dysentery is not a mosquitoor tick-borne disease. Pasteurization kills microorganisms that can cause disease.

Vaccines do not prevent amebic dysentery.

Which instruction would the nurse teach a client about preventive measures for Lyme disease?

"Wear dark-colored dresses."

"Tuck your shirt into your pants."

"Obtain a Lyme disease vaccination annually."

"Wear sandals."

Rationale Lyme disease is a vector-borne disease caused by the spirochete Borrelia burgdorferi and results from the bite of an infected deer tick, also known as the blacklegged

tick. Light-colored, rather than dark-colored clothing is preferred to spot the ticks easily, thereby preventing an insect bite and infection. Wearing closed shoes and boots (not sandals) and tucking the shirt in the pants prevent the entry and the bite of the blacklegged tick. Currently, there is no vaccination available for the prevention of Lyme disease.

Which precaution would the nurse implement for herpes zoster?

Select all that apply. One, some, or all responses may be correct.

Airborne Contact Droplet Standard

Rationale Airborne precautions are used for clients known or suspected to have infections transmitted by the airborne transmission route. Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment. Varicella can be transmitted by the airborne route.

Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet but are not suspended for long periods. Standard precautions are used with every client.

Which statement made by the student nurse indicates ineffective learning about the disaster triage tag system?

"I will use a yellow tag for clients with shock."

"I will use a green tag for clients with closed fractures."

"I will use a red tag for clients with airway obstruction."

"I will use a black tag for clients with massive head trauma."

Rationale According to the disaster triage tag system, a yellow tag is used for clients who require treatment within 30 minutes to 2 hours. Clients with shock require immediate attention and a red tag is appropriate. A green tag is used in clients with minor injuries, such as fractures and abrasions who can be managed with delayed treatment. A red tag is used for the clients who have immediate threats to life, such as an airway obstruction. A black tag is used for clients who are expected to die, such as massive head trauma and high cervical spinal cord injury.

Test-Taking Tip: Disaster triage tags are assigned to clients based on the severity of their injuries. Recall the different tags used in triage in disaster management.

Which action would the administrator of a community hospital take during a mass casualty event?

Call all staff to come into work.

Ask local agencies for staffing assistance.

Close the emergency department (ED) to admissions.

Contact the county health department for assistance.

Rationale A mass casualty event overwhelms local medical capabilities and may require the collaboration of multiple agencies and health care facilities to handle the crisis. This coordination could occur through the county health department. A multicasualty (not mass casualty) event can be managed by a hospital using local resources. This

would include calling all staff to come into work and asking local agencies for staffing assistance. Closing the ED to admissions may or may not be a strategy to handle mass casualties or multicasualty events.

Which way would mass casualty information about an 80 car pileup on the interstate be shared with all staff at the hospital receiving the victims? Select all that apply. One, some, or all responses may be correct.

Group paging Telephone trees Instant computer alert messages Through the National Guard Public service announcements on television

Rationale Group paging systems, telephone trees, and instant computer-based alert messages are the most common means of notifying essential personnel of a mass casualty incident or disaster. The National Guard would not communicate a disaster to a hospital, although they might be dispatched to assist. Public service announcements on television would be appropriate if a catastrophic event occurred, but not for staff at a hospital.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

During the activation of an emergency preparedness plan, which

individual would communicate with the media?

Medical director Emergency department (ED) nurse Director of human resources Hospital chief executive officer

Rationale The person who would most likely serve as a liaison between the health care facility and the media would be the director of human resources. The medical director would most likely decide the number, acuity, and resource needs of clients. The ED nurse would most likely evaluate each client to determine priorities for treatment.

The hospital chief executive officer would most likely assume overall leadership for implementing the emergency plan.

The disaster management team is evaluating the damage that can happen due to a disaster. They also attempt to limit the influence of the disaster on the health community’s function. Which phases of disaster management would the nurse state represents these actions?

Select all that apply. One, some, or all responses may be correct.

Recovery Response Mitigation Evaluation Preparedness

Rationale The attempt to minimize the influence of the disaster on the human health and community function refers to the mitigation phase of disaster management.

Identification of potential risks and evaluating the potential damage before the disaster event indicates the first phase of disaster management, which is preparedness. Recovery is the process of assisting affected clients in regaining a normal level of functioning after a disaster. Response is a process of combating a disaster event and providing assistance to clients affected by the disaster. Evaluation is the process of assessing the response effort to prepare for the future.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which considerations would the mental health nurse keep in mind when preparing to meet with a group of staff nurses who cared for victims of a disaster that occurred in the community? Select all that apply. One, some, or all responses may be correct.

Organize the chairs in a circle.

Plan to meet for 1 to 3 hours.

Set up the audio taping machine.

Ensure food and beverages are available.

Use the organization auditorium for the session.

Rationale The usual arrangement for the most effective group interaction is a circular configuration of chairs. Staff involved in the incident need protected time to

undergo stress debriefing, which generally lasts from 1 to 3 hours per session. Food should be available so that hunger is not a distraction. Typical "ground rules" for stress debriefing include strict confidentiality of information shared during the session and unconditional acceptance of the thoughts and feelings expressed by people within the group. This means that the session should not be audiotaped. The setting should be private. An auditorium would not be private.

The nurse reviews the room assignments for clients who are scheduled for admission. One client is being hospitalized to receive intravenous steroids for management of Crohn disease. The nurse would question the assignment if the client is scheduled to have a roommate who has which illness?

Pancreatitis Thrombophlebitis Bacterial meningitis Acute cholecystitis

Rationale The bacteria that cause meningitis are transmitted via air currents; the client with bacterial meningitis should be in a private room with airborne precautions to protect other people. Pancreatitis is not a communicable disease; it is most often caused by autodigestion of pancreatic tissue by its own enzymes. Thrombophlebitis is not a communicable disease; it is inflammation of a vein (phlebitis) associated with thrombus formation. Cholecystitis is not a communicable disease; it is inflammation of the gallbladder.

Which statement by the client on combination antiretroviral (cART) for the management of human immunodeficiency virus (HIV) indicates

the need for further teaching?

"I must take all doses of the medications as scheduled."

"I will notify the health care provider of any fever."

"All three medications must be taken to prevent medication resistance."

"These antiretroviral medications will cure my HIV infection."

Rationale The use of cART inhibits viral replication but does not kill the virus. Clients will be instructed to take all scheduled doses, notify the health care provider of any fever, and take all three medications in the regimen to prevent resistance and worsening infection.

Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for keywords; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

During a health history, an older client reports having fallen three times in the past 6 months. Which would the nurse ask to obtain other risk factors?

Assessing the level of education attained Evaluating respiratory status Subscribing to a call alert system Asking the client to walk across the room

Rationale When a client reports more than two falls in 12 months, the nurse would obtain further information to determine risk factors. Asking the client to walk across the room can determine any abnormalities in the gait or loss of balance. The level of education is part of the demographic information. Evaluating respiratory status provides more information about the client’s respiratory system. The use of a call alert system indicates the client is maintaining safety.

Once an infant is stabilized after a choking incident, which statement made by the parents indicates a need for teaching?

"The baby is always buckled into the stroller or infant seat."

"The spaces between the slats of the crib are only 2 inches wide."

"The pacifier is never placed on a string around our baby’s neck."

"The crib is filled with many small stuffed animals with button noses."

Rationale The infant could choke on small toys with removable pieces such as buttons. The statement indicates the parents need further teaching. The parents are being safe by buckling the baby in the stroller or infant seat. The space between the slats of the crib should be no wider than 2 3/8 inches apart to prevent injury. The parents are minimizing the risk for injury by never placing the pacifier on a string around the baby’s neck to prevent injury.

Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds.

Continue to analyze the options. If you can eliminate one more choice in a fouroption question, you have reduced the odds to 50/50. While you are eliminating the

wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

After teaching the parents of an infant the ways to prevent sudden infant death syndrome (SIDS), which action indicates a need for further teaching?

Removes pacifiers from strings Uses snug-fitting sheets in crib Eliminates bumper pads from crib Places the infant on stomach to sleep

Rationale Infants should always be placed on their backs or sides to sleep because these positions decrease the risk for SIDS. Therefore the parents placing the infant on the stomach to sleep requires further education. Correct actions performed by the parents include removing pacifiers from strings, using snug-fitting crib sheets, and eliminating bumper pads from the crib.

When preparing to administer medications to a client, which action made by the new nurse requires an intervention?

Obtaining vital signs Scanning medications Using one client identifier Assessing level of orientation

Rationale The nurse should always use two client identifiers to verify the client before administering any medication. Therefore the nurse only using one client identifier requires intervention. The nurse should obtain vital signs before administering certain medications. All medications should be scanned before giving them to the client. Level of orientation will assist the nurse in identifying the client’s ability to take the medications.

Which action by a client taking immunosuppressant medication for rheumatoid arthritis indicates to the nurse the need for additional teaching?

Has bloodwork for complete blood cell count (CBC) obtained Performs frequent hand washing Attends crowded sporting events Implements a home exercise program

Rationale Clients taking immunosuppressant medications need to avoid crowds and people who are sick. Clients will have routine CBC bloodwork obtained to monitor white blood cell count. Frequent hand washing prevents the spread of infection.

Implementing a home exercise program helps maintain joint movement without the need to go to a crowded gym.

When the nurse is developing educational programs for parents of younger school-age children to promote safety, which information would the nurse include that would be appropriate for this age group?

Use a helmet when bike riding.

Place locks on cabinets.

Refrain from alcohol use.

Install front-facing car seats.

Rationale School-age children are at highest risk for injury because of sports and activities.

Head injuries are a significant cause of death, especially those that result from bicycle and scooter use. Therefore the nurse would instruct the parents about consistent use of helmets. Locks on cabinets and front-facing car seats are safety interventions for toddlers and preschool-age children. Alcohol use should be discussed with adolescents.

When the nurse is making a home visit to a family with a toddler, which finding indicates a need for education about home safety?

Fire extinguishers Unlocked cabinets House built in 2000 Front-facing car seat

Rationale The presence of unlocked cabinets in the home can place the toddler at risk for injury due to accidental poisoning. This finding requires parental education about home safety. The presence of fire extinguishers indicates adequate safety for fire prevention. Houses built before 1978 may have lead paint which can place the toddler at risk for neurological deficits. Front-facing car seats are appropriate for toddlers.

The nurse is caring for a client who underwent a Whipple procedure and has started on a soft diet. Which action would the nurse perform first when the client begins to show signs of dumping syndrome?

Assess orientation.

Assist client to lie down.

Decrease carbohydrates.

Withhold fluids at meals.

Rationale The first action the nurse would perform for a client experiencing dumping syndrome is to assist the client when lying down. Later symptoms of dumping syndrome include confusion, so the nurse would later assess level of orientation.

The nurse would decrease the client’s intake of carbohydrates and withhold fluids at meals to prevent further episodes of dumping syndrome.

The nurse is preparing to assess a client with peptic ulcer disease (PUD). Which assessment finding indicates a need for immediate health care provider notification?

Nausea Dyspepsia Black stools Dull abdominal pain

Rationale Black stools indicate the presence of blood in the stool and needs to be immediately

reported to the health care provider. Nausea, dyspepsia, and dull abdominal pain are minor clinical manifestations and can be managed with medications.

The nurse is caring for a client who underwent surgical resection of an oral cancerous tumor. Which client problem is of highest priority to guide care?

Maintain airway.

Monitor vital signs.

Administer intravenous (IV) fluids.

Empty surgical drains.

Rationale The highest priority in planning care for a client who underwent a surgical resection for oral cancer is to maintain the airway and promote gas exchange. Other interventions include monitoring vital signs, administering IV fluids, and empty surgical drains, but these are of lower priority.

Which factor places an infant at risk for sudden infant death syndrome (SIDS)? Select all that apply. One, some, or all responses may be correct.

Breast-feeding Cigarette smoking Prone sleep position Advanced maternal age Lower socioeconomic status

Rationale Cigarette smoking, a prone sleep position, and lower socioeconomic status place an infant at risk for SIDS. Breast-fed infants have a lower incidence of SIDS. Low maternal age is a risk factor for SIDS.

Which education would the nurse provide to a mother of a newborn regarding the safe use of breast milk? Select all that apply. One, some, or all responses may be correct.

"Do not thaw the breast milk in the microwave."

"Expressed breast milk must be stored in a glass container."

"Breast milk can be stored for up to 6 months in the freezer."

"Breast milk may be thawed by mixing it with lukewarm water."

"Expressed breast milk must be used within 72 hours after refrigeration."

Rationale Breast milk should never be thawed or heated in the microwave. Breast milk can be stored for up to 6 months in the freezer. Expressed breast milk can be stored in either a glass or plastic container. Breast milk can be thawed by placing the container of milk in lukewarm water bath (40.5°C [105°F]). Expressed breast milk stored in the refrigerator must be used within 48 hours.

Which education would the nurse provide the parents of an exclusively breast-fed infant about vitamin D supplementation? Select all that apply. One, some, or all responses may be correct.

"Do not administer more than 400 IU per day."

"Add the vitamin D into supplemental formula."

"Read the syringe before administering the vitamin D." "Supplement your breast-feeding with formula fortified with vitamin D." "Do not administer vitamin D supplementation if your baby is solely taking in formula."

Rationale To avoid vitamin D toxicity, the infant should receive no more than 400 IU of vitamin D daily. It is important for the parents to read the markings on the syringe to administer the proper dosage. Vitamin D should not be added into supplemental formula. There is no need to give the infant supplemental formula with vitamin D because the infant is already prescribed liquid vitamin D. Vitamin D supplementation is recommended if the infant is consuming less than 1 liter per day of vitamin D–supplemented formula.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which parental statement would the nurse recognize as requiring additional education about managing infant teething discomfort?

"A frozen teething ring has seemed to help with my baby’s discomfort."

"Occasionally I have given ibuprofen to relieve the discomfort."

"Rubbing my baby’s gums with baby aspirin has been effective in relieving the discomfort."

"I found it helpful to allow my baby to chew on a cold, wet washcloth."

Rationale A parent should be discouraged from rubbing the gums with aspirin because doing so risks infection, irritation of the tissue, or aspiration. A frozen teething ring, occasional administration of ibuprofen, and cold washcloths are acceptable interventions to help relieve the discomfort from teething.

Which information would the nurse include when educating the parents of a 10-month-old about accidental poisoning? Select all that apply. One, some, or all responses may be correct.

Move all plants to a tabletop.

Store cleaning solutions on a top shelf.

Keep the poison control number handy.

Keep your medication stored in your purse.

Avoid storing chemicals in containers also used to keep food.

Rationale A parent should be instructed to keep the poison control number readily available and to avoid storing chemicals in containers that are also used to keep food. A child may be able to reach the tabletop, so the parent should be instructed to not have any poisonous plants in the house; if there are plants, they need to be completely out of a child’s reach. Cleaning solutions should be stored in a locked cabinet.

Medication should not be stored in the parent’s purse because an infant or child may get into the purse and ingest the medicine. All medicines should be secured in a locked cabinet or in a cabinet that the child cannot climb up to and access.

Which action is a priority for the nurse to implement for an infant recently admitted with a diagnosis of diarrhea caused by a Salmonella

infection?

Monitoring oral fluid intake Establishing a play schedule Obtaining a recent food history Establishing a skin care routine

Rationale Enzymes in the stool may irritate the skin; maintaining skin integrity is the priority.

Fluid intake is important to monitor for dehydration, though some infants may receive IV fluids. Establishing a play schedule is not the priority of care. Physiologic problems, such as altered skin integrity, should be addressed first. Although obtaining a food history is important, it is not the priority.

Which action is the priority before administering the antibiotics when a client is admitted with cellulitis of the left leg and a temperature of 103°F (39.4°C) and the primary health care provider prescribes intravenous (IV) antibiotics?

Determine the client’s allergies.

Apply a warm, moist dressing over the cellulitis.

Measure the amount of swelling in the client’s left leg.

Obtain the results of the culture and sensitivity tests.

Rationale Allergies are important. Medication hypersensitivity and anaphylaxis are most common with antimicrobial agents. Applying a warm, moist dressing over the area

is a dependent function; it is not crucial to starting antibiotic therapy. Measuring the amount of swelling in the client’s leg is an important assessment, but it is not crucial to starting antibiotic therapy. Withholding treatment until culture results are available may extend the infection.

Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are often evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

Which nursing action would be included in the plan of care for a client with a chronic venous stasis ulcer who has a negative-pressure wound treatment device prescribed to hasten wound healing?

Replace the wound sponge every 48 hours.

Transport the client to the large oxygen pressure chamber.

Overlap the edges of intact skin with the sponge.

Set the negative vacuum pressure to intermittent.

Rationale The sponge generally is changed every 48 to 72 hours. Routine changing of the sponge minimizes growth of granulation tissue into the foam sponge and allows for assessment of the wound. A large oxygen chamber is used in hyperbaric oxygen therapy. The skin is not overlapped with the sponge. Continuous low-level negative pressure is applied through the suction tube.

Test-Taking Tip: Attempt to select the answer that is most complete and includes the other answers within it. For example, a stem might read, "A child’s intelligence is

influenced by what?" and three options might be genetic inheritance, environmental factors, and past experiences. The fourth option might be multiple factors, which is a more inclusive choice and therefore the correct answer.

Which parent education would the nurse provide about the preferred carrying position for an infant with cerebral palsy prone to scissoring of the legs?

Astride one of her hips Strapped in an infant seat Wrapped tightly in a blanket Under the arm in a football hold

Rationale Muscular hypertonicity often causes scissoring of the legs in infants with cerebral palsy, and prolonged periods in such positions may worsen the infant’s musculoskeletal health. Carrying the infant astride the parent’s hip prevents scissoring by keeping the infant’s legs abducted. An infant seat will not prevent scissoring. Tight wrapping maintains the infant’s legs in a scissored position. When the football hold is used, the infant is carried in a supine position with the legs adducted, which promotes scissoring.

STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress.

Which nursing action occurring within a recently implemented falls

Which nursing action occurring within a recently implemented falls reduction program indicates the need for additional staff education?

Using gait belts for client transfers and ambulation Placing a bedside commode for a client experiencing incontinence Establishing an elimination schedule for clients experiencing confusion Stabilizing a client with hypotension in a standing position for 5 minutes before ambulating

Rationale Clients experiencing hypotension should dangle on the side of the bed for 5 minutes before ambulation. Fall risk reduction programs include using gait belts for transfers and ambulation, using bedside commodes, and establishing an elimination schedule.

Which action by the nurse increase safety in the clinical setting?

Select all that apply.One, some, or all responses may be correct.

Wear a mask when performing daily hygiene Remain current with evidence and best practices Use only quality resources, especially websites Report faulty equipment as soon as discovered Sterilize all intravenous pumps between clients

Rationale Actions by the nurse that increase safety in the clinical setting include keeping current with evidence and best practices, using only quality resources when looking up information, and reporting faulty equipment immediately and not using it until

the repairs are completed. Wearing a mask when performing hygiene is not necessary unless the client is in droplet, airborne, or neutropenic precautions.

Intravenous pumps should be cleaned with a high-level disinfection, not sterilization, process.

Which recommendation would the nurse include when a client asks what to do to remain safe in the hospital? Select all that apply.One, some, or all responses may be correct.

"Ask questions if you have doubts or concerns."

"Keep and bring a list of all the medications you take."

"Be sure to have an attorney in mind just in case you need one."

"Make sure you understand what will happen if you need surgery."

"Do not get any test results unless your health care provider approves it."

Rationale Recommendations that the nurse could give the client to increase safety while hospitalized include asking questions when in doubt or concerned, providing a list of all the medications one takes, and making sure surgical procedures are understood. Recommending to have an attorney in mind may increase the client’s anxiety. The client should get results of any tests or procedures performed.

The nurse teaches a nursing student how to treat poisoning in young children. Which statement by the nursing student indicates the need for further teaching?

"An emergency team should be called if the victim stops breathing."

"Syrup of ipecac should be administered immediately after poisoning."

"The National Poison Control hotline should be called if a poison is ingested."

"The child should be removed from the hazardous environment if the poison has been inhaled."

Rationale The use of syrup of ipecac is not indicated in any kind of poisoning. Calling for an emergency team when a victim has stopped breathing is crucial; in fact, this is the first step in treatment. The National Poison Control hotline provides information about first aid measures to be performed in cases of poisoning. Removing a poisoned child from a hazardous environment prevents the further inhalation of poison.

Which statement by the client reflects understanding of the teaching about how to care for an eye infection?

"Wash the infected eye first, then the noninfected eye."

"Squeeze your eyes closed after administering the drops."

"Wash your hands before and after washing and treating the eye."

"Place the tip of the antibiotic solution drop on the lower lid of the eye."

Rationale The nurse will instruct clients to wash his or her hands before and after treating the eye to prevent spreading or worsening the infection. Clients will be instructed to wash the noninfected eye first because this prevents spreading infection from the infected eye to the noninfected eye. Clients will be instructed to keep eyes open, rather than closing them, after administering the medication because squeezing the lids shut can push the solution out of the eye. Clients need to avoid allowing the

antibiotic solution to come into contact with any surface to prevent contamination.

Which instruction would the nurse provide for a cervical spine injury client with a halo in place? Select all that apply. One, some, or all responses may be correct.

"Attach the vest wrench to the jacket for emergency access."

"Observe the pin sites and report purulent drainage to your doctor."

"Check to make sure one finger fits between the device and your skin."

"Perform neck range of motion by holding and pulling on the halo device."

"Use a long, pointed object to reach any spots that are itchy while wearing the halo."

Rationale Clients will be instructed to attach the wrench device to the jacket for quick access in the event emergency removal is needed. The pin site requires care per policy as ordered by the client’s health care provider; any signs of infection such as purulent drainage need to be reported immediately. The halo should be snug but not cause skin breakdown; clients will need to ensure one finger can fit between the skin and the device at pressure points. Clients should not grab or pull on the halo because its purpose is to immobilize the neck. Sharp objects should not be stuck under the vest to scratch the skin because this can impair the skin, introduce infection, and delay healing.

Which nursing intervention will be the priority when caring for a client with status epilepticus?

Draw blood.

Establish an airway.

Insert a large-bore intravenous (IV) needle.

Administer phenytoin.

Rationale The priority for a client with status epilepticus is establishing an airway to provide oxygenation after the seizure. Blood drawn for arterial blood gases and metabolic indicators, as well as placement of a large-bore IV for medication and fluids, can be completed after the client’s airway is secure. Treatment with phenytoin may be prescribed to prevent further seizure activity but does not take priority over securing a client’s airway.

Which piece of equipment will the nurse remove from the bedside of a client on seizure precautions?

Oxygen Padded tongue blade Suction tubing and canister Airway management equipment

Rationale Padded tongue blades should not be used during a seizure; the intervention is more likely to cause injury to teeth than prevent biting the tongue. Oxygen, suction equipment, and airway management tools are indicated at the bedside of a client on seizure precautions to support the airway and gas exchange.

Which intervention will the nurse include in a care plan for a client with dementia who wanders? Select all that apply. One, some, or all

responses may be correct.

Assess and treat pain.

Avoid loud music, television, and glaring lights.

Have family members monitor client activity when possible.

Use chemical or physical restraint at night to keep the client in bed.

Place the client at the end of the hall to allow use of the hall for wandering.

Rationale Assessing and treating pain in clients with dementia promotes relaxation and prevents unsafe wandering. Avoiding loud music, television, and glaring lights helps decrease confusion and unsafe sensory overload. When possible, family members or volunteers can be "sitters" for clients by providing safe supervision. Chemical or physical restraint is only used as a last resort; it is generally avoided. Clients with dementia who are prone to wander need to be placed away from stairs and elevators, preferably close to the nurse’s station to allow for close monitoring of their activity.

Which intervention will the nurse include in a care plan for a client with Alzheimer disease? Select all that apply. One, some, or all responses may be correct.

Limit choices.

Use all side rails.

Toilet every 2 hours.

Ask open-ended questions.

Encourage participation in self-care.

Rationale Clients with Alzheimer disease need limited choices; having too many choices can increase confusion and frustration. Toileting every 2 hours supports bladder and bowel training and continence. Encouraging participation in self-care supports independence. The use of all side rails or any other form of restraints needs to be avoided in clients with dementia; trying to free themselves from the restraints can lead to injury. Simple "yes or no" questions are best. Open-ended questions can be confusing and overwhelming.

Which teaching points would the nurse include when educating parents of a school-age child to decrease the risk for burn injury?

Select all that apply. One, some, or all responses may be correct.

Securing seat belts properly Using a low heat setting when cooking Recommending enrollment in swimming lessons Instructing on the stop, drop, and roll technique Making sure smoke detectors are installed in the home

Rationale Teaching points to include when educating parents about methods to decrease the risk of burn injury for a school-age client include using a low heat setting when cooking; instructing on the stop, drop, and roll technique; and making sure smoke detectors are installed in the home. Properly securing a seat belt is a teaching point appropriate to prevent injury while in a motor vehicle. Enrollment in swimming lessons is an appropriate teaching point to prevent drown injury.

Which parental education would the nurse include when discussing

how to terminate exposure to a poisonous substance? Select all that apply.One, some, or all responses may be correct.

Empty mouth of substances.

Remove contaminated clothing.

Administer oxygen for inhalation poisoning.

Flush skin or eyes with large amounts of warm water or saline.

Place child side-lying, sitting, or kneeling with head below the chest.

Rationale Emptying the mouth of substances, removing contaminated clothing, and flushing the skin and eyes with large amounts of warm water or saline are methods used to terminate the exposure to a poisonous substance. A victim of inhalation poison should be brought into the fresh air; oxygen is not indicated. Placing a child sidelying, sitting, or kneeling with the head below the chest is done to prevent aspiration.

Which factors most often interfere with access to prenatal care for pregnant women, placing the mother and infant at risk? Select all that apply. One, some, or all responses may be correct.

Language differences Transportation barriers Lack of nurse practitioners Lack of culturally sensitive care providers Discrimination based on sexual orientation

Rationale Languages differences, transportation barriers, lack of culturally sensitive care providers, and discrimination based on sexual orientation most often interfere with access to prenatal care for pregnant women and place the mother and infant at risk.

The availability of advanced practice nurses improves the availability and accessibility to care.

Which musculoskeletal changes directly place pregnant clients at increased risk for falls? Select all that apply. One, some, or all responses may be correct.

Back pain Joint laxity Weight gain Impaired balance Shifting center of gravity

Rationale Pregnant women are at increased risk of falling directly due to joint laxity, impaired balance, and the shifting center of gravity. Back pain and weight gain do not directly contribute to the increased risk of falling for pregnant women.

Which clinical manifestations would the nurse monitor for in a toddler 3 days after ingesting a poisonous substance? Select all that apply. One, some, or all responses may be correct.

Lethargy Jaundice

Renal failure Hypoglycemia Productive cough

Rationale The toddler is at risk for jaundice, liver failure, hypoglycemia, and a coma (lethargy may also be observed) for 2 to 5 days after ingesting a poisonous substance. The renal and respiratory systems are not specifically at risk for further injury.

Which clinical manifestations would the nurse monitor for in a toddler during the latency period after a suspected ingestion of a poisonous plant? Select all that apply. One, some, or all responses may be correct.

Fever Seizures Bleeding Hypoglycemia Metabolic alkalosis

Rationale Symptoms after an ingestion may not occur immediately, a time known as the latency period. A child who has ingested a poisonous substance will be monitored in the latency period of 12 to 24 hours for symptoms of fever, seizures, and bleeding.

During the latency period the child is at risk for hyperglycemia and metabolic acidosis.

Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for keywords; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

Which parental activities would the nurse recognize as placing a preschooler at risk for bodily harm? Select all that apply. One, some, or all responses may be correct.

The parent supervises the child swimming from the kitchen.

The parents leave medications within reach of the child.

A parent tricks the child into eating a vitamin by saying, "This is candy."

A parent only allows the child to watch 2 hours of television each day.

The parents ask the child, "Has anyone touched you inappropriately at school?"

Rationale Activities that the nurse notes as potentially harmful include the child swimming without constant nearby adult supervision, medications that are left within reach of the child, and a parent telling the child that a vitamin is candy. Each of these findings increases the child’s risk for bodily harm, necessitating the need for intervention. Two hours of television is appropriate for a preschool-aged client. A parent asking the client if he or she has ever been touched inappropriately at school is also appropriate and does not place the child at risk for bodily harm.

After completing education on accidental poisoning in the home for the parent of a toddler, which parent statements would concern the

nurse? Select all that apply.One, some, or all responses may be correct.

"My cosmetics are in my purse."

"I only keep children’s chewable vitamins on the counter."

"I keep my cigarettes and lighter on the shelf in the garage."

"The cleaning solutions are in a locked cabinet above the washing machine."

"I make sure all of my medications are stored in a bottle with a childproof cap."

Rationale Toddlers are able to climb most heights, open most drawers or closets, and unscrew most lids. Accidental poisoning can occur with cosmetics, because a purse is easily accessible to a toddler. Leaving the vitamins on the counter places the toddler at risk for accidental poisoning. A toddler can manage to undo a childproof cap. It is recommended that all medications be kept in a locked cabinet. The cigarettes and lighter on a high shelf in the garage and the cleaning solutions kept in a locked cabinet above the washing machine are good strategies to prevent accidental poisoning.

The parent of a preschooler reports to the nurse that their child has started wetting the bed after previously being dry throughout the night. Which question would be appropriate for the nurse to ask?

Select all that apply. One, some, or all responses may be correct.

"Does your child have an illness?"

"Is there a new sibling in the family?"

"Did you recently move to a new home?"

"Does your child regularly visit a house that was built before 1950?"

"Does your child live in a house built before 1978 with ongoing renovations?"

Rationale Stress can cause preschoolers to revert to bed-wetting. Sources of stress for preschoolers may include illness, the birth of a sibling, and relocation to a new home. Regular visits to a house that was built before 1950 or living in a house built before 1978 with ongoing renovations may result in lead poisoning.

Which statement made by a parent indicates a need for further education about emergency treatments of poison ingestion by preschool-aged children?

"I will wait for expert advice to minimize the adverse effects of poisoning."

"I will immediately call the poison control center (PCC) in case of poisoning."

"I will immediately start treatment at home by using gastrointestinal decontamination."

"I will take my child to a health care facility with pediatric emergency treatment services if the type of ingested toxin is unknown."

Rationale Nurses may use gastrointestinal decontamination only after careful evaluation of the potential toxicity of the poison and the risks versus benefits. Parents should not use gastrointestinal decontamination without advice from the PCC. In the case of poisoning, parents should immediately call the PCC before initiating any intervention. Even if the poisoning can be managed at home, parents should always

wait for expert advice to minimize the adverse effects of poisoning. Parents should take the child to a health care facility with pediatric emergency treatment services if the child has ingested an unknown toxin.

The nurse is teaching a group of parents about communicable diseases. Which information about chickenpox would the nurse include?

"Chickenpox is communicable until the vesicles have dried."

"As long as dry scabs remain, chickenpox is still communicable."

"After the high fever has subsided, chickenpox is no longer communicable."

"Chickenpox is no longer communicable when the vesicles are intact with a red areola."

Rationale When all vesicles are dried, chickenpox is no longer transmissible; dried vesicles do not harbor the varicella virus. Dry scabs do not transmit the virus. Chickenpox is not associated with a high fever unless a bacterial complication, such as pneumonia, is present. Intact vesicles with a red areola are mature vesicles, which occur in successive crops; these vesicles contain the varicella virus.

Which comment would the nurse recognize as requiring further parental education about preschooler nutrition?

"We allow our child to drink only pasteurized apple cider."

"We let our child eat sample cookie dough while making cookies."

"We always wash our hands well before any food preparation."

"We use separate utensils for food preparation and for eating."

Rationale Raw cookie dough contains raw eggs, increasing the risk for foodborne illness; therefore this statement indicates the need for further teaching. Allowing the child to drink pasteurized apple cider, washing hands before food preparation, and using separate utensils for food preparation and for eating are appropriate and do not indicate the need for further education.

Which parental statement indicates the need for further education about food safety and choking in a toddler-age client?

"Hot dogs are safe and do not present a choking hazard for my child."

"Ice cream is safe and does not present a choking hazard for my child."

"Chicken nuggets are safe and do not present a choking hazard for my child."

"Mashed potatoes are safe and do not present a choking hazard for my child."

Rationale Due to the risk for choking, large, round foods such as hot dogs should be avoided until the toddler is able to chew effectively. Ice cream, chicken nuggets, and mashed potatoes are not identified as choking hazards for the toddler-age client.

Which situation reflects the second level of Maslow’s hierarchy of needs? Select all that apply. One, some, or all responses may be correct.

A client reports not having any friends.

A client reports being taunted by his boss every day.

A client states that her spouse belongs to a criminal gang.

A client reports that she does not like interacting with people.

A client reports living beside a factory that manufactures harmful chemicals.

Rationale According to Maslow’s hierarchy of needs, the second level of needs involves safety and security needs. This includes both physical and psychological security and safety of the person. Clients who are taunted by their boss every day, have spouses that are part of a criminal gang, or live next to a factory that manufactures harmful chemicals are displaying second-level needs. A client who laments about not having friends or does not like interacting with people is displaying a third level of needs (love and belonging needs).

The nurse is providing discharge education for a parent whose child will be receiving a prescription at home. Which statement by the parent requires correction?

"I will be the only person administering the prescription."

"I am going to create a medication administration time chart."

"The full dose needs to be readministered if my child spits some out."

"I will have you watch me administer this prescription before we leave."

Rationale Spills and spitting out a prescription are common causes of inaccurate dosing in pediatric clients. Parents will be instructed to estimate the amount of medication lost and to readminister that amount, rather than readministering the full dose.

Multiple dosing can occur when more than one person is helping medicate the

child. A chart can be helpful for keeping track of the prescription administration and for preventing duplicate or missed doses. Before the child is discharged, the nurse can observe the parent’s medication administration technique to ensure it is correct and to answer any questions the parent may have.

When preparing to safely administer medications to newborns, it is important for the nurse to recognize which factors as contributors to reduced renal medication excretion? Select all that apply. One, some, or all responses may be correct.

Bladder capacity Renal blood flow Nephron capacity Glomerular filtration Active tubular secretion

Rationale In newborns, renal blood flow, glomerular filtration, and active tubular excretion contribute to reduction of renal medication excretion. Bladder capacity is not associated with the reduction of renal excretion in newborns. The nephron is a structural and functional unit of the kidneys.

Which athletic safety equipment would the nurse recommend for a school-aged child? Select all that apply. One, some, or all responses may be correct.

Gloves Helmet

Padding Eye shields Mouth shields

Rationale General safety equipment recommended for a school-aged child playing active sports includes a safety helmet, padding, eye shields, and mouth shields. Gloves are not necessary unless participating in a specific activity that requires them.

Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

To safely administer medications intravenously in infants, the nurse would be cognizant of which intravenous (IV) medication effect?

Prolonged More intense Peaks more quickly Equivalent to an adult dose

Rationale When a prescription is administered intravenously, the levels decline more slowly in an infant than in an adult. As a result, medication levels in the infant remain above the minimum effective concentration longer than in the adult, thereby causing the

effects of the medication to be prolonged. When administered subcutaneously, the effect of the medication will not only be prolonged, but more intense. When administered intravenously to an infant, the effect of the medication will not necessarily peak more quickly, nor will it be equivalent to an adult dose.

Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

Which factors would the nurse recognize as increasing the incidence of injury to a school-aged child? Select all that apply. One, some, or all responses may be correct.

The protection offered by adults The behavior patterns of the child The physical activity level of the child Dangers present in the environment Participation in extracurricular activities

Rationale The protection offered by adults, behavior patterns of the child, and dangers present in the environment affect the incidence of injury to a school-aged child. The physical activity level of the child or participation in extracurricular activities does not affect the incidence of injury to a school-aged child.

Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

Which aspect of safe medication administration in the pediatric

Which aspect of safe medication administration in the pediatric population does the nurse need to consider? Select all that apply.

One, some, or all responses may be correct.

Medications can cause unanticipated side effects.

Dosing ranges are an important component in the process.

Many medications have not been tested in children.

Medication sensitivity in infants is the same as in adults.

Some of the medications may be ineffective in children.

Rationale Fully two-thirds of medications used in pediatrics have never been tested on children. As a result, complete understanding of the pharmacokinetics and both therapeutic and adverse effects in children may be lacking. As compared to adult dosing, pediatric dosing includes a component of safe dose ranges rather than a single, accepted dose. Some medications are, in fact, ineffective in children.

Medication sensitivity in infants depends on many factors specific to their developmental phase and is not like medication sensitivity in adults.

Which techniques would the nurse suggest to the parent of a toddler to promote medication adherence? Select all that apply. One, some, or all responses may be correct.

Praise the child for taking the medication.

Mix the prescription with a small amount of juice.

Allow the child to suck on a frozen treat before giving the prescription.

Offer a treat "to get the taste out" right after administration of the medication.

Refrigerate the prescription even if the medication does not require refrigeration.

Rationale Techniques that can be used to promote prescription adherence in children include praising the child for taking the medication well, offering a treat "to get the taste out" right after administration of the prescription, refrigerating the prescription even if it does not have to be refrigerated, and offering the child a frozen treat to suck on before the administration of the prescription. Prescriptions should not be mixed in juice; however, the medication may be able to be given with food or milk.

The nurse recognizes that premature infants are at risk for increased sensitivity to medications due to which factors? Select all that apply.

One, some, or all responses may be correct.

Body size Blood-brain barrier Renal drug excretion Hepatic drug metabolism Protein binding of the drugs

Rationale In infants, immaturity of the pharmacokinetic processes, including the blood-brain barrier, renal drug excretion, hepatic drug metabolism, and protein binding of the drugs, as well as drug absorption, all contribute to increased sensitivity to drugs.

Body size does not contribute to the infant’s increased sensitivity to pharmacological agents.

Which gastrointestinal factor affects medication absorption and places infants at risk? Select all that apply. One, some, or all responses may be correct.

Blood flow Intrinsic factor Gastric acidity Emptying time Nutritional status

Rationale Gastric acidity and emptying time are gastrointestinal factors that affect medication absorption in the infant. Blood flow and nutritional status do not affect medication absorption in the infant. Intrinsic factor is necessary for the absorption of vitamin B 12.

Which activities are included in a school’s health program of ongoing health maintenance for a child? Select all that apply. One, some, or all responses may be correct.

Referral Screening Treatment Assessment Intervention

Rationale A school health program is involved in ongoing health maintenance through referral, screening, and assessment activities. Treatment and intervention are not part of ongoing health maintenance. However, counseling and follow-up care are included in routine health services.

Which questions would the nurse ask the parent of a child who is suspected of being bullied at school? Select all that apply. One, some, or all responses may be correct.

"Does your child exhibit any anxiety?"

"Has your child tried to harm himself or herself?"

"How is your child’s academic performance?"

"Has your child committed any criminal acts?"

"Does your child participate socially in school?"

Rationale A child that is being bullied is at increased risk for anxiety, self-harm behaviors, and poor academic performance. Future problems of bullies include a higher risk of antisocial behavior and participation in criminal behaviors.

Test-Taking Tip: The following are crucial requisites for doing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (3) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence.

Which information would the nurse include in parental education

about bullying? Select all that apply. One, some, or all responses may be correct.

A cyberbully can remain anonymous.

Bullying usually takes place at school.

A cyberbully attack can reach a wider audience.

The school-age child is at greatest risk for cyberbullying.

The child is at greatest risk for bullying in high school.

Rationale Cyberbullying involves an electronic medium that is used to harm or bother another. Cyberbullying attacks can be more harmful because it can reach a wider audience and the attacker can remain anonymous. Bullying usually takes place in school hallways or playgrounds. The risk for bullying is greater in elementary and middle school than high school. Cyberbullying occurs more frequently in high school.

Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for keywords; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

Which maturational factor would the nurse recognize is most associated with participating in risk taking behaviors? Select all that apply. One, some, or all responses may be correct.

Prepubescent girl Preadolescent boy

Early developing girl Late developing boy Preadolescent period

Rationale Early appearance of secondary sex characteristics in girls and late development in boys have been associated with participation in risk taking behaviors. A prepubescent girl, preadolescent boy, or the preadolescent period do not have the highest link to risk taking behaviors.

Which would the nurse determine before preparing a child with cerebral palsy (CP) for crutch-walking?

Weight-bearing ability of the child’s four extremities The power in the child’s trunk to drag the legs forward when the child is erect Whether the child’s circulation can tolerate the body being placed in an erect position The ability of the child’s shoulder girdle to support the body’s weight when it leaves the floor

Rationale The choice of gait is based on the weight-bearing capabilities of each of the four extremities. Assessment of the extremities takes priority over assessment of the trunk. The child with CP uses upper extremity strength for crutch control and lower extremity strength to facilitate some movement. The child with CP is unlikely to have orthostatic circulatory impairment. Because of decreased muscle control, it is unlikely that the child is able to use a gait involving complete support of body

weight off the floor.

The nurse places a school-aged child with bacterial meningitis in isolation with droplet precautions. Which is the purpose of these precautions?

They keep the child away from uninfected people.

The infectious process is interrupted as quickly as possible.

The child is protected from contracting a secondary infection.

They prevent the development of a hospital-acquired infection.

Rationale Droplet precautions reduce the transmission of infection from the child to other individuals (cross-infection). The microorganisms are transmitted to others in respiratory droplets. Droplet precautions do not interrupt the infectious process; they protect those in contact with the child from contracting the infection. Droplet precautions do not protect the child from contracting secondary infections; they protect others from being exposed to the child’s pathogens. Thorough hand washing and aseptic techniques, not droplet precautions, limit the spread of hospital-acquired infections.

Which parental statement indicates to the nurse that additional teaching about accident prevention for toddlers is needed?

"I’ll keep medications in a kitchen cabinet."

"I’ll put baby gates at the top and bottom of the stairs."

"I’ll have my child in a regular bed by the time they are 2½ years old."

"I’ll buy my child shoes that close with Velcro instead of laces."

Rationale The kitchen cabinet is not a safe place for medications; toddlers are curious and are capable of climbing and opening cabinets. They must be protected from dangerous areas such as stairs. Secured gates at the top and bottom of stairs provide a barrier.

At a height of 36 inches (91.4 cm) a toddler is ready to use a bed; the average toddler reaches this height at age 2½. Shoes with Velcro can be secured without the need for shoelaces, which may become untied and pose a risk for falls.

Which is the priority topic that the nurse would include when teaching parents about the developmental needs of young toddlers?

Toilet training Temper tantrums Adequate nutrition Accident prevention

Rationale Because of the young toddler’s increased mobility, high level of oral activity, and relative lack of fear or appreciation for danger, accidents are the primary cause of death in children older than 1 year of age. Parents of toddlers often want to discuss toilet training, though this is not the priority. Although learning how to handle temper tantrums is important, it is not the priority. Although adequate nutrition is always important, it is not the priority.

Which nursing intervention would be implemented routinely in the immediate recovery period after a client has a vacuum aspiration abortion?

Giving the client the prescribed oxytocic medication

Preparing the client for discharge within 30 minutes Teaching the client about the various methods of birth control Encouraging the client to take the prescribed antibiotic medication

Rationale Prophylactic antibiotics after a vacuum extraction abortion decrease the incidence of infection. Oxytocics are not used routinely after an abortion unless there is excessive vaginal bleeding. The client is usually observed for 1 to 3 hours before being discharged. Birth control instructions should be given before the abortion; a client is not receptive to teaching immediately after the procedure.

A female client is receiving intravenous antibiotic therapy for toxic shock syndrome. Which statement indicates to the nurse that the client understands the teaching regarding future care?

"I will call the clinic if I get a rash."

"I will call the clinic if the menstrual cramps return."

"I now know how to insert my diaphragm correctly."

"I now know how to perform correct tampon hygiene."

Rationale Toxic shock syndrome may recur during the first 3 months after treatment; a sunburn-like rash with peeling skin often occurs in the late stages of the syndrome.

There is no need for the client to call the clinic if menstrual cramps return, because this is not specifically related to toxic shock syndrome. Whether the diaphragm is inserted properly is not the issue; it is linked to toxic shock syndrome if it is not removed 6 to 8 hours after intercourse. Tampons are linked to the development of

toxic shock syndrome and should not be used by this client at this time.

Which instructions would the nurse include at the time of discharge for a child who has been diagnosed with a mild concussion?

Withhold food and fluids for 24 hours.

Encourage outdoor play and visits with friends.

Arrange for a follow-up visit with the primary health care provider.

Check for changes in responsiveness every 2 hours for 2 days.

Rationale Signs of an epidural hematoma in children usually do not appear for 24 or more hours; parents are instructed to observe the injured child for changes in behavior and to notify the health care provider if they occur. If there is no nausea, food and fluids are not restricted. The child should be encouraged to rest and should be with an adult so responsiveness can be monitored. Arranging for a follow-up visit without a specific date is too vague; the child should be seen by the primary health care provider within 1 to 2 days of the injury.

Which nursing behavior would need to be addressed to improve contact isolation technique?

Not wearing a mask while in the client’s room Wearing gloves but no gown while changing linens Wearing clean gloves while setting the intravenous pump Disinfecting equipment before removing it from the room

Rationale Organisms spread by contact could be present on linen and furniture. Because the nurse will likely come in contact with the bed or the sheets, a gown should be worn.

A mask is not required for contact isolation. Clean gloves are appropriate; sterile gloves are not necessary. No other protective gear is needed, because the nurse’s hands are the only part of the body that might touch the client. Equipment brought into the room must be disinfected before it is removed from the room.

Which intervention would the nurse perform while caring for a preschooler with lead poisoning? Select all that apply. One, some, or all responses may be correct.

Administer chelation therapy Educating the parent on the use of hot water for cooking Prevent further lead exposure Identify the sources of lead in the environment Implement a low-calcium diet

Rationale While caring for a preschooler exposed to lead poisoning, the nurse would administer the chelation therapy, prevent further exposure of the child to lead, and identify the sources of lead in the environment. In an attempt to identify the source of the lead, the nurse would educate the parent to use cold water, instead of hot water, while cooking. The nurse would ensure adequate calcium, vitamin C, and iron in the child’s diet to minimize lead absorption.

Which information would the nurse include when educating a client who is scheduled for uterine artery embolization? Select all that apply.

One, some, or all responses may be correct.

"Do not drink alcohol or smoke for 24 hours before the procedure."

"Stop taking any acid-suppressing medications the day before the procedure."

"Start nonsteroidal anti-inflammatory drugs (NSAIDs), antihistaminic medication, and laxatives the day before the procedure."

"A low-grade fever is normal, but contact the health care provider if your temperature is 102.2°F (38.9°C) or higher."

"After the procedure, nausea and vomiting should not occur, so call the health care provider immediately if these are experienced."

Rationale Preoperative teaching before uterine artery embolization should include instruction for abstaining from alcohol and nicotine for 24 hours before the procedure. Clients who are having the procedure done on an outpatient basis should take NSAIDs, antihistaminic medication, and laxatives beginning the day before the procedure. A low-grade fever might occur from acute fibroid degeneration, but the client should be coached to call the health care provider if she experiences a fever of 102.2°F (38.9°C) or higher. Clients having the procedure on an outpatient basis will usually need to take acid-suppressing medications beginning the day before the procedure.

After the procedure, nausea and vomiting can be expected postoperatively and is caused by acute fibroid degeneration.

Which facts would the nurse share with a client expressing interest in menopausal hormone therapy? Select all that apply. One, some, or all responses may be correct.

"The risk of breast cancer is no higher while using hormone therapy."

"There is an increase in heart disease risk from the use of continuous combined estrogen plus progestin."

"The North American Menopause Society supports the use of estrogen therapy beyond 3 to 5 years to prevent osteoporosis in menopausal women."

"The U.S. Preventive Services Task Force recommends combined estrogen and progestin therapy for postmenopausal women."

"The American College of Obstetricians and Gynecologists encourages nonhormonal alternatives such as selective serotonin reuptake inhibitors."

Rationale There is an increase in heart disease risk from the use of continuous combined estrogen plus progestin. The North American Menopause Society supports the use of estrogen therapy beyond 3 to 5 years to prevent osteoporosis in menopausal women. The American College of Obstetricians and Gynecologists encourages nonhormonal alternatives such as selective serotonin reuptake inhibitors. The risk of breast cancer is higher while using hormone therapy but returns to normal within 3 years of discontinuation. The U.S. Preventive Services Task Force does not recommend combined estrogen and progestin therapy for postmenopausal women to prevent chronic conditions.

Which statements would the nurse include when providing education regarding menopausal hormone therapy? Select all that apply. One, some, or all responses may be correct.

"Studies linking menopausal hormone therapy to breast cancer were erroneous and can be ignored."

"Taking conjugated estrogens is associated with an increased risk of gallbladder disease."

"Menopausal hormone therapy has beneficial cardiovascular effects."

"Tapering off hormone therapy will help a woman avoid the recurrence of menopause symptoms."

"If the treatment is used for 1 to 3 years in a client with no risk factors for heart disease, the benefits may outweigh the risk."

Rationale Studies linking hormone therapy to breast cancer were valid and deserve careful consideration. Taking conjugated estrogens has been linked with gallbladder disease. The benefits of menopausal hormone therapy might outweigh the risks if taken for a short period (1–3 years) by a woman with no risk factors for heart disease. Menopausal hormone therapy does not have beneficial cardiovascular effects on all menopausal women. Older women should be counseled on other methods of treating menopausal symptoms; there may be beneficial cardiovascular effects from menopausal hormone therapy for younger women who only recently entered menopause. Whether a woman tapers off hormone therapy or stops abruptly, she should expect a recurrence of menopause symptoms.

The nurse is teaching students about possible signs of domestic abuse. Which classic characteristic of an abuser would the nurse include? Select all that apply. One, some, or all responses may be correct.

High self-esteem Very assertive demeanor Especially good verbal skills Inability to empathize with others Having a fluid view of gender roles Perception of self as "special" and deserving of special attention

Rationale Abusers are often unable to empathize with others and perceive themselves as "special" and deserving of special attention for being the provider or protector in relationships. Abusers may have low self-esteem and deficits in assertiveness, as well as inadequate communication skills and a rigid view of gender stereotypes.

Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.

When would the nurse provide education to the parent of a child brought to the hospital for an accidental overdose in an effort to decrease the child’s risk in the future?

In the emergency department Upon transfer to the intensive care unit Before discharge from the medical unit At the next scheduled health maintenance appointment

Rationale The best time for the nurse to provide education to the parent of a toddler admitted for an accidental overdose is before discharge from the medical unit to the home environment. If the nurse prematurely attempts to discuss ways of preventing such an incident from recurring (such as in the emergency department or upon transfer to the intensive care unit), the parent’s anxiety will block out any suggestions or offered guidance. It is preferable for the nurse to delay the discussion until the child’s condition is stabilized before discharge from the medical unit. Waiting until

the next scheduled health maintenance appointment places the child at risk for a repeat accidental overdose.

Which parental statement indicates correct understanding of sunburn prevention in a toddler? Select all that apply. One, some, or all responses may be correct.

"I will keep my child indoors between 10:00 AM and 2:00 PM." "I will make sure my child wears a baseball cap while outside."

"I will use a sunscreen with an SPF of 15 or higher for my child."

"I will be sure to reapply sunscreen if my child sweats more than usual."

"I will make sure my child wears cotton clothing with a tight weave while outside."

Rationale To protect the toddler from sunburn, it is important to keep them out of the sun between 10:00 AM and 2:00 PM, ensure the child wears a baseball cap while outside, reapply sunscreen after profuse sweating, and make sure the child is dressed in cotton clothing with a tight weave. These statements all indicate correct understanding of the information presented by the nurse. An SPF of 30 or higher, not 15, should be applied to prevent sunburn.

Which statement by the parent of a toddler indicates the need for further education?

"I should follow the manufacturer instructions regarding use."

"I should allow my child to ride unrestrained for short car trips."

"I should allow my child to have a toy for quiet play while in the car."

"I should encourage my child to help fasten seatbelt buckles."

Rationale Toddlers never should be allowed to ride in a motor vehicle unrestrained, even for short trips. This statement indicates the need for further education. The parental statements regarding following manufacturer instructions, allowing the child to have a toy for quiet play, and encouraging the toddler to assist with buckles all indicate correct understanding.

Which orders would the nurse expect to receive from the primary health care provider for the client at 10 weeks’ gestation who has just been diagnosed with syphilis? Select all that apply. One, some, or all responses may be correct.

A wait-and-see approach Recommendation for elective abortion Screening and testing of sexual partners None, because the syphilis will most likely not affect the fetus in utero Intramuscular benzathine penicillin G, 2.4 million units, 1 dose

Rationale The Centers for Disease Control and Prevention (CDC) recommend the intramuscular administration of 2.4 million units of benzathine penicillin G in 1 dose for those, pregnant or nonpregnant, in whom syphilis has been diagnosed within the preceding year. Syphilis is a bacterial infection, usually spread by sexual contact. This treatment has been found effective for pregnant women and newborns. Diagnosis of syphilis and no allergy to penicillin should be verified before

medication is administered. Sexual partners should be screened and tested to prevent the spread of syphilis. Untreated syphilis can result in stillbirth, preterm birth, and birth defects.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A 2-year-old child is admitted with multiple fractures and bruises, and abuse is suspected. Which assessment finding supports the nurse's suspicion? Select all that apply. One, some, or all responses may be correct.

Bedwetting Thumb-sucking Difficulty consoling Underdevelopment for age Demands for physical closeness

Rationale Abused children may be difficult to console because they have not had positive past interpersonal experiences. Failure to thrive is often seen in abused children. It results from emotional stress as well as from neglect of physical needs. The task of nighttime bladder training may not be completed until 4 or 5 years of age, and sometimes even later. Thumb-sucking is not noteworthy because many children, not just those who are abused, continue to suck their thumbs for several years.

Abused children do not seek physical closeness because their needs for comfort have not been met in the past.

A toddler is admitted with a temperature of 103.5°F (39.7°C), a runny nose, and a productive cough. Respiratory secretion specimens are sent for culture and sensitivity tests and standard precautions are followed until the results are known. Which other precaution would the nurse implement? Select all that apply. One, some, or all responses may be correct.

Droplet Contact Airborne Neutropenic Restriction of parental visitation

Rationale Because the cause of the child’s diagnosis has not been determined, airborne precautions should be instituted. Droplet precautions would be instituted for pertussis. This child does have a fever, which may be indicative of pertussis. Contact precautions are also necessary until a diagnosis is made. Neutropenic precautions protect an immunosuppressed child from exposure to microorganisms from others.

Restricting parental visitation could lead to separation anxiety and stress on the child. The parents may visit after being taught about the special precautions to be taken.

During a period of heavy play, a first-grader with a known history of anemia complains of feeling "woozy." Which action would be the school nurse’s initial response?

Checking the child’s vital signs

Assisting the child to the health office Having the child breathe spirits of ammonia Sitting the child on a chair until the dizziness subsides

Rationale The child’s immediate physical safety takes priority. The child must sit down to avoid falling. The child’s vital signs will eventually be checked; immediate physical safety takes priority over further assessment. Walking at this time is unsafe. Having the child breathe spirits of ammonia is premature; the subjective symptom of dizziness alone does not warrant this intervention.

Which clinical finding would prompt the nurse to withhold a child's allergy hyposensitization injection?

Wheezing Serous otitis media Allergic conjunctivitis Rash on the face and neck

Rationale The introduction of an additional allergen may increase the severity of the child's respiratory distress and cause a life-threatening reaction. Serous otitis media is a common chronic problem among children; it is insufficient justification for withholding the injection. Conjunctivitis is a sign of an allergic response; the injection should be given as long as respiratory problems are not present. A rash on the face and neck is a sign of an allergic response; the injection should be given as long as respiratory problems are not present.

STUDY TIP: A word of warning: Do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn’t work!

Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.

A preschool-age client is admitted to the medical unit with symptoms of lead poisoning. Which question would the nurse ask to determine the source of the lead?

"What year was your home built?"

"Do you have plants in your home?"

"Does your child consume fish in the diet?"

"Where do you store your cleaning solutions?"

Rationale Homes built before 1978 are often painted with lead-based paint, which increases the risk for lead poisoning; therefore, this is an appropriate question for the nurse to ask the parents of this client. Plants, fish, and cleaning solutions are not associated with lead poisoning.

Which action would the public health nurse take to enhance primary prevention efforts in the described community?

Provide pedestrian and motor vehicle safety education to local community residents.

Advocate to local community leaders to prioritize the area for infrastructure improvements.

Collaborate with the local street department to place signage warning community members about unsafe sidewalks.

Allocate health department funds to provide care for community residents who have suffered injuries from motor-vehicle accidents.

Rationale It is important for public health nurses to advocate on behalf of vulnerable populations, in this case for improved infrastructure to provide safe places for community members to be physically active. Although pedestrian and motor vehicle safety may be helpful, it does not address the root cause of the issue in this community. Placement of signage warning residents about the unsafe conditions does not address the root cause of the issue. Allocation of funds to provide care for those that have been injured would be considered secondary or tertiary prevention.

Which intervention by the nurse would be beneficial to promote a healthy lifestyle in an older adult client who lives alone at home and refrains from physical activity for fear of falling when walking ? Select

all that apply. One, some, or all responses may be correct.

Instruct the client to apply bedside rails.

Encourage the client to wear nonskid shoes.

Suggest that the client use an assistive device.

Ask the client to install handrails in the bathroom.

Help the client rearrange furniture in the house.

Rationale The nurse would encourage the client to wear nonskid shoes that provide a firm grip while walking and help reduce the chance of falls. The nurse would suggest that the client use an assistive device such as a cane or walker for support while walking. The nurse would make environmental changes by helping the client rearrange the furniture in the house. This will help reduce the incidence of falls within the house. These interventions reduce the fear of falling and encourage the client to participate in physical activity indoors and outdoors. The bedside rails protect the client from falling from the bed. The handrails in the bathroom assist provide support while using the bathroom.

Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

Nurses providing care for a client who had a skin graft applied over a full-thickness burn on the chest monitored the donor site during the first 24 hours after surgery. Which observation would the nurse report to the primary health care provider immediately?

Small amount of yellowish-green oozing

Moderate area of serosanguineous oozing Epithelialization under the nonadherent dressing Separation of the edges of the nonadherent dressing

Rationale Any amount of yellowish-green oozing indicates infection and should be reported immediately. Serosanguineous oozing is expected. Epithelialization under the nonadherent dressing indicates healing and is desirable. Separation of the edges of the nonadherent dressing is not a problem.

STUDY TIP: Determine whether you are a "lark" or an "owl." Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an arbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each day for study.

Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.

Which client requires immediate treatment based on condition after a lightning strike?

A B C D

Rationale Lightning strikes can cause cardiopulmonary arrest due to the effect of a massive electrical current discharge on the cardiopulmonary system. Client A should be

treated first. Mottled skin and decreased peripheral pulses arise due to arterial vasospasm and resolve spontaneously in several hours. Client B can be treated after client A is treated. A lightning strike can result in temporary paralysis that affects the lower limbs to a greater extent than the upper limbs, but client C does not require immediate treatment. A client with post-traumatic stress disorder can be treated after clients A, B, and C.

The nurse is caring for the newborn of a drug-addicted mother with suspected cytomegalovirus disease. Which etiology would the nurse suspect was the cause of the disease?

Handling a cat litter box Drinking contaminated water Having sex with many partners Eating inadequately cooked meat

Rationale Cytomegalovirus has been recovered from semen, vaginal secretions, urine, feces, and blood; it is commonly found in clients who have human immunodeficiency virus. Toxoplasmosis can be contracted from contaminated cat litter. Contaminated water is associated with hepatitis type A. Toxoplasmosis can be contracted from inadequately cooked meat.

Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to 2 minutes.

The nurse is caring for a client taking a selective serotonin reuptake inhibitor (SSRI) for depression. Which statement by the client requires additional teaching?

"I should take the medication at the same time daily."

"I can stop taking this medication when I feel better."

"I will exercise to control any weight gain the medication may cause."

"I need to report any agitation I experience to the health care provider."

Rationale Clients should never abruptly discontinue an SSRI, because this can cause withdrawal syndrome. The symptoms of withdrawal include dizziness, nausea, sensory disturbances, and dysphoria. Clients will be instructed to take the medication at the same time every day, to increase exercise if the medication contributes to weight gain, and to report any increase in anxiety or agitation to the health care provider.

Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.

The nurse is reviewing the medical record of a client taking lithium for the management of bipolar disorder. Which finding indicates safe therapeutic levels of the medication?

0.3 mEq/L 0.7 mEq/L 1.0 mEq/L 1.7 mEq/L

Rationale

Health care providers prefer lithium levels to be between 0.6 and 0.8 mEq/L. Therefore 0.7 indicates therapeutic safe medication levels. A lithium level of 0.3 mEq/L is subtherapeutic. Lithium levels between 0.8 to 1.0 mEq/L can have more adverse effects. A lithium level of 1.7 mEq/L is significantly toxic and unsafe.

Which food can cause a hypotensive crisis in clients taking monoamine oxidase inhibitors (MAOIs)? Select all that apply. One, some, or all responses may be correct.

Figs Apples Yogurt Pepperoni Cheddar cheese

Rationale MAOIs can cause a life-threatening hypertensive crisis when combined with tyramine. Clients will be instructed to avoid foods that contain tyramine including figs, fermented meats such as pepperoni, and aged cheeses such as cheddar cheese.

Apples and yogurt do not contain tyramine.

Which parental occupations would require the nurse to closely monitor a toddler for lead toxicity? Select all that apply. One, some, or all responses may be correct.

Ceramics Radiator repair Health care

Bridge repair Brass foundry work

Rationale Parental occupations that may place a toddler at risk for lead toxicity include ceramics, radiator repair, bridge repair, and brass foundry work. Health care work does not lead to an increased risk for lead toxicity.

Which nursing intervention is appropriate to include in the plan of care when the nurse is transferring a client with a diagnosis of pheochromocytoma from the bed to a chair?

Supporting the client on the weak side Ensuring that the chair is close to the client's bed Placing sturdy shoes with rubber soles on the client's feet Having the client sit on the side of the bed for a few minutes before the transfer

Rationale Having the client sit on the side of the bed for several minutes allows time for the blood pressure to adjust to the vertical position; this avoids dizziness and the potential for fainting or falling. The nurse would stand in front of the client to provide support when transferring any client from the bed to a chair. Once the client is safely standing, the client can walk to a chair in the room no matter where it is positioned. Although sturdy shoes with rubber soles are ideal when transferring a client from the bed to a chair, it is not the priority.

A student reports that his mother beat him and that he has bruises on

A student reports that his mother beat him and that he has bruises on his back and shoulders. Which initial nursing action is priority?

Notifying Child Protective Services Reporting this information to the principal Calling the parents to arrange a conference Assessing the child for the presence of bruises

Rationale The nurse must validate the presence of physical injury and potential abuse before initiating other interventions. Child Protective Services, the school principal, and the parents should not be notified until signs of possible abuse are verified.

Which assessment question would the nurse ask before administering a monoamine oxidase inhibitor (MAOI) to a client with depression?

Select all that apply. One, some, or all responses may be correct.

"Do you eat bananas?"

"Do you use any illegal drugs?"

"Do you take any allergy medications?"

"Do you eat dairy products like cheese and sour cream?"

"How many alcoholic beverages do you consume each week?"

"How many caffeinated beverages do you drink on a daily basis?

Rationale Serious drug interactions can occur with MAOIs including hypertensive crisis, CNS depression, and anticholinergic reactions. Clients taking MAOIs must adhere to

dietary and medication restrictions to avoid unwanted side effects. Bananas, strong or aged cheeses, alcoholic beverages, pickles, smoked meats, and caffeinated foods all contain tyramine, an amino acid that increases blood pressure. If a client taking an MAOI eats high-tyramine foods, tyramine can quickly reach dangerous levels and cause a serious spike in blood pressure. MAOIs should not be combined with any other psychoactive substances including those found in illegal drugs. MAOIs may increase the effect of antihistamines used for allergies.

Which statement would the nurse include when providing suicide prevention teaching?

"Only psychotic or depressed people commit suicide."

"Suicide only occurs in the lower socioeconomic classes."

"It is harmful to discuss the subject of suicide with clients."

"Suicidal behavior is the leading cause of psychiatric hospitalization for young children."

Rationale There are many myths about suicide. When teaching on the subject, the nurse would provide the facts as well as dispel common myths and misunderstandings about suicide. It is a fact that suicide is the third leading cause of death in persons 15 to 24 years of age, and the rate for children ages 10 to 14 years of age has doubled since 1980. The nurse would include the statement that suicidal behavior is the leading cause of psychiatric hospitalization for young children. Mental illness, particularly depression, is a high-risk factor for suicide, but not all suicidal persons are depressed. Poverty is a risk factor, but suicide occurs in all socioeconomic classes. The nurse demonstrates interest and concern by discussing suicide with clients who are at risk; this is usually beneficial to these individuals.

The nurse is working with a client who is crying and very upset. The

client states, "I don’t want to talk about it; it is too painful." Which question would the nurse ask to obtain the most information about the client’s safety?

"Is there anyone I can notify of your condition?"

"Do you belong to any churches in the area that could help?"

"Do you feel that your life is in danger where you live?"

"Have you ever thought about going to a safe house?"

Rationale The nurse would ask about safe living conditions to determine if the client feels their life is in danger in the home. The questions regarding asking about notifying someone of the client’s condition and about church membership will assess situational support systems. Asking about going to a safe house would be appropriate if the client is found to be in actual danger.

The nurse manager is discussing ways to maintain staff safety in a client mental health unit. Which action by the nurse indicates a need for further education?

The nurse wears stethoscope around the neck.

The nurse moves furniture and removes obstacles in area.

The nurse removes items from the area that can cause harm.

The nurse stands away from the doorway when talking with a client.

Rationale The nurse would never wear a stethoscope or anything around the neck. The client

may grab this and use it to harm the nurse. This nurse’s action requires further education. The nurse would move furniture and remove obstacles to prevent injury if client behavior escalates requiring physical intervention. The nurse would remove items from the area that a client can use to harm others. The nurse would refrain from blocking the doorway when talking with clients. This could be considered hostile by the client.

Which scenarios are examples of the Quality and Safety Education for Nurses (QSEN) competency called quality improvement? Select all that apply. One, some, or all responses may be correct.

The nurse studies old medical cases about clients with Alzheimer disease before formulating the care plan for a client.

The nurse prepares a graph to compare the effectiveness of regular nursing practice with traditional health care practices.

The nurse demonstrates the method of using electronic health records to assure a client about confidentiality of the records.

The nurse designs a new method for ensuring surgical asepsis on the basis of information obtained from facility administrators.

The nurse prepares a flow chart to show the decline in client injuries after implementing a weekly client education program on the use of nurse call lights.

Rationale According to the Quality and Safety Education for Nurses (QSEN) competency called quality improvement, the nurse would use data to monitor the outcomes of care processes. The nurse would also use improvement methods to design and test changes to improve the quality of health care services. The nurse who uses data to compare the effectiveness of two different types of health care practices is an example of quality improvement. The nurse who complies with quality

improvement would design a method of ensuring surgical asepsis to bring about a qualitative change in health care delivery. After implementing a weekly client education program about the use of nurse call lights, the nurse notes a decline in client injuries. The nurse then prepares a flow chart to show the improvement in the safety of the health care delivery system. This is another example of quality improvement. The nurse adheres to evidence-based practice by referring to old cases of Alzheimer disease to formulate a care plan for a new client. The concept of informatics requires the nurse to use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making. The nurse complies with this competency by demonstrating to a client that the proper use of electronic health records helps in maintaining confidentiality of medical information.

Which action would the nurse take when the depressed, suicidal client becomes more energized and communicative?

Continue to assess the client at regular intervals.

Encourage the client to participate in group activities.

Give the client more autonomy to decide about privileges.

Begin to teach the client about medications in preparation for discharge.

Rationale The nurse would continue to assess the client at regular intervals. Although the client appears to be improving, the possibility of suicide is still present, because the client’s physical and psychic energy has increased. Although the client may now be able to participate more fully in groups, the safety issue of monitoring the client’s mood and actions is the priority. It is too soon to increase privileges; the client’s increase in physical and psychic energy may permit the client to act on suicidal thoughts. It is too soon to start teaching the client about medications in preparation for discharge. Discharge would not be indicated until the possibility of suicide has

been resolved.

Which question is the priority for a client diagnosed with bipolar disorder who discloses a variety of chronic health and social issues?

"What do you mean when you say that you don't want to see another day?"

"Would you be willing to cut back on your smoking if you can't stop entirely?"

"Would you like to join a diabetic support group that deals with long-term issues?"

"Have you spoken to a social services representative about your financial issues?"

Rationale Depression is a condition that is often challenging for a client with bipolar disorder.

With depression comes the possibility of suicidal ideation. The client's statement could be interpreted as hopelessness and warrants further investigation to identify any risk of self-harm. Smoking, especially in the presence of chronic obstructive pulmonary disease, and uncontrolled diabetes pose risks; but risk for suicide takes priority over these chronic health problems. Financial counseling can be arranged after priority issues are addressed.

Which statement by the student nurse requires further teaching about which action would be provided for a client who survived an earthquake and presents with abdominal trauma to the emergency department?

"I should ensure a patent airway."

"I should provide fluid replacement therapy."

"I should remove an impaled object immediately."

"I should insert a nasogastric tube to decompress the stomach."

Rationale An impaled object should not be removed until skilled care is provided because it may increase the risk of bleeding. A patent airway should be established to ensure adequate breathing. The client should be provided with fluid replacement to prevent hypotension. A nasogastric tube is inserted to decompress the stomach and to prevent aspiration.

Test-Taking Tip: When a question stem asks for statements by a client, nurse, or student nurse that would indicate the need for further teaching or learning, the question is asking you to pick out the incorrect or wrong response(s), which would require further teaching or learning. When the question stems uses the term effective teaching or learning, the question is asking for you to identify the correct response(s). Read questions carefully to determine if they are asking you to find the correct answers that indicate effective learning or the incorrect answers that require further client or student nurse teaching or learning.

Which information would the nurse include in the teaching plan for a community education session about the family emergency preparedness kit? Select all that apply. One, some, or all responses may be correct.

The kit should be sufficient for 1 day.

Matches should be included in a waterproof container.

Cereal bars and peanut butter crackers should be included.

Insect repellents and deodorants should be avoided.

Household liquid bleach and resealable plastic bags should be included.

Rationale The family emergency preparedness kit provides basic supplies in the event of unexpected dangers such as natural disasters. While preparing this kit, the individual should include matches in a waterproof container. Nonperishable foods such as cereal bars and peanut butter crackers should also be kept in the kit.

Household liquid bleach can be included and used for disinfection, and resealable plastic bags should be also be kept in the kit. The family emergency preparedness kit should be sufficient for at least 3 days, not 1 day. Insect repellents and

deodorants should be included in the kit.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A client and a relative had a fight, and the client is now lying unconscious on the floor. Which action would the nurse take?

Ask the client if the client is okay.

Place a call to security from inside the client’s room.

Find out if there is anyone else in the room.

Call security from outside the client’s room and ask them to make sure the room is safe.

Rationale Safety is priority when responding to a presumably violent situation. The nurse needs to have security enter the room first to ensure it is safe. Then it can be determined if the client is okay and ensured that any other people in the room are safe.

Which important component is included in the nurse's advocate role for a victim of intimate partner violence (IPV)? Select all that apply.

One, some, or all responses may be correct.

Planning for future safety Normalizing victimization Validating the experiences

Promoting access to community services Providing housing for the victim

Rationale The nurse would include planning for future safety, validating the experiences, and promoting access to community services. Planning for the client’s future safety needs, validating the client’s experiences by letting the victim know that he or she is not alone, and promoting access to community services are all important roles of the nurse advocate. An advocate would not normalize the victimization by seeing the abuse as normal in the victim’s relationship and failing to respond to the disclosure of the abuse. The advocate role would include information and resources for housing if needed, but not necessarily provide it.

Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function.

Which nursing interventions would be appropriate for clients who have absent breath sounds because of suffocation due to smoke inhalation during a fire ? Select all that apply. One, some, or all responses may be correct.

Using the jaw-thrust maneuver Preparing to intubate Removing or suctioning any foreign bodies Preparing for needle thoracostomy and chest tube insertion Inserting oropharyngeal or nasopharyngeal airway, endotracheal tube, and cricothyroidotomy

Rationale Suffocation occurs due to lack of oxygen supply to the body. Preparing for intubation is necessary when there is severe respiratory distress or arrest. Needle thoracostomy and chest tube insertion is performed to reduce the pneumothorax tension that may occur in the event of absent breath sounds. Jaw-thrust maneuver is used to open the airway of an unconscious client when there is a neck or spinal injury, not during respiratory distress. Removing or suctioning foreign bodies is performed when assessing the airway with simultaneous cervical spine immobilization. Intubation is not within the scope of practice for registered nurses in all states.

Test-Taking Tip: Try to focus on the meaning of the suffocation. Use your logical thinking and basic understanding of the concept to find the suitable intervention and answer accordingly.

How would the hospital management use the information that a group of 100 bomb blast victims were admitted to the hospital within an hour of the event?

Arrange surgery facilities for 50 victims.

Arrange beds for at least 20 more victims.

Prepare staff to treat 100 more clients.

Shift the 100 existing clients to other hospitals.

Rationale Hospital management can anticipate the total number of victims of a disaster by doubling the number of victims who arrive in the first hour. They should prepare staff to treat 100 additional clients. Generally, half of the victims require surgery

within 8 hours; therefore the hospital management should arrange surgery facilities for at least 100 victims. Generally, 30% of total victims require admission to the hospital; therefore the hospital staff should arrange extra beds for 60 victims (30/200 × 100 = 60). Shifting the 100 existing clients is not appropriate, because other hospitals may also be taking in victims.

Test-Taking Tip: Choose the best answer for questions asking for a single answer.

More than one answer may be correct, but one answer may contain more information or more important information than another answer.

Which emergency department nursing intervention is the priority for victims of a mine explosion who were exposed to dynamite and have injuries caused by a supersonic over-pressurization shock wave?

Administering whole blood as needed Administering intravenous antibiotics as prescribed Assessing liver, long bones, and eyes immediately Assessing lung, gastrointestinal tract, and middle ear injuries immediately

Rationale Explosive devices such as dynamite cause blast injuries that result from the exposure to supersonic over-pressurization shock waves. The wave mainly affects the lungs, gastrointestinal tract, and middle ear of the victims. The nurse first assesses lungs, gastrointestinal tract, and middle ear. The nurse can administer whole blood to the victims as needed but only after assessing lungs, gastrointestinal tract, and middle ear. The nurse can administer intravenous antibiotics as prescribed but only after assessing the lungs, gastrointestinal tract, and middle ear. The nurse can assess liver, long bones, and eyes after assessing the lungs, gastrointestinal tract, and middle ear.

STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.

Which recommendation would the nurse make to the parent of a school-age child regarding medication safety?

"Inform the child that the medicines are bitter."

"Avoid taking medications in front of the child."

"Store medications in a locked storage container."

"Keep all the medications out of the child's reach."

Rationale The school-age child is at risk of being poisoned if there is ingestion of any drugs or medications. The nurse would recommend storing all medications in a locked container or cabinet. Telling the child that the medicines are bitter is not an effective suggestion. Instead, the parent should teach the child about the risks of consuming the medication. The parent can take the medication in front of the child as this does not increase the risk of an ingestion. Keeping the medications out of reach is insufficient, as a school-age child could easily climb to reach the medications.

Which nursing intervention is priority, after collaborating with the emergency response team, for a group of clients admitted to the emergency department after a radioactive explosion in a uranium mine?

Arranging blood transfusions for the clients immediately Starting intravenous fluid administration immediately

Removing client’s clothes and showering clients immediately Performing total body assessment of clients immediately

Rationale Clients who have been exposed to a radioactive explosion may carry radioactive substances along with them and pose danger to other clients and hospital staff. The emergency department staff should first implement decontamination measures such as removing the clothes and showering the clients to reduce the risk. The emergency department nurse can arrange blood transfusions for the clients but only after implementing the decontamination measures. The emergency department team can start intravenous fluids to the clients only after showering the clients. The emergency department staff can perform total body assessments to clients only after implementing decontamination measures.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which clinical finding demonstrates to the nurse that the client can use a standard walker?

Weak upper arm strength and impaired stamina Weight bearing as tolerated and unilateral paralysis Partial weight bearing on the affected extremity and kyphosis Strong upper arm strength and non–weight bearing on the affected extremity

Rationale A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non–weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.

The nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which safeguard would the nurse take during this procedure?

Droplet precautions Reverse isolation Surgical asepsis Medical asepsis

Rationale Catheter insertion requires the procedure to be performed under sterile technique.

Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving.

Which assignments are appropriate when the head nurse of the emergency department (ED) is assigning duties to volunteer nurses to

care for a group of clients injured in a mass casualty situation? Select all that apply. One, some, or all responses may be correct.

The general staff nurse would organize nursing services.

The trauma nurse manager would organize ancillary services.

The medical-surgical nurse would recommend clients for discharge.

The ED nurse leader would direct the ancillary departments to deliver supplies.

The hospital nurse leader would identify clients who can be transferred out of the unit.

Rationale While caring for clients after a disaster, the trauma nurse manager would help in organizing ancillary services to meet client needs. The medical-surgical nurse would collaborate with the primary health care provider in recommending clients for discharge to free inpatient beds. The ED nurse leader would direct the ancillary departments to deliver supplies to meet service needs. The general staff nurse would organize nursing services to provide care for stable emergency department clients. The hospital nurse leader would direct the ancillary departments to deliver supplies, medications, food, instrument trays, and personnel to meet service needs.

Which statement from the student nurse indicates effective learning about maintaining hygiene in a community disaster area?

"I should dispose of human waste bags away from the resident areas."

"I should use sterilizing ultraviolet pens to control odor of human waste bags."

"I should instruct residents to mix toilet chemicals into the bag to avoid a toxic reaction."

"I should encourage digging a pit to serve as an improvised toilet in an austere environment."

Rationale Human waste management is a challenge to maintain hygiene in disaster areas. The nurse would encourage digging a pit in the ground to be used as an improvised toilet in an austere environment. The human waste should be buried in the ground.

Chlorine bleach is added to human waste bags to control odor. The nurse would instruct the residents not to mix toilet chemicals into the bag to avoid toxic reactions.

Test-Taking Tip: When a question stem asks for statements by a client, nurse, or student nurse that would indicate the need for further teaching or learning, the question is asking you to pick out the incorrect or wrong response(s), which would require further teaching or learning. When the question stems uses the term effective teaching or learning, the question is asking for you to identify the correct response(s). Read questions carefully to determine if they are asking you to find the correct answers that indicate effective learning or the incorrect answers that require further client or student nurse teaching or learning.

The nurse would plan to discharge which clients to free up inpatient beds for other disaster victims? Select all that apply. One, some, or all responses may be correct.

Those who can be treated in long-term care Those who can be cared for in rehabilitation Those clients admitted for observation who are bedridden Those with no critical change in condition for the past 3 days Those who have diagnostic evaluations and are bedridden

Rationale Medical-surgical unit nurses, in collaboration with health care providers, decide to recommend clients for discharge to free inpatient beds for disaster victims. Clients who can be treated in long-term care and who can be cared for in rehabilitation should be discharged. Clients who have had no critical change in condition for the past 3 days should also be discharged to free up inpatient beds for disaster victims.

Clients who are admitted for observation and are not bedridden can be discharged.

Clients who have diagnostic evaluations and are not bedridden can be discharged.

Which statement about the psychosocial response of clients when assessing survivors of a mass casualty event made by the nurse executive indicates the need for further explanation?

"I should establish a rapport through honest communication."

"I should use the Impact of Event Scale-Revised in clients with short-term memory loss."

"I should determine the client’s reading level before giving the Impact of Event Scale-Revised tool."

"I should refer the clients with a high score on the Impact on the Event Scale-Revised to a psychiatrist."

Rationale The use of the Impact of Event Scale-Revised (IES-R) scale should be avoided in clients with short-term memory loss. The nurse should establish a rapport through honest communication to help the survivors of a mass casualty event. Determining the client’s reading level is important before giving IES-R tool because it is written at the tenth-grade reading level. The clients with high score on the IES-R are to be referred to a psychiatrist.

Test-Taking Tip: The IES-R is a tool that can be used to assess survivor response to a disaster provided they are cognitively able to respond to questions.

A client with hyperthyroidism has been treated with radioactive iodine ( 131I) to destroy overactive thyroid gland cells. To reduce radiation exposure, which would the nurse consider when providing care?

Wearing a lead-shield apron at all times Limiting time with and increasing distance from the client Wearing a radiation meter to measure exposure Remaining at least 6 feet (1.8 m) away from the client at all times

Rationale When caring for clients who are radioactive, the three most important concepts for reducing radiation exposure are to limit exposure time, increase distance, and use shielding. In this situation, time and distance provide the best reduction in radiation exposure. Wearing a lead-shield apron will help prevent radiation exposure, but time and distance are the first priorities. A radiation meter measures exposure, but does nothing to protect caretakers. Remaining at least 6 feet (1.8 m) away from the client at all times is not a practical approach.

Which factors will influence the amount of psychological stress community members might experience after flooding and building damage caused by a category 4 hurricane? Select all that apply. One, some, or all responses may be correct.

Type of disaster Age of the community members Financial status and employment

Previous medical and psychological histories Preexisting mechanisms to cope with disasters

Rationale All disasters result in psychological stress, which is influenced by the type of disaster, the age of the individuals who are affected by the disaster, the medical and psychological histories of the people affected by the disaster, and preexisting coping mechanisms of the people affected by the disaster. Financial status and employment are not identified as influencing factors of psychological response after a disaster.

In which situation would activation of the emergency preparedness plan be necessary? Select all that apply. One, some, or all responses may be correct.

19 victims of a collapsed pleasure boat brought to a community hospital at 1 AM Saturday 5 victims of suspected food poisoning are brought to an urban hospital at 2 PM on Tuesday 75 victims of a manufacturing plant explosion are brought to an urban hospital at 3 AM on Friday 25 victims of a bus accident are brought to a community hospital for treatment on Christmas morning 30 victims of a fire in a senior citizen’s housing facility brought to a community hospital at 5 PM Monday

Rationale When the number of casualties exceeds the usual resource capabilities, a disaster situation exists. The pleasure boat victims are being taken to a community hospital

on a Saturday night when staffing is typically lower. Likewise, the victims of a manufacturing plant explosion are being taken to an urban hospital during the time of lower staffing. The victims of a bus accident are being taken to a community hospital on a holiday, during which staffing is generally lower. The number of victims from a senior citizen’s housing facility fire is large and could overwhelm available resources at the community hospital. The victims of food poisoning can easily be taken care of by existing staff and resources at an urban hospital on a weekday afternoon.

Which technique would the nurse use to maintain surgical asepsis?

Change the sterile field after sterile water is spilled on it.

Put on sterile gloves before opening a container of sterile saline.

Place a sterile dressing no more than half an inch from the edge of the sterile field.

Clean the surgical area with a circular motion, moving from the outer edge toward the center.

Rationale A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick and allow microorganisms to contaminate the sterile field. The outsides of containers and packages are not considered sterile and sterile gloves are considered contaminated when touching either of these items. Items on the sterile field should be no less than 1 inch from the outer border or edge of the sterile field; any less is not considered sterile. Surgical areas or wounds should be cleaned from the inside edges to the outside edges to prevent recontamination.

Which clients would the medical-surgical nurse identify as appropriate for transfer or discharge to make room for admission of

victims of a disaster? Select all that apply. One, some, or all responses may be correct.

68-year-old client on the third postoperative day since total knee replacement 30-year-old client receiving intravenous insulin for diabetic ketoacidosis 55-year-old client with bleeding esophageal varices receiving iced lavage 80-year-old client being regulated on medication for transient ischemic attacks 72-year-old client beginning oral anticoagulant therapy for a deep vein thrombus

Rationale Clients who are not acutely ill, are stable for transfer to rehabilitation, or have had no critical change in health status for 3 days would be eligible for discharge or transfer to another facility. The client recovering from total knee replacement surgery can be transferred to rehabilitation. The client with transient ischemic attacks can be discharged to home. The client beginning oral anticoagulant therapy for a deep vein thrombus can be discharged to home. The client receiving insulin for diabetic ketoacidosis is unstable and should not be discharged. The client with bleeding esophageal varices is acutely ill and should not be discharged.

The nurses who work in which areas would be the safest to reassign to assist with acute care of trauma victims coming through the emergency department (ED)? Select all that apply. One, some, or all responses may be correct.

Intensive care Postanesthesia care unit

Skin and wound care clinic A general medical-surgical care area A chemotherapy infusion center

Rationale Nurses who care for critically ill clients such as the intensive care nurse and the postanesthesia care unit nurse are the most qualified to assist with acute care of trauma victims in the ED. The skin and wound care, general medical-surgical, and intravenous infusion nurses are less qualified to provide care to trauma victims in the ED.

Which individual would be an appropriate member of a critical incident stress debriefing (CISD) team for a group of staff nurses?

Select all that apply. One, some, or all responses may be correct.

Staff nurse Organization chaplain Organization media representative Primary health care provider trained in critical debriefing Advanced practice mental health nurse

Rationale The CISD team includes a peer member of the group being debriefed. For this group, the CISD team would include a staff nurse. The team may include a primary health care provider trained in critical debriefing. The team leader would be someone with a background in mental or behavioral health. This role would be appropriate for the advanced practice mental health nurse. The chaplain and the

media representative are not identified as being appropriate for the CISD team.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

The nurse teaches a client who is concerned about hepatitis transmission routes. Which type of hepatitis spreads more frequently through food?

A B C D

Rationale An RNA virus transmits hepatitis A, also known as an infectious hepatitis, via the fecal-oral route, most frequently though food. Hepatitis B transmission occurs parenterally, sexually, and by direct contact with infected body secretions. An RNA virus causes hepatitis C and is transmitted parenterally. Hepatitis D is a complication of hepatitis B.

Which would the nurse assess using the PASS acronym to prevent aspiration pneumonia in a client with stomatitis? Select all that apply.

One, some, or all responses may be correct.

Is the client’s airway open?

Does the client have any difficulty swallowing?

Does the client have a history of trouble swallowing?

Has a speech language-pathologist been consulted?

Does the client have any signs or symptoms of dysphagia?

What have been the client’s dietary intake patterns?

Rationale The acronym PASS is used for a fast assessment of a client’s swallowing ability. The acronym stands for Probability of difficulty swallowing, Account for prior swallowing issues, Screen for signs and symptoms of dysphagia, and Speech-language pathologist referral. The acronym does not include the physical assessment of the airway nor dietary intake patterns.

The nurse has taught newborn care and safety to a group of expectant mothers. Which statement by a mother indicates the need for additional teaching?

"I need to put my baby to bed on his back."

"I need to toddler-proof my house when the child starts crawling."

"My baby could choke on any small object that will fit in her mouth."

"I’ll keep my baby in a backward-facing car seat until he’s a year old."

Rationale New guidelines recommend keeping a child in a backward-facing car seat until 2 years of age. Putting a baby to bed in the supine position will reduce the risk of sudden infant death syndrome. The house should be toddler-proofed when the child starts crawling. Choking is a major hazard for the young infant, who will place anything at hand in the mouth.

STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

Which type of injury would be deferred for later treatment during a mass casualty event when the nurse on a community terrorism response team is reviewing triage protocols?

Multiple fractures Closed head injury Internal abdominal trauma Radiation/chemical exposure

Rationale Individuals with serious head injuries are not treated immediately during mass casualty events because the need in those situations is to treat the largest number of people who have the least severe injuries and make the best use of limited resources. People with fractures or survivable radiation or chemical exposures or those requiring uncomplicated abdominal surgeries are treated during mass casualty events.

STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.

Which teaching point regarding safety would the nurse include for

the parent of a school-age client who is a latchkey child?

"Consider getting a guard dog type pet for your child."

"Plan play dates for your child to attend on afternoons you are not home."

"Teach your child not to display the keys used to enter the home after school."

"Provide structured activities for your child to complete while they are home alone."

Rationale Teaching the child not to display the house keys used to enter the home after school is a safety teaching point the nurse would include in the teaching session. Planning for play dates on afternoons the parent will not be home is an important point to emphasize in regards to after-school activities. Getting a pet is a teaching point directed towards decreasing the child’s loneliness while home alone. Providing structured activities for the child is an important point to emphasize regarding after-school activities, not safety.

Which element would the nurse use to integrate evidence in the clinical practice setting? Select all that apply. One, some, or all responses may be correct.

Verbal mandates Financial incentives New assessment tools Clinical practice guidelines Organization policies and procedures

Rationale Evidence is integrated in a variety of ways through new assessment tools, clinical practice guidelines, organizational policies and procedures, new documentation tools, and teaching tools. Verbal mandates, or communicating mandatory behaviors verbally, are not an effective way to institute new evidence into clinical practice.

Financial incentives have not been proven to be effective.

According to the Institute of Medicine (IOM) report in 2011 on envisioning a transformed health care delivery system, which transformation in nursing practice would need to take place? Select all that apply. One, some, or all responses may be correct.

Nurses would need to practice to the full extent of their education and training Nurses would need to achieve higher levels of education and training through improved programs Nurses would need to make quality care affordable for people, families, employers, and governments Nurses would need to become full partners with other health care providers in redesigning the health care system Promote cost-effective prevention, treatment, and intervention practices for cardiovascular disease

Rationale According to the 2011 IOM report, nurses need to be transformed by practicing to the full extent of their education and training, achieving higher levels of education and training through an improved education system that provides seamless progression, and becoming full partners with physicians and other health care providers in redesigning the health care system. Making quality care affordable and

promoting cost-effective preventative, treatment, and intervention practices for cardiovascular diseases are national priority goals.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

The nurse is caring for a toddler receiving chelation therapy and intravenous deferoxamine. Which assessment finding would the nurse be most concerned about?

Fever Emesis Red urine Facial flushing

Rationale Intravenous deferoxamine given too rapidly can cause facial flushing, hypotension, rash, urticaria, tachycardia, and shock. The infusion should be stopped immediately, the line maintained with normal saline, and the health care provider notified immediately. A fever and emesis are concerning but are not adverse effects of either chelation therapy or intravenous deferoxamine. Chelation therapy with deferoxamine may turn the urine red to orange.

Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do

not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question.

Which factors contribute to the frequency of iron poisoning in toddlers? Select all that apply. One, some, or all responses may be correct.

Widespread availability Amount of elemental iron ingested Resemblance of iron tablets to candy Lack of parental awareness of the toxicity Packaging of large quantities in containers

Rationale Factors related to the frequency of iron poisoning of a toddler include widespread availability, resemblance of iron tablets to candy, lack of parental awareness of the toxicity, and packaging of large quantities in containers. The amount of elemental iron ingested is associated with the toxicity and is not identified as a factor related to the frequency of iron poisoning.

Which education would the nurse provide the parent of a toddler about caring for their child during and after treatment for a pinworm

(Enterobius vermicularis) infestation? Select all that apply.

How to identify pinworm eggs Strategies to prevent reinfestation The need for medication for the entire family The importance of hand washing before eating The reason for obtaining stool specimens from the child

Rationale Reinfestation is common because pinworms easily spread to family members who are in close contact with the child. All family members must take the medication to help prevent reinfestation. Toddlers touch dirt and then put their hands in their mouths; hand washing for all family members before eating can help prevent reinfestation. Pinworms, not their eggs, are visible to the naked eye. There is no reason to obtain a stool specimen from the child because the diagnosis is confirmed. The diagnosis is made with a tape test, not a stool specimen.

Which would the nurse emphasize when teaching insulin selfadministration to a child with recently diagnosed diabetes?

The need to wash the hands before preparing the insulin injection The need to shake the bottle of insulin thoroughly before drawing up the dose The need to alternate the sites of the insulin injections among the four extremities The need to rub the injection site briskly for half a minute after giving the injection

Rationale Thorough hand washing is the best infection-prevention technique and should always precede preparation of an injection. Shaking insulin causes air bubbles, which can interfere with preparation of an accurate dose; the bottle should be rolled gently between the palms. Although injection sites should be rotated, the abdomen, not the extremities, is the preferred site for self-administration of insulin. The injection site should not be rubbed, because this will affect absorption of the insulin and cause a reaction at the site.

The nurse counsels a child’s parent about preventive measures associated with accidental poisoning. Which statement by the parent indicates effective learning? Select all that apply. One, some, or all responses may be correct.

"I should refer to medicines as candy."

"I should keep potential poisons out of reach."

"I should not transfer the medication’s contents to another container."

"I should not dispose of all unused and unneeded medications."

"I should securely seal all containers and keep them in a safe place."

Rationale Potentially poisonous substances should always be kept away from the reach of children. Potentially poison contents should not be transferred to alternate containers because of the risks of mislabeling. All containers containing poisons or potential poisons should be properly sealed and locked inside a cabinet to further reduce the accidental exposure. Referring to medication as candy will confuse and tempt the child. All unused and unneeded medications should be disposed in a proper manner to avoid accidental exposure.

The nurse prepares a chart listing the methods of treatment of different types of poisoning in preschool children. Which preschooler’s entry needs to be corrected?

Preschooler A Preschooler B Preschooler C Preschooler D

Rationale Activated charcoal is contraindicated for the treatment of corrosive ingestion because it may infiltrate burned tissue. While treating iron poisoning, whole bowel irrigation may be used if radiopaque tablets are visible on an abdominal x-ray exam.

To treat plant poisoning, the skin or eyes exposed to the poisonous plant should be washed. Metabolic acidosis caused by aspirin poisoning can be treated with sodium bicarbonate transfusions.

The school nurse is teaching a class about bicycle safety. The nurse determines that a child needs further teaching when the child makes which statement?

"I will always wear a helmet and ride with traffic facing me."

"I will always wear a helmet and walk my bike to cross busy streets."

"I will always wear a helmet and keep as close to the curb as possible."

"I will always wear a helmet and stay in a single file when I ride with my friends."

Rationale Bicyclists are required to follow the rules of the road; they must ride with traffic, obey traffic signs and lights, and signal when turning. Walking the bicycle at intersections, riding close to the curb, and staying in single file all help prevent accidents.

Which nursing intervention would be recommended for a client after a radiation implant is inserted as part of internal radiation therapy for cervical cancer?

Ensuring that the client’s diet is low residue

Placing the client in the high-Fowler position Checking the client’s voiding and catheterizing if necessary Staying with the client for half an hour and assessing her for signs of radiation sickness

Rationale Clients with internal radiation for cervical cancer are given a low-residue diet and often medications to suppress peristalsis and prevent pressure from bowel movements. The necessity for this altered diet should be explained to the client. If the head of the bed is elevated, the implant may be dislodged by gravity. A catheter is inserted routinely before loading to prevent bladder distention and possible radiation damage or alteration of implant position. Because the client is the source of radiation, the nurse must limit the time spent with the client to prevent excessive exposure.

Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

Which characteristics of a bully would the nurse include in parental education? Select all that apply. One, some, or all responses may be correct.

Defiant Depressed Aggressive Manipulative Low self-esteem

Rationale Bullies are generally defiant toward adults, manipulative, and have aggressive attitudes. Children who are targeted for bullying often have internalizing characteristics such as depression and low self-esteem.

Which microorganism causes maternal mastitis?

Escherichia coli Group B streptococcus Staphylococcus aureus Chlamydia trachomatis

Rationale Staphylococcus aureus is a resident organism of the skin; it is the causative agent of 95% of the infections that result in maternal mastitis. Escherichia coli is found in the lower intestinal tract; it is not associated with mastitis. Group B streptococcus rarely causes mastitis. Chlamydia trachomatis can cause neonatal pneumonia and conjunctivitis, not mastitis. Frequent hand washing by staff and clients may reduce the risk of infection.

A client with cancer of the cervix has an intracavity radioactive sealed implant in place. Which precaution would the nurse take to protect against excessive exposure to radiation?

Disposing of body fluids in specially marked containers Cohorting two clients who have implanted radiation therapy Leaving used linens in the room until cleared by the Radiation Safety team Encouraging visitors to stay with the client and sit near the lead wall

Rationale Linens should stay in the room until cleared by the Radiation Safety team. The reason is that the sealed implant may have fallen out or been removed by the client and could cause excessive radiation exposure to others if moved out of the room.

When sealed implants are used, body fluids are considered a significant source of radioactivity. Clients undergoing radioactive sealed or unsealed therapy should be in a private room with a private bath. This protects other clients receiving internal radiation from excessive exposure. Children and pregnant women should not visit the client. Visits should last no longer than 30 minutes daily. Visitors should be taught to maintain a 6-foot distance from the source of the radiation. The purpose of the lead wall is to prevent radiation from spreading out of the room. It will not decrease radiation exposure to someone sitting inside the room.

Which method would the nurse use to measure the temperature of a 4-year-old child with leukemia who has mucositis? Select all that apply. One, some, or all responses may be correct.

Digital, rectal Electronic, oral Infrared, tympanic Sensor, ear-based Temporal artery

Rationale The infrared thermometer can be used on the tympanic membrane; it is safe to use for a child with leukemia. Temporal artery thermometers are safe to use and accurate for children with leukemia. Rectal temperature taking is contraindicated in children with leukemia because it may result in trauma to the rectal mucosa. Also,

the use of a rectal probe may be perceived as an intrusive procedure by a 4-year-old.

Most digital thermometers can be used to take oral, axillary, or rectal temperatures.

An oral temperature with an electronic thermometer is not safe for a child with mucositis because of the risk for injury. The ear-based sensor thermometer is used in ambulatory settings; its reliability is a matter of some controversy.

Which parental statement indicates the need for further teaching about the transmission of roundworm?

"The rest of the family won’t need the medicine."

"My little one won’t be able to play in the fields until they gets older."

"We’re going to have to wash everyone’s bedding in soapy water every day."

"We’re going to have to make sure vegetables are well-cooked before we eat them."

Rationale It is not necessary to wash bedding daily because roundworm is not transmitted by fomites. Because the organism is not transmitted from person to person, the family does not have to be medicated. It is advisable to keep small children from playing in areas where there is dirt because young children explore their environment by putting their hands and objects in their mouths. Cooking vegetables should destroy the organism if it is present, so it is advisable.

For which families would the nurse include information on safe sleeping habits as a priority during a scheduled health maintenance visit for a toddler? Select all that apply. One, some, or all responses may be correct.

Irish American

Asian American African American Hispanic American Caucasian American

Rationale Asian American, African American, and Hispanic American families are more likely to co-sleep with their toddlers; therefore, it is essential for the nurse to teach information that enhances safety of this practice. Irish American and Caucasian American clients are less likely to engage in co-sleeping with their children.

Which discharge instructions are appropriate for a client who has undergone uterine artery embolization? Select all that apply. One, some, or all responses may be correct.

"Eat soft, low-fiber foods for 1 to 2 weeks."

"Abstain from vaginal intercourse for 2 weeks."

"Some bleeding and brown drainage should be expected."

"Avoid straining during bowel movements, and take a stool softener if necessary."

"Call the health care provider if you are experiencing any pain, bleeding, or swelling at the puncture site."

Rationale Clients undergoing uterine artery embolization should avoid straining during bowel movements and take a stool softener if necessary. Clients should call their health

care provider if they experience any pain, bleeding, or swelling at the puncture site.

Clients should eat a regular diet, including plenty of fluids and fiber post-discharge.

Vaginal intercourse should be avoided for at least 4 weeks after a uterine artery embolization. Bleeding or brown discharge should be reported to the health care provider and is not normal after a uterine artery embolization.

Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question.

A female client asks the nurse whether she should be tested for osteoporosis. Which statements reflect current advice regarding the prevention of osteoporosis? Select all that apply. One, some, or all responses may be correct.

"A bone mineral density test is the only way to diagnose osteoporosis."

"Everyone with osteoporosis should be treated with bisphosphonates."

"All adults need 1000 mg calcium and 400 to 800 IU of vitamin D each day."

"Women should be evaluated clinically for risk of osteoporosis annually after age 70."

"Postmenopausal women and all adults over the age of 65 should be tested for osteoporosis."

Rationale A bone mineral density test is the only way to diagnose osteoporosis and determine the risk for future fractures. The U.S. Preventive Services Task Force and the National Osteoporosis Foundation recommend testing for all postmenopausal women and all adults over the age of 65. Everyone with osteoporosis will not necessarily be treated with bisphosphonates; many other treatments are available,

including calcitonin, estrogens, estrogen agonist-antagonists, and parathyroid.

Adults under the age of 50 require 1200 mg of calcium and 800 to 1000 IU of vitamin D. All postmenopausal women, regardless of age, should be evaluated clinically for risk of osteoporosis and need for bone mineral density testing.

Which assessment question would help the nurse determine the source of the lead when admitting a toddler with symptoms of lead poisoning?

"What year was your home built?"

"Do you have plants in your home?"

"Does your child consume fish?"

"Where do you store your cleaning solutions?"

Rationale Homes built before 1978 may contain lead-based paint, which increases the risk for lead poisoning; therefore, this is an appropriate question for the nurse to ask the parents of this child. Plants, fish, and cleaning solutions are not associated with lead poisoning.

Which assessment finding indicates to the nurse that an older adult client is at risk for developing an infection? Select all that apply. One, some, or all responses may be correct.

Thin skin Weak cough Sluggish bowel sounds Male-pattern baldness

Indwelling urinary catheter Decreased or absent leg hair

Rationale Thin skin indicates a loss of protection by the integumentary system. A weak cough indicates a loss of protection by the respiratory system. Sluggish bowel sounds indicate a loss of protection by the gastrointestinal system. An indwelling urinary catheter is an invasive device that can introduce microorganisms into the client’s system. Male-pattern baldness does not indicate a loss of protection by a body system. Decreased or absent leg hair indicates decreased perfusion of the extremity and potential arterial involvement.

Which action would the occupational health nurse take that supports secondary prevention efforts to reduce the risk for injury from exposure to contaminated air in the workplace?

Conduct respirator fit tests to ensure proper fit.

Implement annual (or more frequent) respiratory function tests.

Provide training programs to all employees regarding appropriate actions to reduce risks.

Perform compliance checks to ensure employees are wearing the proper protective equipment.

Rationale Screening tests such as respiratory function tests are considered secondary prevention. Ensuring proper fit of respirators, training programs, and compliance checks all support primary prevention efforts.

Which safety measure would the nurse implement when administering methotrexate?

Dispose of gloves used to administer methotrexate in a garbage bag.

Obtain the client’s age for calculation of the dose of methotrexate.

Wear two pair of gloves before removing the syringes from the plastic bag.

Expel additional air from the syringe of methotrexate and prime the needle.

Rationale Two pairs of gloves are worn for safety before removing the syringe of methotrexate from the sealed plastic bag. Gloves used to administer methotrexate are disposed of in a waste container designed specifically for hazardous medications. The dosage of methotrexate is based on the client's height and weight, not age. Additional air should not be expelled from the syringe or the needle primed because the actions could aerosolize the methotrexate.

Which nursing interventions are applicable to a client receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply. One, some, or all responses may be correct.

Restricting visitors Limiting fluid intake Preparing for a precipitate birth Maintaining a quiet environment Keeping magnesium gluconate at the bedside

Rationale Visitors should be limited to significant others to reduce excessive stimuli that could precipitate a seizure. A quiet room helps reduce stimuli and the risk of seizures.

Fluid intake should be restricted as ordered. A precipitous birth is not a usual side effect of magnesium sulfate therapy. Calcium gluconate, not magnesium gluconate, is the antagonist for magnesium sulfate and should be readily available if signs of toxicity appear.

The mother of a 30-month-old toddler who has been treated for pinworm infestation is taught how to prevent a recurrence. Which statement by the mother indicates that the teaching has been effective? Select all that apply. One, some, or all responses may be correct.

"I’ll keep the cat off my child’s bed."

"I’ll disinfect my child’s room every 2 days."

"We’ll need to wash all of our sheets every day."

"I need to tell the school nurse to have the toilets cleaned."

"I’ll have the whole family take the medication again in 2 weeks."

Rationale Washing clothing and bed linens daily will help limit transmission. Medications such as mebendazole, pyrantel pamoate, and pyrvinium are effective but must be repeated in 2 weeks to prevent reinfestation. Cats do not transmit pinworms.

Disinfection of surfaces does not help prevent transmission. Toilets are not the usual mode of transmission; the rectal–oral cycle must be completed for infestation to occur.

Which intervention would the nurse do postoperatively to reduce the

Which intervention would the nurse do postoperatively to reduce the risk of thyroid storm after a client has undergone subtotal thyroidectomy?

Provide a high-calorie diet.

Prevent infection at the surgical site.

Encourage postoperative breathing exercises.

Demonstrate how to support the neck after surgery.

Rationale Conditions such as trauma and infection can precipitate thyroid storm (thyroid crisis, thyrotoxic crisis). A high-calorie diet does not prevent crisis; it restores glycogen reserves depleted by an increased metabolic rate. Postoperative breathing exercises prevent respiratory complications, not thyroid storm. Learning how to support the neck after surgery limits tension on the suture line, thereby decreasing the risk of hemorrhage, not thyroid storm.

Which information about self-care would the nurse include when teaching an adolescent who is undergoing chemotherapy for bone cancer and has stomatitis as a result of chemotherapy? Select all that apply. One, some, or all responses may be correct.

Clean the teeth with a swab.

Drink fluids through a straw.

Brush the teeth three times a day.

Rinse frequently with a mouthwash.

Avoid foods served at extremes of temperature.

Rationale A soft-tipped applicator should be used to help prevent trauma to the oral mucosa.

Drinking fluids through a straw allows the fluid to bypass the sores in the mouth and may be less irritating to the mucosa; it provides comfort. Extremes in temperature may injure the oral mucosa and cause discomfort. Brushing the teeth three times a day will injure the oral mucosa and should be avoided. Rinsing frequently with a mouthwash may irritate the oral mucosa and should be avoided; if mouthwash is prescribed, it should be diluted.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which factors would the nurse consider when assessing a client’s increased risk for suicide? Select all that apply. One, some, or all responses may be correct.

Impulsivity Panic attacks Unemployment Religious beliefs Substance abuse Sense of responsibility to family

Rationale Impulsivity, panic attacks, unemployment, and substance abuse have all been linked with an increased risk for suicide. Religious beliefs and a sense of responsibility to

family are considered protective factors that may decrease the risk of suicide, not increase the risk.

The nurse is caring for a client who had head and neck surgery. Which complication will the nurse try to prevent by positioning the client’s head in functional alignment after surgery?

Cervical trauma Laryngeal spasm Laryngeal edema Wound dehiscence

Rationale Maintaining functional alignment of the head prevents flexion and hyperextension of the neck, both of which place tension on the suture line; tension on the suture line can precipitate wound dehiscence. The cervical vertebrae are designed to flex and hyperextend; there should be no ill effects. Flexion and hyperextension of the neck do not cause laryngeal spasms. Flexion and hyperextension of the neck do not cause laryngeal edema.

Which assessment finding indicates a need to activate the rapid response team when the nurse is caring for a diabetic client with a bacterial infection of the foot?

Hypertonic bowel sounds in all 4 quadrants Blood glucose level 145 mg/dL (8.1 mmol/L) Client report of level 9 pain of the foot (0 to 10 scale) Systolic blood pressure persistently 85 to 90 mm Hg

Rationale Systolic blood pressure less than 90 in a client who is at risk for sepsis (such as this client with a bacterial infection and diabetes) indicates possible sepsis and systemic inflammatory response syndrome (SIRS). The nurse would immediately activate the rapid response team and anticipate collaborative actions such as further diagnostic testing, massive fluid infusion, and administration of vasoconstrictive medications.

Hypotonic bowel sounds may indicate sepsis or SIRS. Blood glucose levels higher than 140 mg/dL (7.7 mmol/L) might indicate sepsis or SIRS in a nondiabetic client, but would not be unusual in a client with diabetes. Level 9 out of 10 pain would require administration of analgesics, but is not as concerning as hypotension and does not require activation of the rapid response team.

Which action would the nurse take for a person hospitalized for alcoholism who becomes boisterous, belligerent, and loud?

Place the client in restraints.

Administer the alcohol withdrawal medication.

Encourage the client to play table tennis with another client.

Set firm limits on the client’s behavior while enforcing adherence to them.

Rationale The nurse would administer the alcohol withdrawal medication. The client is hospitalized for alcoholism and needs the withdrawal medications based upon the client’s behaviors. Restraining a disturbed, belligerent client can result in injury, because restraints generally increase anxiety and acting out. The client’s attention span is too short for table tennis. Any measures directed at verbal or physical correction of the client’s behavior will be ineffective because of the alcohol.

The nurse is applying a dressing to a client’s surgical wound using

The nurse is applying a dressing to a client’s surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field.

Which physical principle causes the sterile field to become contaminated?

Dialysis Osmosis Diffusion Capillarity

Rationale When a sterile surface becomes wet, microorganisms from the unsterile surface below the sterile field will be drawn up, contaminating the sterile field. The absorption of fluids by gauze results from the adhesion of water to the gauze threads; the surface tension of water causes contraction of the fiber, pulling fluid up the threads. Dialysis is separation of substances in solution using their differing rates of diffusion through a membrane. Osmosis refers to movement of water through a semipermeable membrane. Diffusion is movement of molecules from a high to a low concentration.

Which tertiary interventions would the nurse use for a young adult who sustained injuries as a result of physical battering by her partner?

Select all that apply. One, some, or all responses may be correct.

Contacting family members to provide support Discussing the legal ramifications of not pressing charges Offering to discuss the abusive behavior with her spouse Identifying the benefits of attending a support group for battered women

Providing her with information regarding local domestic violence shelters

Rationale Providing information, regarding support groups or local domestic violence shelters, is a tertiary intervention because it is focused on preventing further abuse.

Contacting family members should not be done without the consent of the client; it violates the client’s confidentiality. Discussing legal ramifications is unsolicited advice that is outside the nurse’s scope of practice. Discussions with the partner are not advised because this could worsen tensions and result in additional battering.

Which action describes the process of artificial active immunity?

Antibodies are passed from one person to another.

Antibodies against an antigen are produced naturally in the body.

Antibodies are made after an antigen is injected into the body.

Antibodies produced by one body or animal are transferred to another body or animal.

Rationale Artificial active immunity is the protection developed by vaccination or immunization; the immune system responds by making antibodies. Natural passive immunity occurs when antibodies are passed from one person to another, such as in the case of a mother to the fetus. Natural active immunity occurs when the body responds naturally by making antibodies against an antigen. Passive immunity occurs when the antibodies against an antigen are transferred to a person’s body after first being made in the body of another person or animal.

Test-Taking Tip: Identify option components as correct or incorrect. This may help

you identify a wrong answer.

A client has a large, open abdominal wound. The health care provider’s prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing?

Use two square gauze pads to cleanse the wound, one for each half of the wound.

Apply new Montgomery straps each time the dressing is changed.

Hold the wet gauze with the tips of the forceps higher than the wrist.

Cleanse the wound with wet, sterile gauze from the center of the wound outward.

Rationale Wounds should be cleansed from the center outward or from the top to the bottom; this ensures that cleansing is done from the least to the most contaminated area. A new sterile gauze square should be used for each swipe of the wound. More than two gauze squares will be needed to cleanse a large abdominal wound. Using the same gauze square again will contaminate the wound. Montgomery straps are changed only when they become soiled or begin to loosen from the client’s skin.

Montgomery straps are applied to each side of a wound. The central sections are folded back when the dressing is changed. When folded back in place over the new dressing and secured with a tie, they keep the dressing in place without having to replace the tape each time the dressing is changed. Forceps should always be held with the tips lower than the wrist. If they are held with the wrist lower than the tips of the forceps, cleansing solution can flow down the instrument and the hand and arm of the nurse, contaminating the fluid. When the wrist is then raised above the

forceps, the contaminated fluid will flow back down the forceps into the wound.

A client is admitted to the hospital for the implantation of radon seeds in the oral cavity. Which nursing intervention would be performed after the procedure?

Providing a regular diet within 2 days Administering nursing care for short periods at a time Giving frequent mouth care at least four times daily Encouraging ambulation in the hallway three times daily

Rationale Nursing care should be organized and administered efficiently so that the nurse’s exposure to radiation is kept to a minimum. A regular diet is contraindicated until the radon seeds are removed because chewing can dislodge the seeds. Frequent mouth care is contraindicated because it can dislodge the seeds; drying of the mucous membranes cannot be prevented. The client should not ambulate in the hallway, because this will expose others to radiation.

A client is receiving therapy that includes a radioactive sealed implant.

Which nursing intervention would be implemented to protect against exposure to radiation?

Wearing a dosimeter film badge at all times Limiting exposure to the client to 1 hour daily Using long-handled forceps to retrieve a dislodged implant Ensuring that visitors maintain a minimum distance of 3 feet from the client

Rationale Using long-handled forceps keeps the sealed implant away from the nurse as the implant is retrieved and placed in a lead container kept in the client’s room.

Wearing a dosimeter film badge offers no protection from exposure to radiation; it only measures the nurse’s exposure to the radiation. Exposure should be limited to no more than 30 minutes daily. Visitors should maintain a minimum distance of 6 feet from the radiation source and visit for only 30 minutes daily.

The nurse is providing colostomy care to a client with methicillinresistant Staphylococcus aureus (MRSA) infection. Which personal protective equipment (PPE) would the nurse use? Select all that apply.

One, some, or all responses may be correct.

Gloves Gown Mask Goggles Shoe covers Hair bonnet

Rationale Standard PPE, which should be used for performing colostomy care in a client positive for MRSA, includes gloves, gown, and goggles. A combination mask/eye shield may be used when caring for this client; however, a mask is not necessary. A mask would be necessary if the client had MRSA of the nares. Shoe covers and hair bonnet are not required for the client care situation described.

The primary nurse, leaving the unit for lunch, provides a verbal report

The primary nurse, leaving the unit for lunch, provides a verbal report for the covering nurse. The report included one client’s prescription for morphine: 2 mg intravenously (IV) every 3 hours for abdominal pain secondary to major abdominal surgery that morning. During the primary nurse’s lunch, the client complains of pain at a level 8 out of 10 on the pain scale. Which action would the covering nurse perform first?

Determine the documented time of the last administration of pain medication.

Verify that the written prescription matches the administration record.

Encourage nonpharmacological measures initially to relieve the pain.

Explain that the primary nurse will be back from lunch in a few minutes.

Rationale Before administering any medication for the first time, the nurse must verify the accuracy of the prescription. The prescription as it appears in the medication administration record is verified against the prescription written by the health care provider in the client’s medical record. This ensures that the prescription was transcribed accurately. Checking when the pain medication was last given is done after the prescription is verified. Nonpharmacological measures are used for mild to moderate pain, not pain at a level 8 on a 0 to 10 scale that is associated with recent major abdominal surgery. The client’s pain must be addressed immediately. The covering nurse should verify and give the pain medication as prescribed.

Which nursing intervention is the priority for an infant with a myelomeningocele before surgical correction?

Minimizing infection Preventing trauma to the sac

Monitoring for increasing paralysis Prevention of hypothermia

Rationale A myelomeningocele is thinly covered and fragile. Trauma to the sac can damage functioning neural tissue; an intact sac eliminates a potential portal of entry for microorganisms. Although minimizing infection is extremely important, it is not the priority; care of the sac is even more important, because an intact sac bars entry by microorganisms. Although observation for paralysis is an important nursing measure, it is not the priority. The open defect may make thermal homeostasis more difficult to maintain, but prevention of trauma to the sac is a higher priority.

Which water temperature choice would the nurse use when preparing to give a client a tepid bath?

Cool Warm Lukewarm Hot

Rationale The temperature choice for a tepid bath is lukewarm. The rest of the choices are too cold or too hot.

Which education would the nurse provide about activated charcoal as a method of gastrointestinal decontamination in preschoolers who have ingested poison? Select all that apply. One, some, or all

responses may be correct.

"The use of activated charcoal may cause constipation and intestinal obstruction."

"Activated charcoal should always be administered through a nasogastric tube."

"Activated charcoal should be administered within 2 hours of the poison ingestion."

"Activated charcoal should be mixed with small amounts of chocolate milk or fruit syrup."

"Activated charcoal may be used in children who have ingested large amounts of quinine."

Rationale Activated charcoal may be used for gastrointestinal decontamination in preschoolers who have ingested poison. However, its use may cause constipation and intestinal obstruction. To increase the child’s acceptance of activated charcoal, the nurse should mix the activated charcoal with small amounts of chocolate milk or fruit syrup before administering the medication to the child. Children who have ingested large amounts of quinine can be administered activated charcoal. A nasogastric tube may be required to administer activated charcoal in small children; however, the nurse may serve activated charcoal orally through a straw by mixing it with chocolate milk or fruit syrup. Activated charcoal should be administered within 1 hour, not 2 hours, of the poison ingestion.

When planning nursing care for a child with acute poststreptococcal glomerulonephritis, which would the nurse emphasize that the child and family must maintain?

A bland diet high in protein

Bed rest lasting at least 4 weeks Isolation from children with infections A daily intramuscular dose of penicillin

Rationale During the acute stage, anorexia and general malaise lower the child’s resistance to infection, so the child should be isolated from others with infections. A bland diet is not necessary, but high-protein and high-sodium foods should be avoided. Bed rest is not a necessary restriction. It is encouraged when the child is easily fatigued.

Antibiotics are not necessary for all children with acute glomerulonephritis, only those with persistent streptococcal infections. The intramuscular route is not used.

The practitioner prescribes no weight bearing on a leg that has been casted because of a fracture of the femur. How would the nurse determine the appropriate length of the crutches for this child? Select all that apply. One, some, or all responses may be correct.

The crutches should reach 2 inches (5 cm) below the axillae.

The tips of the crutches should rest 6 inches (15.2 cm) outside the feet.

There should be a snug fit under the axillae when the child walks.

There should be a slight stoop of the shoulders when the child walks.

The elbows should be extended when the crutches are held at the crossbar.

Rationale There is no pressure on the brachial plexus when the crutches reach to 2 inches (5 cm) below the axillae. Placing the ends of the crutches 6 inches (15.2 cm) from the

outsides of the feet provides the maximal base of support when the child ambulates.

A snug fit can cause pressure and injury to the brachial plexus. Stooping of the shoulders when the child walks indicates that the crutches are too short. When the child is holding the crossbar, the elbows should be flexed slightly (no more than 30 degrees), and the shoulders should be straight.

A client with cervical cancer is undergoing a course of internal radiation. She has an indwelling urinary catheter and a vaginal applicator in place. Once the primary health care provider has loaded the applicator with the radiation source, which actions would the nursing care plan include?

Changing linens several times a day Leaving the urinary catheter undisturbed Cleansing the perineal area with a mild antiseptic twice daily Removing equipment from the room immediately after it is used

Rationale Preventing the occurrence of complications is a major goal during internal radiation treatment. If the source of radiation is disturbed, injury to the client, as well as to the personnel caring for her, may result. The area surrounding the urinary catheter is not touched or cleansed. Linens are changed only when necessary; they are kept in the client’s room until therapy is complete. As a means of preventing dislodgement of the radiation applicator, the area surrounding the source of internal radiation is not touched or cleansed. Displacement may result in unnecessary tissue damage or exposure of the nurse to radiation. Equipment is usually kept in the client’s room until the source of radiation is removed.

Which source of lead would the nurse assess for when providing care

to a child with lead poisoning? Select all that apply. One, some, or all responses may be correct.

Water Pottery Stained glass Collectible toys Vinyl miniblinds

Rationale Water, pottery, collectible toys, and vinyl miniblinds are all sources of lead that should be included in the nurse’s assessment for a toddler-age client who is admitted with lead poisoning. The making of stained glass, not stained glass itself, is a source of lead.

A child is admitted to the pediatric unit with a tentative diagnosis of acute glomerulonephritis (AGN). Which finding would the nurse expect the laboratory report to reveal?

Decreased sedimentation rate Increased serum complement Increased antistreptolysin O (ASO) titer Decreased blood urea nitrogen level

Rationale An increased ASO titer indicates the presence of a previous streptococcal infection;

levels are highest with AGN, bacterial endocarditis, and scarlet fever. The sedimentation rate is increased in glomerulonephritis; it signifies an inflammatory process. A reduction in serum complement (C3) activity occurs early in the disease process of glomerulonephritis. The blood urea nitrogen level is increased, not decreased, with glomerulonephritis because of impaired glomerular function, with azotemia occurring as a result.

A child is admitted with a fever of 103°F (39.4°C), stiffness of the neck, and general malaise. Which action would the nurse take?

Increase fluids Administer oxygen Give a tepid sponge bath Institute droplet precautions

Rationale Droplet precautions prevent the spread of infection to others; isolation is a priority and should be implemented immediately. There is no indication that the child is dehydrated; fluid maintenance is a continuing goal. There is no indication that the child needs oxygen. Oxygen is not given routinely; it is given if the child has a decreased oxygen saturation level. A sponge bath is not given because these children are sensitive to stimuli, and movement causes increased discomfort.

Which question would the nurse include in the assessment process for the parent of a toddler diagnosed with lead toxicity not related to a household item?

"Do you teach for a living?"

"Do you refinish furniture?"

"Do you work in a hospital?"

"Do you work with children?"

Rationale Occupational exposure to lead can occur when a parent is involved in furniture refinishing; therefore this is a question the nurse would include in the assessment process. Teaching, working in a hospital, and working with children are not occupational exposure risks for lead.

Which action would the local health department nurse take to enhance local response when the local health department has been receiving reports of a recent increase in symptoms including headaches, dizziness, weakness, and nausea among local migrants in the region to help harvest tomato crops?

Provide education to local providers and health centers regarding signs and symptoms of pesticide exposure.

Ensure that resources are available during work hours to support adequate hydration.

Initiate an epidemiologic study to identify the potential cause of the current symptoms.

Conduct an assessment of the entire population (workers and their families) to determine possible causes of the current symptoms.

Rationale Migrant workers who work in fields are often exposed to high levels of pesticides, an issue enhanced if housing is located near the fields. It is important that local health care providers and other community entities are aware of the signs and symptoms

of pesticide poisoning so that cases can be addressed early. Hydration is also important; however, current signs and symptoms indicate potential pesticide poisoning. Epidemiologic studies are undertaken when a cluster of illnesses is noted for which there seems to be no logical explanation. In this scenario, the signs and symptoms noted combined with the work being performed indicates a known cause; thus an epidemiologic study or full population assessment are not indicated.

Which action would the nurse take for a client diagnosed with borderline personality disorder who receives the wrong meal tray and angrily states, "The next time I see the dietician, I’m going to throw this tray at her"?

Suggest that the client calm down while explaining that sometimes trays get mixed up.

Teach the client that the behavior is inappropriate while sending the client out of the dining room.

Tell the client that it is frustrating not to get the correct tray but that throwing the tray at the dietician is unacceptable behavior.

Inform the client that throwing the tray at the dietician will make matters worse and may result in the client being placed in seclusion.

Rationale The nurse would tell the client that it is frustrating not to get the correct tray but that throwing the tray at the dietician is unacceptable behavior. Validating the client’s frustration and correcting the behavior are the most appropriate responses; safety is a priority. Suggesting that the client calm down while explaining that sometimes trays get mixed up does not validate the client’s feelings. Sending the client out of the room without offering support and direction is not an appropriate nursing response. Threatening seclusion is an inappropriate nursing intervention; seclusion is always the last resort and should not be used as a threat.

Which home visit observation indicates the client with acquired immunodeficiency syndrome (AIDS) integrated acute care discharge teachings? Select all that apply. One, some, or all responses may be correct.

Snacked on apple slices Toothbrush soaking in laundry bleach Picked up a sandwich after petting the cat Washed dishes with warm, soapy water before using Applied gloves before weeding a houseplant

Rationale The client with AIDS is immunosuppressed and is prone to infections. The toothbrush should be soaked weekly in a bleach solution and then rinsed thoroughly with hot water before using. Dishes used for eating should be washed with soap and warm water. Gloves should be worn when working with soil.To reduce infection risks, the client should avoid eating fresh fruit. The client would wash his or her hands after touching pets and before eating.

Which action by the new employee indicates effective learning after the registered nurse gives instructions about providing care for a hospitalized client with a human immunodeficiency (HIV) infection?

Keeping fresh flowers in the client’s room Encouraging the client to eat fresh fruits and vegetables Keeping a dedicated disposable glove box in the client’s room Changing gauze-containing wound dressings every other day

Rationale A client with an HIV infection is at a high risk of contracting infections. The nurse would keep a dedicated disposable glove box in the client’s room and avoid using supplies from a common area. The nurse would refrain from keeping potted plants and flowers in the client’s room because they act as sources of potentially infectious bacteria and fungi. A client with an HIV infection would be discouraged from consuming raw fruits and vegetables and would instead be provided with wellcooked food to reduce risk of food borne pathogens. To reduce the risk of infections, the nurse would change gauze-containing wound dressings every day.

Which priority approach would the nurse take for a newly admitted client who is found to be experiencing command auditory hallucinations?

Identifying the content of the messages in the auditory hallucinations Determining whether the command hallucinations are frightening to the client Helping the client determine whether the voices are outside or inside the client’s head Monitoring the client’s ability to refrain from listening to the messages from the voices

Rationale The nurse would identify the content of the messages in the auditory hallucinations.

During the acute phase, it is important to have the client describe the content of the hallucinations so safety issues may be identified. Determining whether the command hallucinations are frightening to the client is not the priority; most clients find hallucinations frightening. Helping the client recognize whether the voices are outside or inside the client’s head is not the priority. Monitoring the client’s ability

to refrain from listening to the messages from the voices is important, but it is not the priority at this time.

Which need is the priority for a cognitively impaired older adult who has a cut on the forehead based on the assessment data in the client's chart?

Adequate fluid to prevent dehydration Assessment for possible physical neglect Nutrition adequate to prevent weight loss

Implementation of fall-prevention interventions

Rationale The signs/symptoms and history suggest possible physical neglect. If physical neglect is occurring, measures to prevent dehydration, weight loss, or falls will not correct the underlying safety issue.

Which actions would be included in the safety plan for a woman in crisis, who is emotionally and physically abused by her husband?

Select all that apply. One, some, or all responses may be correct.

Limiting contact with the abuser Determining a safe place to go in an emergency Memorizing the domestic violence hotline number Obtaining a bank loan to finance leaving the abuser Arranging for a family member to assist her in leaving

Rationale It is important that the client have a safe place to go and a plan for getting there.

The client needs to know the hotline number if there is an emergency. It is best to memorize the number because if it is written down the abuser may find it. Any change, especially one in which the abuser becomes angry, may cause the woman to experience more abuse. Although the client will require money to leave the abusive situation, it is best to save money a little at a time rather than try to obtain a loan and alert the abuser of the desire to leave. It is not advisable to tell a family member about the plan to leave because the person may tell the abuser.

Which interventions would the nurse implement when a client who

Which interventions would the nurse implement when a client who attempted suicide by slashing the wrists is transferred from the emergency department to a mental health unit? Select all that apply.

One, some, or all responses may be correct.

Obtain vital signs.

Assess for suicidal thoughts.

Institute continuous monitoring.

Initiate a therapeutic relationship.

Inspect the bandages for bleeding.

Say, "You have so much to live for."

Rationale The nurse would obtain vital signs, assess for suicidal thoughts, institute continuous monitoring, initiate a therapeutic relationship, and inspect the bandages for bleeding. Obtaining vital signs is an intervention that must be performed in this situation; physiological stability must be maintained. The nurse would assess for suicidal thoughts because suicidal impulses take priority. The nurse would institute continuous monitoring to stop the client from acting on suicidal impulses while treatment is in progress. A therapeutic relationship must be developed so the client can trust the nurse to provide a safe environment and aid emotional recovery. The nurse would inspect the bandages for bleeding to determine the physical status of the client. Telling clients that they have much to live for does not promote therapeutic communication and is not appropriate; it is belittling the client in this situation.

Which statement indicates the meaning of "a shift to the left" when evaluating the white blood cell count differential?

Heightened phagocytosis

Functioning bone marrow Infection is being contained Increased immature neutrophils

Rationale A "shift to the left" in the white blood cell count differential indicates immature neutrophils are being released into the blood. The immature neutrophils are not capable of phagocytizing. The bone marrow is unable to produce mature neutrophils, and the infection is continuing, not being contained.

Which nursing intervention is the most important when caring for a 3-year-old child with nephrotic syndrome?

Regulating diet Encouraging fluids Preventing infection Encouraging ambulation

Rationale Infection is a constant threat because of a poor general state of nutrition, a tendency toward skin breakdown in edematous areas, corticosteroid therapy, and lowered immunoglobulin levels. Although the intake of foods with high nutritional value should be encouraged, this is not the priority. Fluid monitoring is important in determining whether a fluid restriction is indicated. Ambulation is to be encouraged, but preventing infection is the highest priority.

A child with beta-thalassemia (Cooley anemia) is admitted to the

ambulatory care unit for a transfusion. Which instruction would the nurse include in the plan of care?

Encourage fluids.

Restrict activities.

Protect from infections.

Offer small meals frequently.

Rationale Children with a chronic illness such as hemolytic anemia should not be exposed to the additional stress of infection. Regular intake of fluid is recommended. Activity is not restricted, although the child may self-restrict activity because of anemiainduced fatigue. Regular meals with the family should be encouraged.

Which action would the nurse perform immediately after applying capsaicin to a client with diabetic neuropathy?

Monitor for skin irritation.

Perform a painful procedure.

Notify the health care provider.

Remove gloves and wash hands.

Rationale Topical applications of local anesthetics such as capsaicin are used to interrupt transmission of pain signals to the brain in a client with diabetic neuropathy. The nurse has to use gloves or wash the hands with soap and water after application of capsaicin to prevent nerve blockage in the nurse. The client should be monitored for

skin irritation at the site of application. Painful procedures are performed only when the client loses pain perception at the site. The health care provider is notified if the client has severe side effects.

The nurse would assess the airway of a patient with simultaneous spine stabilization in which order?

1.

Use jaw-thrust maneuver.

2.

Remove or suction any foreign bodies.

3.

Insert oropharyngeal or nasopharyngeal airway or endotracheal tube or perform cricothyroidotomy.

4.

Immobilize cervical spine using rigid cervical collar and cervical immobilization device.

Rationale While assessing the airway with simultaneous cervical spine stabilization, the nurse should first start interventions to assess respiratory distress, assess the airway for patency, and check for any bleeding or edema. The nurse uses the jaw-thrust maneuver to open the client’s airway and then removes or suctions any foreign bodies to avoid toxicity. Next, the nurse inserts an oropharyngeal or nasopharyngeal airway or endotracheal tube or performs cricothyroidotomy to open the airway when other methods are ineffective. This should be followed by immobilizing the cervical spine using a rigid cervical collar and cervical immobilization device.

Which nursing action is most important for a client with urinary

retention related to benign prostatic hyperplasia who has a secondary diagnosis of delirium related to urosepsis and a prescription for the insertion of an indwelling urinary retention catheter?

Secure a prescription for wrist restraints.

Orient the client to time, place, and person.

Involve family members in the client’s care.

Determine whether any unsafe behavior patterns exist.

Rationale The nurse should determine whether the client is a danger to self or others before planning and implementing care. In the absence of unsafe behavior, the nurse should not apply wrist restraints, because there is not a risk of the client pulling the urinary catheter. Pulling on the indwelling urinary catheter may be a concern because this may cause an injury; however, the nurse would attempt less restrictive alternatives first. Use of a restraint is a last resort. Orienting the client to time, place, and person is appropriate for the client with delirium; however, this will not protect the client from attempting to pull out the urinary catheter or from engaging in other unsafe behaviors. Although family members should be involved in the client’s care, assessing the client or protecting the client from injury is not the responsibility of family members.

Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

According to the disaster triage tag system, which client has been correctly tagged?

A B C D

Rationale

According to the disaster triage tag system, a yellow band should be applied to clients with conditions that are not life threatening, such as open fractures. Client B would receive effective treatment. A green disaster triage tag should be applied to a client who has minor injuries such as contusions of the lower limb. A red tag should be applied to a client with life-threatening conditions such as airway obstruction and shock. A black tag is applied to the clients who are expected to die due to severe injuries such as massive head trauma. Clients A, C and D have been incorrectly tagged.

Which is the correct technique when using an otoscope to examine the ears of an infant?

Pull pinna up and back Pull pinna up and forward Pull pinna down and back Pull pinna down and forward

Rationale Due to the upward curvature of the ear canal in infants, the nurse would pull the pinna down and back to visualize the tympanic membrane. The pinna will be pulled up and back in an older child because the ear canal curves downward and forward.

Pulling the pinna forward during an otoscope exam is inappropriate and will not assist with straightening the curved ear canal.

Which intervention would the nurse implement to prevent infection of the newborn in a pregnant client with gonorrhea?

Oral antibiotics for newborn Schedule a cesarean section

Silver nitrate ophthalmic ointment Intravenous antibiotic before delivery

Rationale In the United States it is required for all newborns to be given prophylactic treatment with either silver nitrate, erythromycin, or tetracycline eye solution to prevent perinatal transmission of gonorrhea. Oral antibiotics are used if a newborn tests positive for gonorrhea. A pregnant client with gonorrhea is not required to deliver via cesarean section. Administering an intravenous antibiotic before delivery will not decrease the risk of perinatal transmission.

Which priority action would the nurse perform when caring for a client with suspected anaphylaxis?

Obtain full set of vital signs.

Assess airway and oxygenation.

Determine level of consciousness.

Notify the client’s health care provider.

Rationale The first action the nurse will perform when caring for a client with suspected anaphylaxis is to assess respiratory status including airway and oxygenation. Next the nurse will notify the Rapid Response Team. After the airway and oxygenation have been assessed, the nurse will obtain vital signs, assess level of consciousness, and notify the health care provider.

Which action indicates the need for additional teaching when the

nurse is educating a client on the use of heat and cold for osteoarthritis (OA) pain?

Places ice pack on skin Uses ice pack for 20 minutes Applies lightweight heating pad Tests water before getting into shower

Rationale When using hot and cold packs, clients will be instructed to avoid placing ice packs directly on the skin because it can cause damage. To prevent skin injury, clients will be instructed to use ice packs for 20-minute intervals, apply a lightweight heating pad, and test the water temperature before getting into the shower.

Which action would be included in an organization’s policy for hand hygiene? Select all that apply. One, some, or all responses may be correct.

Wash hands before applying sterile gloves.

Wash hands before touching any of the client’s personal items.

Wash with either soap and water or alcohol-based hand rub (ABHR) before client contact.

Wash with soap and water when hands are visibly soiled with blood.

Wash with ABHR if hands are not visibly soiled.

Wash hands, between fingers, and under nails for 60 seconds.

Rationale A hand hygiene policy should include washing hands before applying sterile gloves, washing with either soap and water or an ABHR before client contact, washing with soap and water when hands are soiled with blood, and washing with an ABHR if hands are not visibly soiled. The hands should be washed after contact with inanimate objects in the immediate vicinity of the client. The Centers for Disease Control recommends washing the hands, between fingers, and under nails for a minimum of 20 seconds.

Which is not a potential nutritional risk in pregnancy?

Diabetes Hypertension Use of tobacco Frequent pregnancies

Rationale Indicators of potential nutritional risk in pregnancy include diabetes, adolescence, use of tobacco, and frequent pregnancies (three within 2 years). Hypertension is not a potential nutritional risk in pregnancy.

Which nurse would be the most appropriate to reassign to assist in the operating room for emergency surgeries being performed on trauma victims?

Intensive care nurse Ambulatory care staff nurse Postanesthesia care unit nurse

Surgical suite staff development trainer

Rationale Even though the nurse is a trainer, the nurse’s specialty is surgical suite, which makes them the most qualified to assist in the operating room for emergency surgeries being performed on trauma victims. The intensive care, ambulatory care, and postanesthesia care nurses may have experience with critically ill clients but will not have the expertise to assist with surgical procedures.

Which statement by a client with human immunodeficiency virus (HIV) with a low viral load who has been asymptomatic for years indicates the need for additional education on the disease process?

"I inform all my partners of my HIV-positive status."

"I should not skip any doses of antiretroviral medication."

"I occasionally have oral sex without the use of protection."

"I have never shared or reused any of my diabetic supplies."

Rationale Clients who are HIV positive, even those with very low or absent viral loads, need to be instructed to practice safe sex. This includes using protection in all sexual encounters, including oral sex. Clients will be instructed to inform all partners of HIV-positive status, ensure they do not skip doses of antiretroviral medication, and never share or reuse needles.

Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to

choose from the remaining responses.

Which type of hepatitis is commonly spread by consuming contaminated food and water or by fecal contamination? Select all that apply. One, some, or all responses may be correct.

Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E

Rationale Hepatitis A and E most commonly are spread through the fecal-oral route. Hepatitis B most commonly is spread through the sharing of needles and through unprotected sex. Hepatitis C and D most commonly are spread through intravenous (IV) drug needle sharing.

A medical-surgical nurse completes the admission assessment on a client diagnosed with a urinary tract infection. The client’s admitting weight is 165 lb (74.8 kg). The vital signs are temperature 96°F (35.6°C), pulse 110 beats per minute, respirations 20 per minute, and blood pressure 88/56 mm Hg. The client received 3 L of normal saline in the emergency department. The total urine output for the past 2 hours was 20 mL via a urinary drainage system. Which intervention would the nurse recommend to the primary health care provider?

Transfer the client to a critical care unit.

Discontinue the urinary catheter immediately.

Administer another 1 L bolus of sodium chloride.

Begin a dopamine hydrochloride drip for renal perfusion.

Rationale The client has a known infection, is exhibiting signs of sepsis, and is unresponsive to fluid therapy as evidenced by the low blood pressure. The client is showing signs of renal failure. The client is manifesting probable signs of septic shock requiring a higher level of care. This question requires the medical/surgical nurse to synthesize the client’s manifestations and make an evaluation of the need for more invasive care than is available on the admitting unit. The urinary catheter is necessary to continue monitoring the urine output in this acute client. Giving another fluid is plausible, but this client weighs 75 kg, requiring a maximum of 3 L of fluid to be given before a diagnosis of severe sepsis. The client requires more invasive monitoring than can be done on a medical/surgical unit to determine if more fluid or vasopressors are required.

Which statement indicates understanding after the nurse provides discharge teaching to a client with acquired immunodeficiency syndrome (AIDS) and a low white blood cell (WBC) count? Select all that apply. One, some, or all responses may be correct.

"My roommate will take care of our cat’s litter box."

"I will rinse my toothbrush in bleach once a week."

"I will use a different cup every time I have a drink."

"I will eat at least one piece of fresh fruit every day."

"I will walk at the mall twice a week to keep up my strength."

"I will wash my hands thoroughly after shaking hands with anyone."

Rationale When a client with AIDS has a low WBC, it is necessary to avoid possible sources of infection. When the WBC is low, the client should avoid changing the litter box, and cups and glasses should not be reused. The client should rinse the toothbrush in bleach weekly and then rinse out the bleach with hot water. Hands should be washed with an antimicrobial soap before eating and drinking, after touching a pet, after using the toilet, and after shaking hands with anyone.Raw fruit and vegetables should be avoided, as should large gatherings of people who might be ill.

The child who is human immunodeficiency virus (HIV) positive has CD4 count that shows severe immunosuppression. Which immunizations can the child be given safely at this time? Select all that apply. One, some, or all responses may be correct.

Varicella Hepatitis A Polio vaccine (IPV) Measles, mumps, rubella (MMR) Diphtheria, tetanus, pertussis (DTaP)

Rationale The varicella and MMR vaccines should not be administered in the presence of severe immunosuppression because they are live vaccines. Hepatitis A, IPV, and DTaP are not live vaccines; therefore they are appropriate for any child, regardless of immune status.

In which order would the nurse perform resuscitation interventions

for airway-breathing-circulation as part of a primary survey of a client?

1.

Establish airway by positioning, suctioning, and oxygen (O2) as needed.

2.

Assess breath sounds and respiratory effort.

3.

Prepare for chest decompression if needed.

4.

Maintain vascular access using a large-bore catheter.

5.

Use direct pressure for external bleeding.

Rationale The primary survey includes assessment of airway/cervical spine, breathing, circulation, disability, and exposure. First, the nurse would establish airway patency by positioning, suctioning, and providing O 2 as needed. Assess breath sounds and respiratory effort and provide chest decompression, if needed, to assess breathing.

Maintain vascular access using a large-bore catheter and use direct pressure for any external bleeding.

Which client is at an increased risk for hospital-acquired pneumonia?

Client who was admitted yesterday with hypoxia and fever Client who has been on mechanical ventilation for 5 days Client who reports being on an airplane with other sick individuals Client who was admitted to the hospital 5 days ago for abdominal pain

Rationale Hospital-acquired pneumonia occurs in nonintubated clients and begins 48 hours after admission. A client admitted 5 days ago with abdominal pain would meet the criteria and is at increased risk for hospital-acquired pneumonia. A client admitted the previous day has not been in the hospital at least 48 hours. A client on mechanical ventilation is intubated and does not meet the criteria for hospitalacquired pneumonia. A client who has been on an airplane with other ill individuals would be at risk for community-acquired pneumonia.

Which statement indicates a misunderstanding of the process when teaching a client about automatic epinephrine injectors?

"I will keep my injectors in my car and in my personal bag all the time."

"I will keep the device away from light."

"If the cap is loose, I will obtain a replacement device."

"I will have at least two medication-filled devices on hand at all times."

Rationale Storing of the injectors in a car exposes the medication to extreme temperatures (hot and cold). The device should be protected from light. If the cap is loose or comes off accidentally, the client should obtain a replacement device. The client should have at least two medication-filled devices on hand in case more than one dose is required.

Which parent education would the nurse provide the father about the contagiousness risk for his baby when telling the nurse that his niece and nephew recently had chickenpox (varicella) but that their lesions are completely healed or have scabs and are no longer draining?

"The most contagious time is before the spots appear until they are crusted.

It’ll be safe to visit."

"People with open lesions shouldn’t visit. Tell them to stay home."

"People are contagious for one week after the lesions appear."

"The baby received immunity from the mother at birth. It will be safe for them to visit."

Rationale Chickenpox (varicella) is an infectious respiratory disease primarily spread by droplets; the chief contagious period occurs 1 day before the lesions appear until the vesicles have crusts. Chickenpox is spread primarily in respiratory droplets but also may spread from discharge from the uncrusted lesions. People are considered contagious right before the lesions appear until all are crusted. Passive immunity at birth does not provide complete protection; infants need to be protected against those with active infection.

Which leukocyte is responsible for the allergic response?

Basophils Monocytes Eosinophils Macrophages

Rationale Basophils stimulate the inflammation of allergy and hypersensitivity reactions.

Monocytes are responsible for the destruction of bacteria and cellular debris before maturing into macrophages. Eosinophils act against parasitic infestations and limit

inflammatory reactions. The main function of the macrophages is phagocytosis.

Which intervention promotes safe movement of objects to protect the back?

Pull rather than push objects.

Use handles or grips on the object.

Do not twist the back during movement.

Be attentive to maintaining good posture.

Rationale Use handles or grips when moving objects to avoid shifting.When moving objects, it’s best to push rather than pull. Avoid twisting the back when moving objects.

Attention to good posture supports back health and helps prevent injury.

Which would the nurse include when teaching clients about the potentially serious consequences of using diuretics during pregnancy? Select all that apply. One, some, or all responses may be correct.

Preeclampsia Severe hypovolemia Acute hypervolemia Gestational diabetes Reduced placental perfusion

Rationale Severe hypovolemia and reduced placental perfusion are two potentially serious consequences of using diuretics during pregnancy. Preeclampsia, acute hypervolemia, and gestational diabetes are not among the potentially serious consequences of using diuretics during pregnancy.

Test-Taking Tip: Make certain that the answer you select is reasonable and attainable under ordinary circumstances and that the action can be carried out in the given situation.

Which clinical finding during labor induction requires the nurse to discontinue the oxytocin infusion?

Contractions occurring every 3 minutes and lasting 60 seconds Elevation of blood pressure from 110/70 to 135/85 mm Hg over 30 minutes Rupture of membranes with amniotic fluid that contains threads of blood and mucus Several late fetal heart rate decelerations that return to baseline after the contraction is over

Rationale Late decelerations suggest uteroplacental insufficiency, which is an indication that the oxytocin infusion should be stopped. Continuing the infusion may compromise the status of the fetus. Contractions that occur every 3 minutes and last 60 seconds are within acceptable parameters; they require continued monitoring, and the infusion of oxytocin may be continued. An increase in blood pressure from 110/70 to 135/85 mm Hg during the past 30 minutes or rupture of the membranes requires continued monitoring but does not make it necessary for the infusion of oxytocin to be stopped.

A client who had thoracic surgery is admitted to the postanesthesia care unit. The nurse notes that a chest tube is in place and is attached to a disposable plastic, water-seal drainage system. To provide appropriate care of the chest tube and drainage unit, which step would the nurse take next?

Ensure the security of the connections from the client to the drainage unit.

Empty the drainage container and measure and record the amount.

Verify that there is vigorous bubbling in the wet suction control compartment.

Check that the fluid level in the water-seal compartment increases with expiration.

Rationale The system must remain airtight (closed) to prevent collapse of the lung. The system is kept closed; a record of drainage is kept by marking the outside of the container or chamber. It should bubble but not vigorously; vigorous bubbling will not increase the suction but will cause the fluid to evaporate more rapidly. The water level will fluctuate as the client inhales and exhales. The level will increase with inspiration and decrease with expiration; this is known as tidaling.

Which action by an uninfected individual would not pose a risk of exposure to human immunodeficiency virus (HIV)?

The uninfected individual only has intercourse with his or her spouse.

The individual donates a pint of blood to the blood bank.

The individual uses a condom each time he or she has sexual intercourse.

The individual limits sexual contact to those individuals without HIV antibodies.

Rationale Equipment used in blood donation is disposable; the donor does not yet come into contact with anyone else’s blood. Risk of exposure within a monogamous marriage depends on the spouse’s previous behavior. Although condoms do offer protection, they can rupture or be improperly used; risks of infection are present with any sexual contact. Finally, individuals may be infected before testing positive for the antibodies; therefore individuals can transmit the virus long before they know they are infected.

Which laboratory finding would the nurse anticipate identifying in the reports of a client exposed to pollen who reports a runny, stuffy nose and itchy, watery eyes with the nasal examination revealing swollen and pink nasal mucosa?

Immunoglobulin E (IgE) level of 150 IU/mL Eosinophil count of 2% Percentage of neutrophils of 80% Total white blood cell (WBC) count of 3 billion cells/L

Rationale A runny, stuffy nose and itchy, watery eyes and swollen, pink mucosa indicates allergic rhinitis. A normal level of IgE is less than 100 IU/mL. The laboratory reports of a client with allergic rhinitis may have IgE level 150 IU/mL. The normal eosinophils count is 1% to 2%. The percentage of neutrophils remains normal (50% to 70%) in clients with allergic rhinitis. Total WBC count may be increased or remain normal in clients with allergic rhinitis. The normal range of WBC count lies between 3.5 and 10.5 billion cells/L. A WBC count of 3 billion cells/L indicates leukopenia.

Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

Which statement would be made by the nurse teaching a client about the use of tampons? Select all that apply. One, some, or all responses may be correct.

"Wash your hands before inserting a tampon."

"Use a superabsorbent tampon during the daytime."

"Use sanitary napkins at nighttime."

"Report any physical changes while using a tampon."

"Avoid using feminine deodorant sprays and douches during tampon use."

Rationale Organisms such as Staphylococcus aureus and Streptococcus pyogenes may cause toxic shock syndrome (TSS) from tampon use. The client should wash the hands before inserting a tampon to maintain good hygiene. Limiting tampon use also reduces TSS, so the client should use sanitary napkins at night. High temperatures, vomiting, and diarrhea are clinical manifestations of TSS caused by tampon use.

Clients should report these symptoms immediately to the primary health care provider. The client should not use a superabsorbent tampons because they decrease the need to change tampons on a frequent basis. Current research does not link TSS to concurrent use of tampons with the use of feminine deodorant sprays or douches.

Which bioterrorism agent presents with dysphasia, dry mouth, drooping eyelids, blurred vision, vomiting, and diarrhea initially, and

within 24 hours, the client develops bilateral cranial nerve impairment and descending weakness?

Plague Anthrax Botulism Smallpox

Rationale These symptoms are found with botulism. Symptoms of lymphatic plague include fever and chills, painful lymphadenopathy, gastrointestinal symptoms, and progressive weakness.With anthrax and smallpox, a rash will be noted.

Which term describes an example of microorganisms transmitted via indirect contact?

Kissing Deer tick Dirty hands Contaminated water

Rationale Indirect contact transmission involves the transfer of microorganisms from a source to a host by passive transfer from a contaminated article or hands. With direct contact, the source and host have physical contact from skin to skin or from mucous membrane to mucous membrane through kissing. A deer tick is an example of the transmission of infection between a vector or an insect that carries pathogens

between two or more hosts. Ingesting infected water is a form of direct contact transmission of microorganisms.

Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds.

Continue to analyze the options. If you can eliminate one more choice in a fouroption question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

In which stage would the nurse teach the client that syphilis is not considered contagious?

Tertiary stage Primary stage Secondary stage Incubation stage

Rationale The tertiary stage is noncontagious; tertiary lesions contain only small numbers of treponemes. The primary stage lasts 8 to 12 weeks; the chancre is teeming with spirochetes, and the individual is contagious. The duration of the secondary stage is variable (about 5 years); skin and mucosal lesions contain spirochetes, and the individual is highly contagious. The incubation stage lasts 2 to 6 weeks; spirochetes proliferate at the entry site, and the individual is contagious.

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which evidenced-based nursing intervention links to reducing catheter associated urinary tract infections (CAUTIs) in clients requiring long-term indwelling catheters?

Perform catheter care twice a day.

Replace the catheter on a routine basis.

Administer cranberry tablets three times a day.

Administer prophylactic antibiotics twice a day for the duration of the catheter placement.

Rationale A biofilm made up of bacteria develops on long-term indwelling catheters. The best way to eliminate this biofilm is to perform routine perineal hygiene daily. The efficacy of cranberry tablets in decreasing the frequency of urinary tract infections has not been established. Antibiotic therapy may increase the growth of microbes within the biofilm.

Which type of hepatitis develops into a chronic form of the disease?

Select all that apply. One, some, or all responses may be correct.

Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E

Rationale

Hepatitis B and C generally develop into chronic hepatitis. Hepatitis D is an incomplete virus that can become chronic and is dependent on the presence of hepatitis B to survive. Hepatitis A and E are acute, self-limiting infections that resolve over time and do not develop into chronic hepatitis.

In which order, from the most to the least urgent, would the nurse triage clients based on their conditions?

1.

Overdose and bradypnea

2.

Multiple trauma

3.

Gynecological disorder

4.

Simple laceration

5.

Minor burns

Rationale A client who has overdosed and has bradypnea is categorized under emergency severity index 1 (ESI-1), which indicates that the life or organ threat to the client is clear and the client needs to be seen immediately. The client with multiple trauma is triaged as ESI-2, which indicates that the client’s condition is likely to be lifethreatening; they should receive treatment within 10 minutes. The client with a gynecological disorder who is triaged under ESI-3, which indicates that the life threat to the client is unlikely, can be seen after 1 hour. A client with simple

lacerations is categorized as ESI level 4, showing no threat to life, and the assessment could be delayed. A client with minor burns categorized under ESI level 5 with no threat to life could have treatment delayed.

Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

In which order would the nurse perform the actions when inspecting the chest of a client with a suspected heart attack after a fire?

1.

Inspect the chest for paradoxical chest movements.

2.

Palpate the sternum, clavicles, and ribs.

3.

Auscultate breath sounds and heart sounds.

4.

Evaluate the client for rib fractures, pulmonary contusion, blunt cardiac injury, and hemothorax.

5.

Obtain a chest x-ray and 12-lead electrocardiogram (ECG).

Rationale Primarily, the nurse would inspect the chest for paradoxical chest movements and large sucking chest wounds. The nurse would then palpate the sternum, clavicles, and ribs for deformity, point tenderness, and crepitus. Then breath sounds should be auscultated as well as heart sounds in addition to tension pneumothorax and

open pneumothorax, and the client should be evaluated for rib fractures, pulmonary contusion, blunt cardiac injury, and hemothorax. This should be followed finally by a chest x-ray and 12-lead ECG in a client with a suspected heart attack.

In which order would the nurse provide prioritized care for clients with the following conditions?

1.

Penetrating chest trauma

2.

Chest pain resulting from ischemia

3.

Hip fracture

4.

Cystitis

5.

Minor burns

Rationale A client with penetrating chest trauma is categorized under emergency severity index (ESI) level 1, which indicates that the life threat or organ threat to the client is obvious and the client needs to be treated immediately by the primary health care provider. A client with chest pain resulting from ischemia is categorized under ESI level 2, which indicates the condition is likely to be life threatening but not obvious and should be seen within 10 minutes. A client with hip fracture is categorized under ESI level 3, which indicates that injury is unlikely to be life threatening and the client can be seen after 1 hour. A client with cystitis is categorized under ESI

level 4, indicating no threat to life, and that assessment can be delayed. Client with minor burns is categorized under ESI level 5, which indicates the least urgency.

Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

Which information about infection prevention would the nurse include when planning discharge teaching for a client being treated with chemotherapy for leukemia?

"Wash hands before eating and after using the toilet."

"Take your temperature daily and report elevations of 1 °F (0.5 °C)."

"Avoid use of antimicrobial soaps when showering or bathing."

"Increase your daily intake of fresh fruits and vegetables."

Rationale Hand washing is essential to infection prevention and will be performed by the client and all caregivers and visitors. Even mild temperature elevation may indicate severe infection in the immunocompromised client and should be reported by the client to the health care provider.Antimicrobial soaps are recommended for immunocompromised clients, especially when cleaning the axillary and genital areas. Fresh fruits and vegetables carry bacteria; cooked fruits and vegetables generally are recommended for immunocompromised individuals.

After the nurse educator teaches about postoperative care of a vascular bypass client, which statement by the new nurse indicates that more education is needed?

"A cool, pale extremity can indicate vascular reocclusion."

"Hourly assessment of the extremity is needed for the first 24 hours."

"A client report of throbbing pain typically indicates vascular reocclusion."

"Ongoing pain even after use of the patient-controlled analgesia (PCA) pump indicates possible occlusion."

Rationale Throbbing pain occurs with the pulsations of arterial blood flow and is common after arterial bypass as blood flow is restored to the extremity. Occlusive pain is often severe, continuous, and aching or burning. A cool, pale extremity without a pulse indicates occlusion. Perfusion of the affected extremity is monitored hourly in the first 24 hours after surgery. The PCA pump may not be effective against occlusive pain, which is caused by ischemia of tissues.

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