NCSBN ON-LINE REVIEW QUESTIONS WITH 100% CORRECT ANSWERS

FIRST 100 QUESTIONS AND ANSWERS IN PREVIEW 1.A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted ...

FIRST 100 QUESTIONS AND ANSWERS IN PREVIEW 1.A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return D: Improve venous return. Elevating the leg both improves venous return and reduces swelling. Client comfort will be improved as well. 2. The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client? A) Clean the meatus, begin voiding, then catch urine stream B) Void a little, clean the meatus, then collect specimen C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine A: Clean the meatus, begin voiding, then catch urine stream. A clean catch urine is difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it’s best to just slip the container into the stream. Other responses do not reflect correct technique 3. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident C) 72 year-old recovering from surgery after a hip replacement 2 hours ago D) 75 year-old who is in skin traction prior to planned hip pinning surgery. C: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first. The 16 year-old should be seen next because it is still the first post-op day. The 75 year-old is potentially vulnerable to age-related physical and cognitive consequences in skin traction should be seen next. The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury. 4. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? A) Comatose, breathing unlabored B) Glascow Coma Scale 8, respirations regular C) Appears to be sleeping, vital signs stable D) Glascow Coma Scale 13, no ventilator required B: Glascow Coma Scale 8, respirations regular. The Glascow Coma Scale provides a standard reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a neurological impairment. Using the term comatose provides too much room for interpretation and is not very precise. 5. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug? A) Bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time C: Prothrombin time. Coumadin is ordered daily, based on the client''s prothrombin time (PT). This test evaluates the adequacy of the extrinsic system and common pathway in the clotting cascade; Coumadin affects the Vitamin K dependent clotting factors. 6.A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first? A) Notify both the surgeon and provider B) Administer the prn dose of albuterol C) Apply oxygen at 2 liters per nasal cannula D) Repeat the peak flow reading in 30 minutes B: Administer the prn dose of albuterol. Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client''s baseline reading is a medical alert condition and a short-acting beta-agonist must be taken immediately. 7.A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? A) The client lost 2 pounds in 24 hours 1B) The client’s potassium level is 4 mEq/liter. C) The client’s urine output was 1500 cc in 5 hours D) The client is to receive another dose of Lasix at 10 PM C: The client’s urine output was 1500 cc in 5 hours. Although all of these may be correct information to include in report, the essential piece would be the urine output. 8.A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? A) a report of 10 pounds weight loss in the last month B) a comment by the client "I just can't sit still." C) the appearance of eyeballs that appear to "pop" out of the client's eye sockets D) a report of the sudden onset of irritability in the past 2 weeks C: the appearance of eyeballs that appear to "pop" out of the client''s eye sockets. Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves'' Disease. It can result in corneal abrasions with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed. 9. The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the provider immediately? A) prolonged inspiration with each breath B) expiratory wheezes that are suddenly absent in 1 lobe C) expectoration of large amounts of purulent mucous D) appearance of the use of abdominal muscles for breathing B: expiratory wheezes that are suddenly absent in 1 lobe. Acute asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. However, sudden cessation of wheezing is an ominous or bad sign that indicates an emergency -- the small airways are now collapsed. 10.During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time? A) leave a book about relaxation techniques B) write out a daily exercise routine for them to assist the client to do C) list actions to improve the client's daily nutritional intake D) suggest communication strategies D: suggest communication strategies. Alzheimer''s disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client. By use of select verbal and nonverbal communication strategies the family can best support the client’s strengths and cope with any aberrant behavior. 11.An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 160/100 to 180/110 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the provider? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse A: Slurred speech. Changes in speech patterns and level of conscious can be indicators of continued intracranial bleeding or extension of the stroke. Further diagnostic testing may be indicated. 12. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the parent indicates that teaching has been inadequate? A) "I will keep the cast uncovered for the next day to prevent burning of the skin." B) "I can apply an ice pack over the area to relieve itching inside the cast." C) "The cast should be propped on at least 2 pillows when my child is lying down." D) "I think I remember that my child should not stand until after 72 hours." D: "I think I remember that my child should not stand until after 72 hours.". Synthetic casts will typically set up in 30 minutes and dry in a few hours. Thus, the client may stand within the initial 24 hours. With plaster casts, the set up and drying time, especially in a long leg cast which is thicker than an arm cast, can take up to 72 hours. Both types of casts give off a lot of heat when drying and it is preferable to keep the cast uncovered for the first 24 hours. Clients may complain of a chill from the wet cast and therefore can simply be covered lightly with a sheet or blanket. Applying ice is a safe method of relieving the itching. 13. Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate action is required? A) pH below 7.3 B) Potassium of 5.0 C) HCT of 60 D) Pa O2 of 79% 2C: HCT of 60. This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation. In the absence of insulin, which facilitates the transport of glucose into the cell, the body breaks down fats and proteins to supply energy ketones, a by-product of fat metabolism. These accumulate causing metabolic acidosis (pH < 7.3), which would be the second concern for this client. The potassium and PaO2 levels are near normal. 14. The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test? A) Client should be NPO after midnight B) Client should receive a sedative medication prior to the test C) Discontinue anti-coagulant therapy prior to the test D) No special preparation is necessary D: No special preparation is necessary. This is a non-invasive procedure and does not require preparation other than client education. 15. A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition? A) dyspnea B) heart murmur C) macular rash D) Hemorrhage B: heart murmur. Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain and lungs, and obstruct blood flow. 16. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from A) a tissue bank." B) a pig." C) my thigh." D) synthetic skin." C: my thigh.". Autografts are done with tissue transplanted from the client''s own skin. 17.A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills A: Diffuse expiratory wheezing. In asthma, the airways are narrowed, creating difficulty getting air in. A wheezing sound results. 18. A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority? A) Maintaining proper body alignment B) Frequent neurovascular assessments of the affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assist the client with movement in bed B: Frequent neurovascular assessments of the affected leg. The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage. 19. The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time? A) Daily needs and concerns B) The overview cardiac rehabilitation C) Medication and diet guideline D) Activity and rest guidelines A: Daily needs and concerns. At 2 days post-MI, the client’s education should be focused on the immediate needs and concerns for the day. 20. A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem? A) allergies B) scabies C) regression D) pinworms 3D: pinworms. Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Scabies is an itchy skin condition caused by a tiny, eight-legged burrowing mite called Sarcoptes scabiei . The presence of the mite leads to intense itching in the area of its burrows. 21. The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? A) Risk for dehydration B) Ineffective airway clearance C) Altered nutrition D) Risk for injury B: Ineffective airway clearance. The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation. Thus, a priority is maintaining an open airway, preventing aspiration. Other nursing diagnoses are then addressed. 22. The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best? A) Fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk B: Ground beef patty, lima beans, wheat roll, raisins, milk. Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice: It is high in iron and is appropriate for a toddler. 23. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance? A) Metabolic acidosis B) Metabolic alkalosis C) Some increase in the serum hemoglobin D) A little decrease in the serum potassium B: Metabolic alkalosis. Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse. Options C and D are correct answers but not the best answers since they are too general. 24. A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which statement? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water B: Continue with the regular diet and include oral rehydration fluids. Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate. 25. The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) formula or breast milk B) broth and tea C) rice cereal and apple juice D) gelatin and ginger ale A: formula or breast milk. The usual diet for a young infant should be followed. 26. A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is A) call for emergency transport to the hospital B) immobilize the limb and joints above and below the injury C) assess the child and the extent of the injury D) apply cold compresses to the injured area C: assess the child and the extent of the injury. When applying the nursing process, assessment is the first step in providing care. The "5 Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis). 27. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings B: Whole milk is difficult for a young infant to digest. Cow''s milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. In addition, it contains little iron and creates a high renal solute load. 428. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? A) Solid foods are introduced one at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake D) Solid foods should be mixed with formula in a bottle A: Solid foods are introduced one at a time beginning with cereal. Solid foods should be added one at a time between 4-6 months. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food. 29. The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a priority? A) Limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise B: Client controlled analgesia. Management of a sickle cell crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort. 30. The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first? A) Perform traumatic procedures B) Use minimal physical contact C) Proceed from head to toe D) Explain the exam in detail B: Use minimal physical contact. The nurse should approach the toddler slowly and use minimal physical contact initially so as to gain the toddler''s cooperation. Be flexible in the sequence of the exam, and give only brief simple explanations just prior to the action. 31. What finding signifies that children have attained the stage of concrete operations (Piaget)? A) Explores the environment with the use of sight and movement B) Thinks in mental images or word pictures C) Makes the moral judgment that "stealing is wrong" D) Reasons that homework is time-consuming yet necessary C: Makes the moral judgment that "stealing is wrong". The stage of concrete operations is depicted by logical thinking and moral judgments. 32. The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse? A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improves the health of mother and fetus." A: "Folic acid should be taken before and after conception.". The American Academy of Pediatrics recommends that all childbearing women increase folic acid from dietary sources and/or supplements. There is evidence that increased amounts of folic acid prevents neural tube defects. 33. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? A) Spaghetti B) Watermelon C) Chicken D) Tomatoes B: Watermelon. Watermelon is high in potassium and will replace potassium lost by the diuretic. The other foods are not high in potassium. 34. While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions? A) Maintain good oral hygiene and dental care B) Omit medication if the child is seizure free C) Administer acetaminophen to promote sleep D) Serve a diet that is high in iron A: Maintain good oral hygiene and dental care. Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized. 35. The nurse is offering safety instructions to a parent with a four month-old infant and a four year-old child. Which statement by the parent indicates understanding of appropriate precautions to take with the children? 5A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket to play with my four year-old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year-old naps on the sofa." D) "I have the four year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." D: The infant seat is to be placed on the rear seat. Small children and infants are not to be left unsupervised. 36. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? A) "The injury is expected to heal quickly because of thin periosteum." B) "In some instances the result is a retarded bone growth." C) "Bone growth is stimulated in the affected leg." D) "This type of injury shows more rapid union than that of younger children." B: "In some instances the result is a retarded bone growth.". An epiphyseal (growth) plate fracture in a 7 year-old often results in retarded bone growth. The leg often will be different in length than the uninjured leg. 37. The parents of a 4 year-old hospitalized child tell the nurse, “We are leaving now and will be back at 6 PM.” A few hours later the child asks the nurse when the parents will come again. What is the best response by the nurse? A) "They will be back right after supper." B) "In about 2 hours, you will see them." C) "After you play awhile, they will be here." D) "When the clock hands are on 6 and 12." A: "They will be back right after supper." Time is not completely understood by a 4 year-old. Preschoolers interpret time with their own frame of reference. Thus, it is best to explain time in relationship to a known, common event. 38. The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken A) once each day B) 3 times daily after meals C) with each meal or snack D) each time carbohydrates are eaten C: Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of all foods that are eaten. 39. A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boil the tap water for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled "lead free" to mix the formula C: Let tap water run for 2 minutes before adding to concentrate. Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solder used in sealing water pipes. Letting tap water run for several minutes will diminish the lead contamination. 40. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair D: Whitish oval specks sticking to the hair. Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children over 2 years of age, and meticulous combing and removal of all nits. 41. When interviewing the parents of a child with asthma, it is most important to assess the child's environment for what factor? A) Household pets B) New furniture C) Lead based paint D) Plants such as cactus A: Household pets. Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust. 42. The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying? 6A) DTaP B) Hepatitis B C) Polio D) H. Influenza A: DTaP. The majority of reactions occur with the administration of the DTaP vaccination. Contradictions to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within 7 days of the immunization. 43.The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? A) "I think you or your partner needs to stay with the child while in the hospital." B) "Oh, that behavior will stop in a few days." C) "Keep in mind that for the age this is a normal response to being in the hospital." D) "You might want to "sneak out" of the room once the child falls asleep." C: The protest phase of separation anxiety is a normal response for a child this age. In toddlers, ages 1 to 3, separation anxiety is at its peak 44. A couple experienced the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize? A) To discuss feelings with each other and use support persons B) To focus on the other healthy children and move through the loss C) To seek causes for the fetal death and come to some safe conclusion D) To plan for another pregnancy within 2 years and maintain physical health A: To discuss feelings with each other and use support persons. To communicate in a therapeutic manner, the nurse''s goal is to help the couple begin the grief process by suggesting they talk to each other, seek family, friends and support groups to listen to their feelings. 45. The nurse is performing a pre-kindergarten physical on a 5 year-old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? A) vastus intermedius B) gluteus maximus C) vastus lateralis D) dorsogluteaI C: vastus lateralis. Vastus lateralis, a large and well developed muscle, is the preferred site, since it is removed from major nerves and blood vessels. 46. A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A) Non stress test B) Abdominal ultrasound C) Pelvic exam D) X-ray of abdomen B: Abdominal ultrasound. The standard for diagnosis of placenta previa, which is suggested in the client''s history of painless bleeding, is abdominal ultrasound. 47. A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states "This is not my baby, and I do not want it." After repositioning the child safely, the nurse's best response is A) "This is a common occurrence after birth, but you will come to accept the baby." B) "Many women have postpartum blues and need some time to love the baby." C) "What a beautiful baby! Her eyes are just like yours." D) "You seem upset; tell me what the pregnancy and birth were like for you." D: "You seem upset; tell me what the pregnancy and birth were like for you." A non-judgmental, open ended response facilitates dialogue between the client and nurse. 48. The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's parent reports that the child "feels very warm" to touch. The first action by the nurse should be to A) reassure the parent that this is normal B) offer the child cold oral fluids C) reassess the child's temperature D) administer the prescribed acetaminophen C: reassess the child''s temperature. A child''s temperature may have rapid fluctuations. The nurse should listen to and show respect for what parents say. Parental caretakers are often quite sensitive to variations in their children''s condition that may not be immediately evident to others. 749. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is critical for the nurse to include in the plan of care? A) hourly urine output B) white blood count C) blood glucose every 4 hours D) temperature every 2 hours A: hourly urine output. Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition. 50. A client is admitted to the rehabilitation unit following a cerebral vascular accident (CVA) and mild dysphagia. The most appropriate intervention for this client is to A) position client in upright position while eating B) place client on a clear liquid diet C) tilt head back to facilitate swallowing reflex D) offer finger foods such as crackers or pretzels A: position client in upright position while eating. An upright position facilitates proper chewing and swallowing. 51. A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse? A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device C: Assessing the client''s ability to participate in self care and/or the reliability of a caregiver. The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option. 52. A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered B: Administer epinephrine 1:1000 as ordered. All the answers are correct given the circumstances, but the priority is to administer the epinephrine, then maintain the airway. In the early stages of anaphylaxis, when the patient has not lost consciousness and is normotensive, administering the epinephrine is first, and applying the oxygen, and watching for hypotension and shock, are later responses. The prevention of a severe crisis is maintained by using diphenhydramine. 53. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. The physiological basis for this instruction is that the medication A) retards pepsin production B) stimulates hydrochloric acid production C) slows stomach emptying time D) decreases production of hydrochloric acid B: stimulates hydrochloric acid production. Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers. 54. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what? A) Dystonia B) Akathisia C) Brady dyskinesia D) Tardive dyskinesia D: Tardive dyskinesia. Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements. These findings are often described as Parkinsonian. 55. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? A) Drowsiness, lethargy, and inactivity B) Dry mouth, nasal congestion, and blurred vision C) Rash, blood dyscrasias, severe depression D) Hyperglycemia, weight gain, and edema 8C: Rash, blood dyscrasias, severe depression. Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics. 56. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? A) Complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) Continue to take prophylactic doses for at least 5 years after the diagnosis B: Begin treatment with acyclovir at the onset of symptoms of recurrence. When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Medications for herpes simplex do not cure the disease; they simply decrease the level of symptoms. 57. A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? A) Hypothermia B) Edema C) Dyspnea D) Epistaxis D: Epistaxis. A large dose of aspirin inhibits prothrombin formation and lowers platelet levels. With an overdose, clotting time is prolonged. 58. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first? A) Potassium levels B) Blood pH C) Magnesium levels D) Blood urea nitrogen A: Potassium levels. The most common cause of digitalis toxicity is a low potassium level. Clients must be taught that it is important to have adequate potassium intake especially if taking diuretics that enhance the loss of potassium while they are taking digitalis. 59. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement from the assessment data is likely to explain his noncompliance? A) "I have problems with diarrhea." B) "I have difficulty falling asleep." C) "I have diminished sexual function." D) "I often feel jittery." C: "I have diminished sexual function." Inderal, a beta-blocking agent used in hypertension, prohibits the release of epinephrine into the cells; this may result in hypotension which results in decreased libido and impotence. 60. The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time? A) Risk for fluid volume deficit related to morphine overdose B) Decreased gastrointestinal mobility related to mucosal irritation C) Ineffective breathing patterns related to central nervous system depression D) Altered nutrition related to inability to control nausea and vomiting C: Ineffective breathing patterns related to central nervous system depression. Respiratory depression is a life-threatening risk in this overdose. 61. Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice C: A decrease in lethargy. Lactulose produces an acid environment in the bowel and traps ammonia in the gut; the laxative effect then aids in removing the ammonia from the body. This decreases the effects of hepatic encephalopathy, including lethargy and confusion. 62. The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS C: Unprotected sex. Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risks for infection. 963. While interviewing a new admission, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to A) ask the client what she is feeling B) assess the client for auditory hallucination C) recognize the behavior as a side effect of medication D) re-focus the discussion on a less anxiety provoking topic A: ask the client what she is feeling. The initial step in anxiety intervention is observing, identifying, and assessing anxiety. The nurse should seek client validation of the accuracy of nursing assessments and avoid drawing conclusions based on limited data. In the situation above, the client may simply need to use the restroom but be reluctant to communicate her need! 64. A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse? A) Listen quietly without comment B) Ask for further information on the spies C) Confront the client’s delusion D) Contact the government agency A: Listen quietly without comment. The client''s comments demonstrate grandiose ideas. The most therapeutic response is to listen but avoid being incorporated into the client’s delusional system. 65. The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? A) Increased serum glucose B) Decreased albumin C) Decreased potassium D) Increased sodium retention C: Decreased potassium. In bulimia, loss of electrolytes can occur in addition to other findings of starvation and dehydration. 66. A client, recovering from alcoholism, asks the nurse, "What can I do when I start recognizing relapse triggers within myself?" How might the nurse best respond? A) "When you have the impulse to stop in a bar, contact a sober friend and talk with him." B) "Go to an AA meeting when you feel the urge to drink." C) "It is important to exercise daily and get involved in activities that will cause you not to think about drug use." D) "Let’s talk about possible options you have when you recognize relapse triggers in yourself." D: This option encourages the process of self evaluation and problem solving, while avoiding telling the client what to do. Encouraging the client to brainstorm about response options validates the nurse’s belief in the client’s personal competency and reinforces a coping strategy that will be needed when the nurse may not be available to offer solutions. 67. Therapeutic nurse-client interaction occurs when the nurse A) assists the client to clarify the meaning of what the client has said B) interprets the client’s covert communication C) praises the client for appropriate feelings and behavior D) advises the client on ways to resolve problems A: assists the client to clarify the meaning of what the client has said. Clarification is a facilitating/therapeutic communication strategy. Interpretation, changing the focus/subject, giving approval, and advising are non-therapeutic/barriers to communication. 68. Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills? A) Offer the client frequent opportunities to interact with 1 person B) Provide the client with frequent opportunities to interact with other clients C) Assist the client to analyze the meaning of the withdrawn behavior D) Discuss with the client the focus that other clients have similar problems A: Offer the client frequent opportunities to interact with 1 person. The withdrawn client is uncomfortable in social interaction. The nurse-client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships. 69. An important goal in the development of a therapeutic inpatient milieu is to A) provide a businesslike atmosphere where clients can work on individual goals B) provide a group forum in which clients decide on unit rules, regulations, and policies C) provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions D) discourage expressions of anger because they can be disruptive to other clients C: provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions. A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. 1070. A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you’re so perfect and pure and good." An appropriate response for the nurse is A) "Is that why you’ve been staring at me?" B) "You seem to be in a really bad mood." C) "Perfect? I don’t quite understand." D) "You seem angry right now." D: "You seem angry right now.". The nurse recognizes the underlying emotion with a matter of fact attitude, but avoids telling the clients how they feel. 71. A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action is the best in response to the client’s attire? A) Gently remind her that she is no longer on stage B) Directly assist client to her room for appropriate apparel C) Quietly point out to her the dress of other clients on the unit D) Tactfully explain appropriate clothing for the hospital B: Directly assist client to her room for appropriate apparel. It assists the client to maintain self-esteem while modifying behavior. 72. When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue as indicating a need for intervention. A) Angry outbursts at significant others B) Fear of being left alone C) Giving away valued personal items D) Experiencing the loss of a boyfriend C: Giving away valued personal items. Eighty percent of all potential suicide victims give some type of indication that selfdestructiveness should be addressed. These clues might lead one to suspect that a client is having suicidal thoughts or is developing a plan. 73. Which statement made by a client indicates to the nurse that the client may have a thought disorder? A) "I’m so angry about this. Wait until my partner hears about this." B) "I’m a little confused. What time is it?" C) "I can't find my 'mesmer' shoes. Have you seen them?" D) "I’m fine. It's my daughter who has the problem." C: "I can''t find my ''mesmer'' shoes. Have you seen them?". A neologism is a new word self invented by a person and not readily understood by another. Using neologisms is often associated with a thought disorder. 74. In a psychiatric setting, the nurse limits touch or contact used with clients to handshaking because A) some clients misconstrue hugs as an invitation to sexual advances B) handshaking keeps the gesture on a professional level C) refusal to touch a client denotes lack of concern D) inappropriate touch often results in charges of assault and battery A: some clients misconstrue hugs as an invitation to sexual advances. Touch denotes positive feelings for another person. The client may interpret hugging and holding hands as sexual advances. 75. A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are A) brittle hair, lanugo, amenorrhea B) diarrhea, nausea, vomiting, dental erosion C) hyperthermia, tachycardia, increased metabolic rate D) excessive anxiety about symptoms A: brittle hair, lanugo, amenorrhea. Physical findings associated with anorexia also include reduced metabolic rate and lower vital signs. 76. Which intervention best demonstrates the nurse's sensitivity to a 16 year-old’s appropriate need for autonomy? A) Alertness for feelings regarding body image B) Allows young siblings to visit C) Provides opportunity to discuss concerns without presence of parents D) Explores his feelings of resentment to identify causes C: Provides opportunity to discuss concerns without presence of parents. This intervention provides the teen with the opportunity to have control and encourages decision making. 77. The nurse's primary intervention for a client who is experiencing a panic attack is to A) develop a trusting relationship B) assist the client to describe his experience in detail 11C) maintain safety for the client D) teach the client to control his or her own behavior C: maintain safety for the client. Clients who display signs of severe anxiety need to be supervised closely until the anxiety is decreased because they may harm themselves or others. 78. A client was admitted to the eating disorder unit with bulimia nervosa. The nurse assessing for a history of complications of this disorder expects A) Respiratory distress, dyspnea B) Bacterial gastrointestinal infections, overhydration C) Metabolic acidosis, constricted colon D) Dental erosion, parotid gland enlargement D: Dental erosion, parotid gland enlargement. Dental erosion and parotid gland enlargement due to purging are common complications of binge eating followed by self-induced vomiting. 79. Which of the following times is a depressed client at highest risk for attempting suicide? A) Immediately after admission, during one-to-one observation B) 7 to 14 days after initiation of antidepressant medication and psychotherapy C) Following an angry outburst with family D) When the client is removed from the security room B: 7 to 14 days after initiation of antidepressant medication and psychotherapy. As the depression lessens, the depressed client acquires energy to follow the plan. 80. A client is admitted to a psychiatric unit with delusions. What findings could the nurse observe that would be consistent with delusional thought patterns? A) Flight of ideas and hyperactivity B) Suspiciousness and resistance to therapy C) Anorexia and hopelessness D) Panic and multiple physical complaints B: Suspiciousness and resistance to therapy. Clinical features of paranoid delusional disorder include extreme suspiciousness, jealousy, distrust, and a belief that others intend to invoke harm. 81. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "The urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D) "We notice muscle weakness and some unsteadiness." C: "Clothes are becoming tighter across her abdomen.". One of the most common signs of neuroblastoma is increased abdominal girth. The parents'' report that clothing is tight is significant, and should be responded to with additional assessments. 82. Parents call the emergency room to report that a toddler has swallowed drain cleaner. The triage nurse instructs them to call for emergency transport to the hospital. The nurse would also suggest that the parents give the toddler sips of _______ while waiting for an ambulance. A) Tea B) Water C) Milk D) Soda B: Water. Small amounts of water will dilute the corrosive substance prior to gastric lavage. 83. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? A) Ask the teenager to wait until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from the partner C) Refer the teenager to a community pediatric hospital emergency department D) Proceed with the triage process in the same manner as any adult client D: Proceed with the triage process in the same manner as any adult client. Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this married client has the legal capacity of an adult. 84. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness 12D: Abdominal mass and weakness. Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability. 85. The nurse is preparing the teaching plan for a group of parents about risks to toddlers and is including the proper communication in the event of accidental poisoning. The nurse should tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate? A) The parents' name and telephone number B) The currency of the immunization and allergy history of the child C) The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance D) The affected child's age and weight D: The affected child''s age and weight. All of the above information is important. However, after the substance is identified the age and weight are the priorities. This gives the appropriate health care providers an opportunity to calculate the needed dosage for an antidote while the child is being transported to the emergency department. After this information, the time of the 86. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would the nurse suspect is relevant to this disease? A) Our child had chickenpox 6 months ago. B) Strep throat went through all the children at the day care last month. C) Both ears were infected at 3 months of age. D) Last week both feet had a fungal skin infection. B: Strep throat went through all the children at the day care last month.. Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2 to 6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that the child most likely also had strep throat. Sometimes such an infection has no clinical symptoms. 87. The nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate? A) High doses of aspirin will be continued for some time B) Complete recovery is expected within several days C) Active range of motion exercises should be done frequently D) The measles, mumps and rubella vaccine should be delayed D: The measles, mumps and rubella vaccine should be delayed. Discharge instructions for a child with Kawasaki disease should include the information that immunoglobulin therapy may interfere with the body''s ability to form appropriate amounts of antibodies. Therefore, live immunizations should be delayed. 88. A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to A) limit milk and milk products B) encourage bed activities and games C) plan nursing care around lengthy rest periods D) promote a diet rich in iron C: plan nursing care around lengthy rest periods. The initial priority for this client is rest due to the inability of red blood cells to carry oxygen. 89. The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? A) Antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside within the first 24 hours C: Assess movement and sensation of extremities. Following corrective surgery for scoliosis, neurological status requires special attention and assessment, especially that of the extremities. 90. The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized? A) Call the Poison Control Center once the situation is identified B) Empty the child's mouth in any case of possible poisoning C) Keep the child as quiet as possible if a toxic substance was inhaled D) Do not induce vomiting if the poison is a hydrocarbon B: Empty the child''s mouth in any case of possible poisoning. Emptying the mouth of poison prevents further ingestion and should be done first to limit damage from the substance. Note that all of the actions are correct, but option B is the priority. 91. The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? A) Lethargy 13B) Irritability C) Negative Moro D) Depressed fontanel B: Irritability. Signs of increased intracranial pressure (IICP) in infants include bulging fontanel, instability, high-pitched cry, and cries when held. Vital sign changes include pulse that is variable, e.g., rapid, slow and bounding, or feeble. Respirations are more often slow, deep, and irregular. 92. The nurse is caring for a 4 year-old two hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? A) Vomiting of dark emesis B) Complaints of throat pain C) Apical heart rate of 110 D) Increased restlessness D: Increased restlessness. Restlessness and increased respiratory and heart rates are often early signs of hemorrhage. 93. The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? A) Storing the packed red cells in the medicine refrigerator while starting IV B) Slow the rate of infusion if the client develops fever or chills C) Limit the infusion time of each of the unit to a maximum of 4 hours D) Assess vital signs every 15 minutes throughout the entire infusion C: Limit the infusion time of each of the unit to a maximum of 4 hours. Infuse the specified amount of blood within 4 hours. If the infusion will exceed this time, the blood should be divided into appropriately sized quantities. 94. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? A) Prothrombin Time (PT) and partial thromboplastin time (PTT) B) Red blood cell and white blood cell counts C) Blood urea nitrogen and creatinine clearance D) Liver enzymes (AST and ALT) D: Liver enzymes (AST and ALT). Because acetaminophen is toxic to the liver and causes hepatic cellular necrosis, liver enzymes are released into the blood stream and serum levels of those enzymes rise. Other lab values are reviewed as well. 95. A nurse admits a premature infant who has respiratory distress syndrome (RDS). In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to A) stabilize thermoregulation B) maintain alveolar surface tension C) begin normal pulmonary blood flow D) regulate intracardiac pressure B: maintain alveolar surface tension. RDS is primarily a disease related to a developmental delay in lung maturation. Although many factors may lead to the development of the problem, the central factor is the lack of a normally functioning surfactant system in the alveolar sac from immaturity in lung development since the infant is premature. 96. The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to A) assess for abdominal distention B) maintain infant in an upright position C) begin formula feedings when infant is alert D) pump the shunt to assess for proper function A: assess for abdominal distention. The child is observed for abdominal distention because cerebrospinal fluid may cause peritonitis or a postoperative ileus as a complication of distal catheter placement. 97. A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: ”My child seems to have problems in learning to count and recognizing basic colors.” Based on this data, the nurse suspects that the child is most likely showing the effects of which problem? A) congenital abnormalities B) chronic toxoplasmosis C) fetal alcohol syndrome (FAS) D) lead poisoning C: fetal alcohol syndrome (FAS). Major features of FAS consist of facial and associated physical features, such as small head circumference and brain size (microcephaly), small eyelid openings, a sunken nasal bridge, an exceptionally thin upper lip, a short, upturned nose and a smooth skin surface between the nose and upper lip. Vision difficulties include nearsightedness (myopia). Other findings are mental retardation, delayed development, abnormal behavior such as short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety. Many behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome. 1498. A 15 year-old client has been placed in a Milwaukee brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower." A: "I will only have to wear this for 6 months.". The brace must be worn long-term, during periods of growth, usually for 1 to 2 years. It is used to correct curvature of the spine. 99. The nurse is caring for a 4 year-old admitted after receiving burns to more than 50% of his body. Which laboratory data should be reviewed by the nurse as a priority in the first 24 hours? A) Blood urea nitrogen B) Hematocrit C) Blood glucose D) White blood count A: Blood urea nitrogen. Glomerular filtration is decreased in the initial response to severe burns, with fluid shift occurring. Kidney function must be monitored closely, or renal failure may follow in a few days. 100. The nurse is caring for a client with a colostomy pouch. During a teaching session, the nurse appropriately recommends that the pouch be emptied A) when it is 1/3 to 1/2 full B) prior to meals C) after each fecal elimination D) at the same time each day A: when it is 1/3 to 1/2 full. If the pouch becomes more than half full it may separate from the flange