NSG 201 Saunders Review Test 1 (Nursing, Client Education) GRADED A Questions and Answer solutions with rationale/ 100% CORRECT.

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NSG 201 Saunders Review Test 1 1.ID: 9477033456 A client is being discharged home after a routine hip replacement surgery. The nurse is instructing the client on how to prevent postoperative compl... ications. What statements by the client would indicate the need for further teaching? Select all that apply. A. “Limiting fiber is necessary to avoid diarrhea.” Correct B. “I should empty my bladder when I feel the urge.” C. “Avoiding pain medication will prevent constipation.” Correct D. “I should drink plenty of liquids like iced tea or coffee.” Correct E. “I should continue with my physical therapy and walking.” Rationale: Constipation is common after surgery due to pain medication, decreased movement, and anesthesia. Fiber intake should be encouraged as it promotes the prevention of stool retention. Although pain medication can cause constipation, it should not be avoided in the post-operative period. Drinking plenty of fluids is encouraged for both bowel and bladder maintenance, but the client should choose non-caffeinated options. Physical therapy, walking, and exercise will help prevent constipation. Emptying the bladder when the urge is present can help prevent urinary tract infections. Test taking strategy: Note the strategic words need for further teaching. These words indicate a negative event query and the need to select the incorrect client statements. Think about the measures needed for bowel and bladder control to answer correctly. Review: bowel and bladder maintenance. Level of Cognitive Ability: Evaluating Client Need: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care: Perioperative Care Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health Promotion, Teaching and Learning/Patient Education References: Giddens, J. (2013). Concepts for nursing practice. (p. 143). St. Louis, MO: Mosby. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 969, 1089-1090). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 2.ID: 9477039828 The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client speaks limited English. What should the nurse do to ensure the client and family receives the most accurate information? Select all that apply. A. Provide culturally sensitive education. Correct B. Encourage family members to obtain a tuberculosis skin test. Correct C. Provide written instructions in English for the client to reference. D. Encourage the client and family to wash all dishes by hand to prevent the spread of infection. Incorrect E. Urge all family and close contact community members to seek and complete treatment to enhance compliance. Correct Rationale: As always, the nurse must provide culturally sensitive education. Because tuberculosis is highly contagious, all family members and close community members should have a tuberculosis skin test, seek treatment, and remain compliant. A full course of 6-9 months of treatment is needed to prevent re-infection. Instructions written in English are not helpful for the client with limited English skills. Washing dishes by hand is not the best way to prevent infection; rather a dishwasher should be used if available. Test Taking Strategy: Focus on the strategic word most to select correct options that relate to appropriate teaching for both the client and family members. Also, focusing on the data in the question will assist in answering. Review: Tuberculosis Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Implementation Content Area: Fundamentals of Care: Infection Control Priority Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education References: Giger, J. (2013). Transcultural nursing assessment & intervention. (6th ed. p. 445, 455). St. Louis: Mosby. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 533). St. Louis: Mosby. Awarded 1.0 points out of 3.0 possible points. 3.ID: 9477038294 A client with anxiety has just been seen by the health care provider and has been prescribed alprazolam. The client asks the nurse how long it will take for the medication to build up a steady state in her body. If the half life of this medication is approximately 11 hours, approximately how long will it take for this medication to build up and reach a steady state? hours Incorrect Correct Responses A. 55 Rationale: The half life of a medication is the amount of time it takes for 50% of the medication to leave the system. Steady state is the point where the concentration of the medication is equal based on the medication leaving the body system and new medication entering the system. Alprazolam has a half life of 11 hours. For all medications, it takes approximately five times the half life to reach steady state. Therefore the steady state for this medication is 55 hours (11 x 5 = 55). Test taking strategy: Focus on the subject, the time it takes to achieve a steady state of alprazolam in the body. Use the half life of the medication to calculate. Follow the calculation for steady state of five times the half life and verify your answer using a calculator. Review: half life of alprazolam. Level of Cognitive Ability: Understanding Client Need: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Fundamentals of Care: Medications and Administration Priority Concepts: Cellular Regulation, Safety HESI Concepts: Cellular Regulation, Safety References: Rosenjack Burchum, Rosenthal (2016), pp. 374-375 Stuart, G. (2013). Principles and practice of psychiatric nursing (10th ed., p. 526). St. Louis, MO: Mosby. Awarded 0.0 points out of 1.0 possible points. 4.ID: 9477033419 The nurse is observing the cardiac monitor of a client and notes this cardiac rhythm (refer to figure). What is the initial nursing action? A. Check for a pulse Correct B. Notify the health care provider C. Obtain a 12 lead electrocardiogram (ECG) D. Begin cardiopulmonary resuscitation (CPR) Rationale: Ventricular tachycardia can be stable or unstable depending on whether the client has a pulse or not. In this case, assessing the client’s pulse is the initial action. Obtaining a 12 lead ECG and notifying the health care provider may be necessary but are not initial actions. Initiating CPR may be necessary of the ventricular tachycardia becomes unstable and cardiac arrest occurs. Test-Taking Strategy: Note eh strategic word, initial. Use the steps of the nursing process and recall that assessment is the first step and the first action to take. Review: Ventricular Tachycardia Level of Cognitive Ability: Analyzing Client Need: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health: Cardiovascular Priority Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 799-800). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 5.ID: 9477032613 A mother brings her 9-month-old child to see the pediatrician and has concerns that the child may have a developmental delay because the child cannot roll over yet. for the nurse should ask the mother about which risk factors associated with a developmental delay? Select all that apply. A. Age B. Race Incorrect C. Income D. Chronic illness E. Low birth weight Correct F. Environmental exposure to toxins Correct Rationale: Developmental delays can occur at any age, however, it is most commonly seen in infancy through adolescence. Developmental delays can occur regardless of race. Children living in poverty, those with chronic illnesses, low birth weight, or exposure to environmental exposure to toxins are at a higher risk for developmental delays. Test taking strategy: Focus on the subject, risk factors associated with a developmental delay. Recall that developmental delays that occur in children are caused by prenatal, birth, social, and health risks. This will help eliminate the incorrect answers of age and race. Review: risk factors for developmental delays Level of Cognitive Ability: Analyzing Client Need: Health Promotion and Maintenance Integrated Process: Nursing Process/Assessment Content Area: Developmental Stages: Infancy to Adolescence Priority Concepts: Development, Patient Education HESI Concepts: Developmental, Teaching and Learning/Patient Education References: Giddens, J. (2013). Concepts for nursing practice. (p. 4). St. Louis, MO: Mosby. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 18-19, 432, 777). St Louis: Mosby. Awarded 1.0 points out of 4.0 possible points. 6.ID: 9477043118 The nurse in a pediatric unit is planning the staff assignments for children with developmental delays. When planning the assignment, the nurse decides to assign those children who have social or emotional delays amongst different nurses. Which children should be assigned to different nurses? Select all that apply. A. A child with autism Correct B. An infant with fetal alcohol syndrome Incorrect C. A child with attention deficit disorder D. A child with generalized anxiety disorder Correct E. A child with expressive language disorder Incorrect Rationale: A developmental delay is defined as not meeting the expected developmental level. Social and emotional developmental delays include those affecting personality, emotion, or behaviors. Two examples are autism, and generalized anxiety disorder. Attention deficit disorder and fetal alcohol syndrome are classified as cognitive developmental delays, and expressive language disorder is a communication developmental delay. Test Taking Strategy: Focus on the subject, planning assignments and children with social and emotional developmental delays. Use knowledge of the different types of developmental delays to eliminate those options. Review: developmental delays Level of Cognitive Ability: Creating Client Need: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Developmental Stages: Infancy to Adolescence Priority Concepts: Care Coordination, Development HESI Concepts: Care Coordination, Development References: Giddens, J. (2013). Concepts for nursing practice. (p. 4, 8-9). St. Louis, MO: Mosby. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 147-148). St Louis: Mosby. McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal- child nursing (4th ed., pp. 1492-1493). St. Louis: Elsevier. Awarded -1.0 points out of 2.0 possible points. 7.ID: 9477035226 The client has been prescribed amoxiciilin 250 mg three times daily for sinusitis. The medication is supplied in a 500 mg tablet. How many tablet(s) would the nurse prepare every 8 hours to administer the correct dose? Fill in the blank. Record the answer using one decimal place. tablet(s) Correct Correct Responses A. 0.5 Rationale: Use the medication calculation formula to calculate the correct dose. Desired 250 mg Available = 500mg Test-Taking Strategy: Focus on the subject, a medication calculation. Once you have performed the calculation, verify your answer with a calculator. Be aware of non-important numbers in the question that can be confusing. In this question, three times a day and 8 hours are not used in the calculation. Lastly, ensure that your answer makes sense. Review: medication calculations. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Fundamental of Care: Medication/IV Calculations Priority Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 486-487). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 8.ID: 9477039851 The nurse is caring for a client admitted to the hospital for shortness of breath and edema in both lower extremities. The client is prescribed furosemide 40mg by the intravenous route once daily. What information in the chart would warrant the nurse to verify continuing the prescription with the health care provider (HCP)? Refer to chart. H i s t o r y a n d P h y s i c a l La bo rat or y Fin din gs M ed ic at io ns E x p i r Bl oo d pr es Li si no pr il a t o r y r a l e s o n a u s c u l t a t i o n sur e 14 5/ 94 m m Hg 2 0 m g or all y da ily P e r i p h e r a l V a Se ru m Po tas siu m 3. 5 m Eq /L At or va st at in 1 0 m g or all s c u l a r D i s e a s e ( P V D ) (3. 5 m m ol/ L) y at be dt im e A. Expiratory rales B. Atorvastatin prescription C. Peripheral vascular disease D. Potassium level of 3.5 mEq/L (3.5 mmol/L) Correct Rationale: Furosemide is a potassium-losing diuretic. The serum potassium level of 3.5mEq/L (3.5 mmol/L) is on the lower limit of normal, and the nurse should anticipate that the potassium level would drop with the administration of furosemide. Therefore, the nurse should verify continuing the prescription if this potassium level was noted. Expiratory rales are an expected finding with fluid overload and furosemide would be an appropriate treatment. Atorvastatin and peripheral vascular disease are not impacted by the administration of furosemide. Test-Taking Strategy: Focus on the subject, the need to verify continuing the prescription. Note the data in the question and that the client is receiving furosemide. Recall that furosemide is a potassium-losing diuretic. Think about the side and adverse effects of this medication to answer correctly. Review: furosemide Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Analysis Content Area: Fundamentals of Care: Fluids & Electrolytes Priority Concepts: Collaboration, Safety HESI Concepts: Collaboration/Managing Care, Safety Reference: Rosenjack Burchum, Rosenthal (2016), pp. 456-457. Awarded 1.0 points out of 1.0 possible points. 9.ID: 9477033433 A nurse employed at a nursing home is caring for a client who has recently been transferred from the hospital to the nursing home. The client is confused and is acting out. The nurse suspects the client is suffering from relocation stress. The nurse should include which helpful actions in the plan of care? Select all that apply. A. Encourage friends and family to visit frequently. Correct B. Establish a trusting relationship with the client as soon as possible. Correct C. Change rooms frequently to prevent the client from becoming bored. D. Ensure the client is an active part of decision making regarding their care. Correct E. Allow the client to move around the halls as desired to decrease the confusion and acting-out. Rationale: Relocation stress can occur when a client is removed from their usual surrounding such as home. In order to provide safe and quality care, encourage friends and family to visit the client often and establish a trusting relationship with the client as soon as possible. It is important for the client to have an active role in decision-making. In order to lessen confusion, the nurse should provide the client time to become familiar with the immediate surroundings such as his or her room before allowing or encouraging ambulation to new surroundings; allowing the client to move around the halls as desired may increase confusion and acting-out behaviors. Likewise, changing the client’s room frequently may increase confusion. Test-Taking Strategy: Focus on the subject, relocation stress. Also note that the client is confused and acting-out. Think about this type of stress and the manifestations and what you might expect from a client who is experiencing relocation stress. Use that knowledge to determine appropriate nursing actions. Review: relocation stress. Level of Cognitive Ability: Creating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Planning Content Area: Fundamentals of Care: Safety Priority Concepts: Safety, Stress HESI Concepts: Safety, Stress and Coping References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed. p. 19). St. Louis, MO: W.B. Saunders Company. Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 70). St. Louis: Mosby. Awarded 2.0 points out of 3.0 possible points. 10.ID: 9477034772 The nurse is caring for a client in the hospital and is reconciling the client’s home medications. The client is taking Lactobacillus, a probiotic over-the counter medication. The nurse is discussing the supplement with the client. What statement by the client would warrant the need for further teaching? Select all that apply. A. “I can take my probiotic at any time of day or night.” Correct B. “Probiotics can be found in yogurt and some juices.” C. “I should take this supplement to prevent gas and bloating.” Correct D. “Because I’m lactose intolerant, a probiotic would not benefit me.” Correct E. “This supplement will help me avoid getting diarrhea from antibiotics.” Incorrect Rationale: Probiotics are live microorganisms that are similar to those found naturally occurring in the gastrointestinal tract. Probiotics should be taken as directed, usually with a meal, and can have a side effect of gas and bloating. If gas an bloating do occur, the client should be advised to try a different type of probiotic. Probiotics are recommended for those clients who are lactose intolerant. Probiotics are found in foods such as yogurts and some juices and can be helpful to treat antibiotic-associated diarrhea. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select he incorrect client statements. Use knowledge of probiotic supplements to determine the correct options. Review: the uses and effects of probiotics Level of Cognitive Ability: Evaluating Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Pharmacology: Gastrointestinal Medications Priority Concepts: Client Education, Health Promotion HESI Concepts: Health Promotion, Teaching and Learning/Patient Education References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed. p. 10). St. Louis, MO: W.B. Saunders Company. Rosenjack Burchum, Rosenthal (2016), pp. 1325-1326. Awarded 1.0 points out of 3.0 possible points. 11.ID: 9477042148 The nurse educator is presenting a lecture on child neglect. Which statement by one of the students indicates that the teaching has been effective? Select all that apply. A. “A sign of neglect are bruises on the child’s body.” B. “Neglected children show aggression after age 10.” C. “Neglect is parental failure to meet a child’s basic needs.” D. “Neglected children often have learning problems and low self- esteem.” Correct E. “Neglect occurs when a parent does not seek medical attention for a sick child.” Correct Rationale: Neglect has serious consequences for children. Basically, there are 5 types of child neglect: physical neglect; psychological or emotional neglect; medical neglect; mental health neglect; and educational neglect. One sign of physical neglect is bruising on the child’s body. Neglect is the parental failure to meet a child’s basic needs such as: food, shelter, comfort, love, and medical attention. Consequences of neglect include: learning problems, low self-esteem, developmental delays, passivity and juvenile delinquency. Children who are neglected often show signs of aggression before the age of 2. Test-Taking Strategy: Focus on the strategic word “effective”. Determine which statements indicate that the teaching has been effective, by determining which statements are true. Note the age of the child in option 2. This will assist in eliminating this option. Review: Signs of child abuse. Level of Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Teaching and Learning Content Area: Leadership/Management Giddens Concepts: Health Care Law, Interpersonal Violence HESI Concepts: Health Policy/Systems – Health Care Law, Violence References: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p. 353). St. Louis: Mosby. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 562). St Louis: Mosby. Awarded 3.0 points out of 4.0 possible points. 12.ID: 9477032667 The nurse is obtaining the medical history from an older client with a black eye and bruising to the head. The nurse suspects that the client has been abused, and that there may be a history of abuse. Which statement by the client indicates the need for further questioning by a social worker? Select all that apply. A. “Perhaps I somehow did this to myself.” Correct B. “I tripped over a rug and now I have a black eye.” Correct C. “I got into a car accident yesterday and the airbag deployed.” D. “Well, I don’t remember anything that would have caused the injuries.” Correct E. “Sometimes my grandson becomes angry with me when I can’t give him money.” Correct Rationale: There are certain elements in the medical history that raise concern for physical abuse. Perpetrators may provide a history of events that are incomplete or inconsistent with injuries seen. Many individuals who experience interpersonal violence are unable or afraid to provide an accurate account of events. Often individuals will provide a history of trauma that is inconsistent with the physical examination. It is unlikely that these injuries were self-inflicted or the result of tripping over a rug. Having no recollection of how an injury occurred should be an alert to the nurse, as well as statements that another person caused the injury. The nurse should immediately report this to a health care provider and the social worker so that proper intervention and follow-up can be arranged. A car accident with air bag deployment could reasonably cause the injuries to the client. The nurse should continue on with assessment, treatment and arrange follow-up care for the client. Test-Taking Strategy: Focus on the subject, “abuse to an older client”. Determine which statements made by the client would indicate that abuse may be occurring. Abuse individuals often make statements that do not correlate with injuries. Eliminate option 3, because air bag deployment could have caused the client’s injuries. Review: Signs of abuse in the older client. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Leadership/Management Giddens Concepts: Clinical Judgment, Interpersonal Violence HESI Concepts: Health Policy/Systems – Health Care Law, Violence References: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p. 354.). St. Louis: Mosby. Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 565-566). St Louis: Mosby. Awarded 3.0 points out of 4.0 possible points. 13.ID: 9477043128 The nurse is meeting with an older client who was brought into the health care facility for evaluation. According to the family member, the client has lost a large amount of weight recently and does not eat much. Which actions would be the most important for the nurse to take? Select all that apply. A. Assess the client's eyesight. Correct B. Question the client about urinary habits. C. Obtain a list of the client's medications. Correct D. Determine the fit of the client's dentures. Correct E. Assess the client for mental status changes. Correct Rationale: Older adults in the community or in any health care setting are most at risk for poor nutrition. The nurse should review the medical history to determine the possibility of increased metabolic needs or nutritional losses, chronic disease, trauma, recent surgery of the gastrointestinal tract, drug and alcohol abuse, and recent significant weight loss. Each of these conditions can contribute to malnutrition. As part of a thorough assessment, the nurse should assess the client's eyesight. Clients with poor vision are often not able to drive to obtain groceries or cook for themselves. The nurse should also obtain a list of the client's medications, both prescription and over-the-counter. Certain medications can alter the taste perception and decrease the desire to eat. It is also important for the nurse to determine the fit of the client's dentures. Poor fitting dentures can lead to painful sores, which lead to a decrease in food intake. The nurse should also include an assessment of the client's mental status, observing for behavoir that may be abnormal for the client. Utilizing the family member's knowledge of the client's typical behavior will be important in the treatment of this client. While the client's urinary status is important to assess, it is not the most important action for the nurse to take at this time because it is not directly related to weight loss. Test-Taking Strategy: Focus on the strategic words, “most important”. Next, determine which actions would help the nurse determine the cause of the client’s weight loss. Eliminate option 2, because questioning the client’s urinary habits would not be directly related to determining the cause of weight loss. Review: Older Adult Nutrition. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity. Integrated Process: Nursing Process/Implementation. Content Area: Nutrition Giddens Concepts: Clinical Judgment, Nutrition HESI Concepts: Clinical Decision-Making/Clinical Judgment, Metabolism - Nutrition Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1341). Philadelphia: Saunders. Awarded 3.0 points out of 4.0 possible points. 14.ID: 9477042181 The nurse is caring for a malnourished client with dementia and a history of rheumatoid arthritis, and is creating a plan of care for the client’s nutrition. Which nursing actions are most appropriate for increasing the client's caloric intake? Select all that apply. A. Provide pain medications as needed. Correct B. Play soft, calming music during mealtimes. Correct C. Serve the food at the appropriate temperature. Correct D. Provide the client with six small meals per day. Correct E. Encourage the client to eat quickly, to prevent fatigue. Rationale: Malnutrition results from inadequate nutrient intake, increased nutrient losses, and increased nutrient requirements. Inadequate nutrient intake can be linked to poverty, lack of education, substance abuse, decreased appetite, and a decline in functional ability to eat independently, particularly in older adults. In order to support the client, the nurse should provide pain medication as needed so that the client is comfortable during meal times. The nurse can make mealtime positive by providing a quiet environment, which is conducive to eating. Soft music may calm those with advanced dementia or delirium. It is important that the nurse serve the client’s food at the appropriate temperature, in order to make the food appealing to the client. Arranging for the client to eat six small meals per day, instead of three large meals, may increase the client’s desire to eat, and prevent the client from being overwhelmed by a large amount of food at each meal. It is important that the nurse avoid rushing the client through a meal, but allow as much time as needed. Resource: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1340, 1343). Philadelphia: Saunders. Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Eliminate option 5, because this action would likely cause the client to take in fewer calories. Review: Malnutrition. Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Nutrition Giddens Concepts: Health Promotion, Nutrition HESI Concepts:Health, Wellness, and Illness – Health Promotion, Metabolism - Nutrition Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1340, 1343). Philadelphia: Saunders. Awarded 3.0 points out of 4.0 possible points. 15.ID: 9477036624 The nurse is educating a client on obesity. Which statements by the client indicate a need for further teaching? Select all that apply. A. "Type II diabetes is a complication of obesity". B. "I will likely develop obstructive sleep apnea". C. "Physical inactivity is one of the causes of obesity". D. "My heart and lungs are mildly affected by obesity". Correct E. "It is unlikely that I will develop peripheral artery disease". Correct Rationale: Obesity refers to an excess amount of body fat when compared with lean body mass. After receiving education from the nurse, the client should be able to state that complications and risks of obesity such as type II diabetes and peripheral artery disease and other cardiovascular and respiratory system complications such as obstructive sleep apnea. It is also important that the nurse discuss the causes of obesity, which include physical inactivity. Encouraging the client to exercise 20 minutes per day can decrease the risk of obesity and life threatening illnesses. Test-Taking Strategy: Focus on the strategic words, “need for further teaching.” Think about the physiological effects of obesity to assist in answering correctly. Eliminate statements that show that the teaching has been effective, such as options 1, 2, and 3. These options demonstrate that the client has an adequate understanding of the consequences of obesity. Options 4 and 5 are incorrect, showing the client would benefit from further education from the nurse. Review: Obesity. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Nutrition Giddens Concepts: Client Education, Nutrition, HESI Concepts: Health, Wellness, and Illness: Nutrition/ Teaching and Learning:Patient Education Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1350). Philadelphia: Saunders. Awarded 2.0 points out of 2.0 possible points. 16.ID: 9477038260 The nurse is attending a teaching sessionatt on communicating with the ill child. Which statement by the nurse indicates that the teaching has been effective? Select all that apply. A. "I will strive to maintain honesty and trust with each child". Correct B. "Children are often reluctant to ask questions, when they fear the answers". Correct C. "Providing as much information as possible will help ease the child's fears". Incorrect D. "Complete honesty may cause problems for some family and staff members". Correct E. "To prevent misunderstandings, I should ask the child to explain what is known". Correct Rationale: Communication is the most important factor in establishing a good relationship with the child and family. The nurse caring for the ill child should strive to make the child feel comfortable, as well as decrease any fears that the child may have. After listening to the lecture on communication with the ill child, the nurse should understand the need to strive to maintain honesty and trust with each child. Lack of honesty and trust can hinder care and leave the child feeling frightened. The nurse should also understand that children often are reluctant to ask questions when they fear the answers. The nurse should keep the child informed, while clarifying any questions the child has. Clarifying questions can help the nurse avoid providing more information than the child wants or can handle emotionally. Providing too much information may be overwhelming and frightening to the child. It may also inhibit future questions and interaction with the nurse. It is important for the nurse to consider that not everyone agrees with complete honesty; at times, parents may directly ask the nurse to withhold information from the child. It is important that the nurse maintain honesty, using terms that the parents agree upon. One of the most important aspects of communicating with a child is to have the child explain what is already known to them about their illness. The nurse can then answer questions accordingly without overwhelming the child with information. Test-Taking Strategy: Focus on the strategic word, “effective.” Think about the developmental process and the effects illness can cause Determine which statements show that the nurse has an understanding of the topic, communication with the ill child. Eliminate option 3, because this statement indicates that more education is needed. Review: Communication techniques. Level of Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Child Health Giddens Concepts: Caregiving, Communication.. HESI Concepts: Communication, Developmental Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of (10th ed. pp. 92-94). St Louis: Mosby. Awarded 1.0 points out of 4.0 possible points. 17.ID: 9477039896 A client is being assessed for post-partum depression. Which actions by the client would indicate a need for follow-up by the nurse? Select all that apply. A. Not responding to the infant’s cries. Correct B. Crying after talking with spouse on the phone. Correct C. Stating that family was not supportive of the pregnancy. Correct D. Making statements about being fat and unattractive now. Correct E. Stating that that the infant latched on properly during a feeding. Rationale: The weeks following the birth are a time of vulnerability to psychiatric disorders, such as depression for many women, causing significant distress for the mother, disrupting family life, and, if prolonged, negatively affecting the child's emotional and social development. Mood and anxiety disorders are particularly likely to recur or worsen during these weeks. Such conditions can interfere with attachment to the newborn and family integration, and some may threaten the safety and well-being of the mother, the newborn, and other children. It is important that the nurse frequently assess the client for post-partum depression. Ignoring the infant’s cries should alert the nurse that further assessment is needed. Crying after talking with a spouse of the phone could indicate a problem at home. Statements of non-supportive family members need to be addressed by the nurse, for the safety and well-being of the client and infant. The nurse should also address the client’s statements about body image, educating the client about what is normal and what is not normal in the post-partum period. Stating that the infant latched on during a feeding is a positive action and would not indicate the need for further assessment. Test-Taking Strategy: Focus on the strategic words, “need for follow-up.” Determine which actions by the client indicate that the client could be experiencing post-partum depression. Eliminate option 5, because this statement is positive and does not indicate that the client is experiencing post- partum depression. Review: Post-partum depression. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity Giddens Concepts: Clinical Judgment, Mood and Affect HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., pp. 748-749). St. Louis: Elsevier. Awarded 3.0 points out of 4.0 possible points. 18.ID: 9477038244 The nurse is evaluating a client who is four weeks post-partum. Which statement by the client would indicate a need for intervention? Select all that apply. A. "I feel like giving up." Correct B. "My husband never helps me with the baby." Correct C. "My baby will not stop crying and I can't take it anymore." Correct D. "I wish I could get more than four hours of sleep at a time." E. "My milk has come in and my baby is nursing every 2 hours." Rationale: Post-partum depression is an intense and pervasive sadness with severe and labile mood swings and is more serious and persistent than postpartum blues. Intense fears, anger, anxiety, and despondency that persist in the new mother past the baby's first few weeks of life are not a normal part of postpartum blues. These symptoms rarely disappear without professional help. The nurse should be aware of statements that could place the well-being of the client and infant at risk, such as wanting to give up or reporting lack of support from a spouse. An inconsolable infant should be evaluated to determine the cause of crying. Most clients in the post-partum period struggle with sleep due to the infant waking up for feedings, which is a normal part of infant life in the first few weeks. An infant who nurses every two hours at four weeks of life is a normal finding and does not require an intervention. Test-Taking Strategy: Focus on the strategic words, “need for intervention.” Determine which actions by the client indicate that the nurse should intervene. Eliminate options 4 and 5, because these statements are positive and do not indicate a need for the nurse to intervene. Review: post-partum depression. Level of Cognitive Ability: Analyzing Client Needs: Psychosocial Integrity. Integrated Process: Nursing Process/Assessment Content Area: Maternity Giddens Concepts: Clinical Judgment, Mood and Affect HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., p. 749). St. Louis: Elsevier. Awarded 2.0 points out of 3.0 possible points. 19.ID: 9477036611 The client is being discharged home after the delivery of a healthy infant. The nurse is educating the client on how to prevent postpartum depression. Which activities are the most appropriate for the nurse to suggest? Select all that apply. A. Exercise on a regular schedule Correct B. Eat a healthy, well-balanced diet Correct C. Try to sleep when the baby sleeps Correct D. Don’t overcommit yourself to activities that will be tiring Correct E. Stay home with the baby as much as possible, to promote bonding Incorrect Rationale: The postpartum nurse must observe the new mother carefully for any signs of tearfulness and conduct further assessments as necessary. Nurses must discuss post-partum depression to prepare new parents for potential problems in the postpartum period. The nurse can provide activities and recommendations to improve the client’s health and well-bring. Exercising on a regular basis will help the client feel better and maintain physical health, as well as eating a healthy diet. The nurse should also suggest avoiding over commitment to activities that will tire the new mother. The nurse should advise the client to sleep when the infant sleeps. While it is important for the client to bond with the infant, the client should not be isolated from friends and family. Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Determine which activities will assist the client in preventing post-partum depression. Eliminate option 5 because it isolates the client from others and could lead to post-partum depression. Review: Prevention of post-partum depression. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity. Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health, Wellness, and Illness – Health Promotion, Teaching and Learning/Patient Education Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., p. 748). St. Louis: Elsevier. Awarded 2.0 points out of 4.0 possible points. 20.ID: 9477039870 The nurse is preparing to discharge a child who was treated in the emergency department. Which should the nurse consider when planning medication discharge instructions for the client's parents? Select all that apply. A. Provide the child's parents with a simple dosing schedule. Correct B. Create a medication schedule that fits the parent’s lifestyle. Correct C. Assist the child’s parents in obtaining the medication at an affordable cost. Correct D. Ensure that the child's family is able to read the written discharge instructions. Correct E. Refer the family to the pharmacist with questions about medication side effects. Incorrect Rationale: Medicating infants and children is an important nursing responsibility. The nurse plays a key role in administering medications, supporting the child and family during the experience, and teaching the child and parents about pharmacologic aspects of the child's care. The nurse should not only coordinate the child's care, but also the discharge process. It is important that the nurse create a medication schedule that fits the family’s lifestyle and provide the family with a simple dosing chart. This helps to ensure that the childreceives proper medication dosing and prevents medication errors. The nurse should consider cost of prescribed medications and providing the family with resources as needed. During the discharge process, the nurse should verify that the family can read the written discharge instructions and answer any questions about the prescribed medications, including side effects. Test-Taking Strategy: Focus on the subject, “discharge planning“ and “medication instructions.” The discharge process is often complex, the nurse should take actions to simplify this as much as possible. Eliminate options 5, because the nurse should review medications and side effects with the family during the discharge. Although the pharmacist is an excellent resource, it is the nurse’s responsibility to teach about the medication. Review: Discharge teaching. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Giddens Concepts: Care Coordination, Client Education HESI Concepts: Collaboration/Managing Care – Care Coordination, Teaching and Learning/Patient Education Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of h ed. pp. 932-933). St Louis: Mosby. Awarded 1.0 points out of 4.0 possible points. 21.ID: 9477042110 The nurse is preparing to administer blood to a client. Which actions by the nurse are the most appropriate before administration of the blood? Select all that apply. A. Assess laboratory values. Correct B. Obtain and assess vital signs. Correct C. Evaluate the client’s venous access. Correct D. Identify the client by room number and bed. E. Check the health care provider’s prescriptions with another nurse. Correct Rationale: Preparation of the client for transfusion therapy is critical, and institutional blood product administration procedures must be carefully followed. Before administering any blood product, review the agency's policies and procedures. The nurse should take care to ensure that the client is adequately prepared to receive the blood. This is accomplished by assessing the client’s laboratory values, in order to determine the client’s need for intervention. The nurse should be aware of the health care facilities policies and procedures regarding blood administration. The nurse should also obtain and assess the client’s vital signs, prior to blood administration. This is completed so that the nurse can detect any change from the client’s baseline during the administration. The client’s venous access should be assessed prior to the blood administration, ensuring that at least a 20 gauge IV is in place and patent. Checking the health care provider’s prescription with another nurse is a crucial step that must be completed. The nurse should not simply identify the client by room number and bed. The nurse must follow the policies and procedures set by the health care facility for safe blood administration. Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Determine which actions should be completed by the nurse prior to blood administration. Eliminate option 4, because this step is unsafe and could lead to client harm. The nurse should identify the client using appropriate and safe identifier guidelines. The nurse should take steps to provide for client safety during blood administration. Review: Blood Administration. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Analysis Content Area: Blood Administration Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., p. 822). St. Louis: Saunders. Awarded 3.0 points out of 4.0 possible points. 22.ID: 9477041089 The nurse is evaluating a medication prescription written by the health care provider. Which pieces of information should the nurse verify has been included in the prescription? Select all that apply. A. The specific dosage Correct B. The client’s home address C. The generic medication name Correct D. The length of time for the administration Correct E. The route and frequency of administration F. Correct Rationale: Medication safety is extremely important in all health care settings. The Joint Commission publishes new and updated National Patient Safety Goals (NPSGs) every year. The nurse should be prepared to evaluate each medication prescription to ensure that the proper information is included, and intervene when necessary to provide safe client care. The information should include: the specific dosage, generic drug name, length of drug administration and route and frequency of administration. The medication prescription does not need to include the client’s home address. Test-Taking Strategy: Focus on the subject, “verifying the required information in a medication prescription.” Determine what information is pertinent for safety. Eliminate option 2, because the client’s home address is not considered pertinent information in this situation. Review: Components of a medication prescriptions Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Assessment Content Area: Fundamentals of Care: Safety Giddens Concepts: Care Coordination, Safety HESI Concepts: Care Coordination, Safety Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 489-490). St. Louis: Mosby. Awarded 3.0 points out of 4.0 possible points. 23.ID: 9477039841 The nurse is caring for a postoperative client with a patient controlled analgesia (PCA) pump. When creating the client’s plan of care, which opiate-induced side effects should the nurse monitor? Select all that apply. A. Sedation Correct B. High blood glucose C. Increased appetite D. Nausea and vomiting Correct E. Elevated cardiac enzymes Rationale: Patient-controlled analgesia (PCA) is a common way to address the problem of inadequate analgesia by allowing the client to control the dosage of opioid received. This approach to pain control can improve pain relief and increase client satisfaction. It can also decrease the amount of opioid consumption per day when compared with nurse-administered intermittent dosing methods. When creating the plan of care, the nurse should anticipate opiate-induced side effects, and be prepared to monitor for them and manage them. These side effects include sedation, nausea, and vomiting. High blood glucose, increased appetite and elevated cardiac enzymes are not typical opiate-induced side effects. Test-Taking Strategy: Focus on the subject, “opiate-induced side effects.” Think about the physiological effects of an opiate on the body to assist in answering correctly. Review: Opiate-induced side effects. Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Giddens Concepts: Care Coordination, Pain HESI Concepts: Care Coordination, Pain Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 43-44, 271). St. Louis: Saunders. Awarded 2.0 points out of 2.0 possible points. 24.ID: 9477041052 The nurse is providing discharge instructions to a client with rheumatoid arthritis who is taking leflunomide. Which instructions should the nurse give to the client? Select all that apply. A. “You may lose your hair.” Correct B. “It is ok to drink alcohol.” C. “Diarrhea is a common side effect.” Correct D. “It has been shown that leflunomide can cause birth defects.” Correct E. “Leflunomide is a potent medication that is generally tolerated.” Correct Rationale: Medication therapy and nonpharmacologic interventions are used to manage systemic inflammation and joint pain. The expected outcome is that the disease goes into remission and its progression slows. When creating and providing discharge instructions, it is important that the nurse include accurate information. The nurse should educate that the client that hair loss and diarrhea are possible. Women of child-bearing age should remain strict with birth control, as the medication can cause birth defects. The client should be educated that while leflunomide is a potent medication, it is generally well tolerated. Test-Taking Strategy: Focus on the subject, “discharge instructions for the client receiving leflunomide.” Use general medication guidelines to assist in answering correctly. Remember alcohol should not be consumed if the client is taking medications. Review: Discharge instructions for leflunomide. Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology Giddens Concepts: Client Education, Safety HESI Concepts: Teaching and Learning/Patient Education, Safety Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 308, 310). St. Louis: Saunders. Awarded 3.0 points out of 4.0 possible points. 25.ID: 9477034713 The nurse is caring for a client who has been admitted to the intensive care unit with acute pulmonary edema. After assessing the client, the nurse administers furosemide as prescribed. Which actions by the nurse are the most important after administering the medication? Select all that apply. A. Assess lung sounds Correct B. Measure urine output Correct C. Obtain and monitor vital signs Correct D. Document the client’s meal intake E. Assess the client for pitting edema Incorrect Rationale: The client with pulmonary edema usually needs aggressive treatment and continuous cardiac monitoring. The nurse should be prepared to assess the client and manage the pulmonary edema efficiently. The most important interventions for the nurse to take after administration of the medication include: assessing the client lung sounds and vital signs and measuring the urine output. These interventions will assist in evaluating client status and response to treatment and alert the nurse to any deterioration in the client’s health. Documenting the client’s meal intake and assessing for pedal edema are not the most important actions to take after administering the medication. Test-Taking Strategy: Focus on the strategic words, “most important.” Recall that furosemide is a diuretic and think about its expected effects in the treatment of pulmonary edema. Review: furosemide and pulmonary edema Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity. Integrated Process: Nursing Process/Implementation Content Area: Pharmacology Giddens Concepts: Gas Exchange, Perfusion HESI Concepts: Oxygenation/Gas Exchange, Perfusion Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 689, 715). St. Louis: Saunders. Awarded 2.0 points out of 3.0 possible points. 26.ID: 9477038207 The nurse preceptor is orienting a new nurse on an acute medical-surgical unit and educating the nurse on peripherally inserted central catheters (PICCs). Which statement by the new nurse indicates an understanding of a PICC? Select all that apply. A. “The tip of the PICC line sits in the superior vena cava.” Correct B. “Insertion of the PICC line occurs in the operating room.” Incorrect C. “PICCs can accommodate infusions of all types of therapy.” Correct D. “PICCs with a lumen size of 14 Fr or larger can be used for blood sampling.” Correct E. “PICCs are the most appropriate for client’s who require short-term antibiotics.” Rationale: A peripherally inserted central catheter (PICC) is a catheter inserted through a vein of the antecubitcal fossa (inner aspect of the bend of the arm) or the middle of the upper arm. When educating the new nurse on the purpose and use of PICC lines, the nurse preceptor should discuss the placement of the PICC line, including where the PICC line is placed in the body. The nurse should explain that PICC line insertions are typically done at the client’s bedside, by a nurse with specialized training. PICC lines can accommodate infusions of all types of therapy because the tip sits in the superior vena cava, where the rapid blood flow quickly dilutes the infusion. The nurse preceptor should include information about blood sampling, such as only sampling blood from a PICC line with a lumen size of a 14 Fr or larger. The new nurse should also recognize that PICC lines are often used for client’s who require long-term antibiotics, in order to protect the vein and skin tissue. Test-Taking Strategy: Focus on the subject, “an understanding about a PICC line.” It is necessary to know about these types of infusion catheters in order to answer correctly. Thinking about the anatomical location of the tip of the catheter may assist in answering correctly. Review: PICC lines. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Intravenous Administration Giddens Concepts: Safety, Teaching and Learning HESI Concepts: Teaching and Learning/Patient Education, Safety Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 193-194). St. Louis: Saunders. Awarded 2.0 points out of 3.0 possible points. 27.ID: 9477039859 The nurse is assigned to care for a client who needs an intravenous (IV) catheter inserted and will receive an IV infusion of a vesicant medication. When creating a plan of care for the client, which interventions should the nurse include in the plan? Select all that apply. A. Assess the skin integrity Correct B. Monitor the site frequently Correct C. Place the IV at an area of flexion D. Educate the client about the signs and symptoms of infiltration Correct E. Understand the vesicant potential before administering the infusion Correct Rationale: It is important that the nurse take time to prepare for the IV infusion before administering any medication. The nurse should assess the client’s skin integrity prior to selecting an IV site. The nurse should avoid placing the IV at an area of flexion, such as in the antecubital space, or any other space that will limit or prevent the client’s range of motion. The nurse should plan to monitor the site frequently for signs of infiltration. The nurse should also educate the client about the signs and symptoms of infiltration and inform the client to alert the if any signs such as discomfort occur. Prior to administering the infusion, the nurse should understand the vesicant potential. Test-Taking Strategy: Focus on the subject, “creating a plan of care for a client receiving an IV infusion of a vesicant medication.” Remember that the nurse needs to know what is being administered before administration. Next remember that assessing and monitoring is always a part of a plan of care as is client education. Eliminate option 3 noting the words “area of flexion.” Review: Skin Integrity. Level of Cognitive Ability: Creating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Intravenous Administration Giddens Concepts: Health Care Quality, Tissue Integrity HESI Concepts: Quality Improvement/Health Care Quality, Tissue Integrity Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 191-192, 379). St. Louis: Saunders. Awarded 4.0 points out of 4.0 possible points. 28.ID: 9477041010 The nurse is preparing to administer oral potassium chloride to a client. What should the nurse keep in mind about this medication? Select all that apply. A. Potassium has a strong, unpleasant taste. Correct B. Potassium can only be mixed with water. Incorrect C. Potassium may be taken in a liquid or solid form. Correct D. Potassium chloride can cause nausea and vomiting. Correct E. Potassium may be given as an intramuscular (IM) injection. Rationale: Interventions for hypokalemia aim to determine the cause, prevent further potassium loss, increase serum potassium levels, and ensure client safety. When preparing to administer potassium to the client, the nurse should keep in mind that potassium has a strong, unpleasant taste that is often difficult to mask. The client should be made aware of this beforehand. Oral potassium may be taken as either a liquid or a solid. This is important to keep in mind for clients who have difficulty swallowing large pills. The nurse should be aware that potassium chloride can cause nausea and vomiting, therefore it is recommended that the client take the medication with food. Potassium can be mixed with a variety of liquids, in order to make the medication more pleasant for the client. Potassium should never be administered IM, because it is a severe tissue irritant. Test-Taking Strategy: Focus on the information in the question, “administration of oral potassium.” Eliminate option 2 because of the closed-ended word “only.” Noting that the question is asking about oral administration will assist in eliminating option 5. Review: Potassium chloride Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Pharmacology Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Lilley, L., Rainforth Collins, S., Harrington, S., & Snyder J. (2014). Pharmacology and the nursing process (7th ed., pp. 487-488). St. Louis: Mosby. Awarded 0.0 points out of 3.0 possible points. 29.ID: 9477036698 The nurse is caring for a client with a latex allergy. Upon entering the client’s room, the nurse should plan to take which action as the priority? A. Perform a skin assessment B. Perform a physical assessment C. Ask if the client needs pain medication D. Remove the banana from the client’s breakfast tray E. Correct Rationale: A sensitivity or allergy to certain substances alerts the nurse to other possible cross allergies. The nurse should be aware of this and prevent allergic reactions whenever possible. The nurse should know that the client with an allergy to latex, may also be allergic to bananas. The priority action that the nurse should plan to take when entering the client’s room, is to remove the banana from the client’s breakfast tray. The other actions can be completed once the risk of allergic reaction has been removed. Test-Taking Strategy: Focus on the strategic word, “first” and focus on the data in the question, that the client has a latex allergy. It is necessary to know cross- sensitivities to answer correctly. Eliminate options 1, 2, and 3, because these actions can safely wait until the banana has been removed from the client’s breakfast tray. Also note that options 1 and 2 are comparable or alike and can be eliminated. Review: latex allergy Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management: Prioritizing Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 402-403). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 30.ID: 9477043159 The nurse has been assigned to care for an older client with a hip fracture who had surgical repair. After receiving report, the nurse learns that the health care provider has prescribed meperidine for pain management. Which action should the nurse take first? A. Prepare the medication B. Verify the dosage of meperidine Incorrect C. Assess the client’s pain score before administration. D. Clarify the medication prescription with the health care provider. Correct Rationale: After fracture treatment, the client often has pain for a prolonged time during the healing process. The health care provider commonly prescribes opioid and non-opioid analgesics, anti-inflammatory drugs, and muscle relaxants. The nurse should immediately recognize that meperidine is contraindicated for the older client because it has toxic metabolites that can cause seizures and other complications. The first step the nurse should take is to clarify the prescription with the health care provider. The other steps should not be done. Test-Taking Strategy: Focus on the strategic word, “first” and focus on the data in the question and that the client is an older client. Determine which step the nurse should take first when receiving the medication order. Eliminate options, 1, 2, and 3, because this medication should not be given to an older client. Review: contraindications for meperidine Level of Cognitive Ability: Synthesizing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management: Prioritizing Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., p. 42). St. Louis: Saunders. Awarded 0.0 points out of 1.0 possible points. 31.ID: 9477043140 The nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA) endovascular stent graft. What priority actions should the nurse include in the plan of care? Select all that apply. A. Assess for pedal pulses Correct B. Monitor urinary output Correct C. Administer analgesics as needed Correct D. Keep the head of the bed elevated to at least 60 degrees Incorrect E. Encourage use of an abdominal pillow when coughing or deep breathing F. Correct Rationale: A priority nursing action after an AAA repair with a graft is to ensure patency of the graft. In order to do this, the nurse would monitor vital signs, pedal pulses, urinary output, and extremity color at least hourly. Pain medication is administered as needed and as prescribed and administered regularly for better pain management. The head of the bed is maintained at 45 degrees or less to prevent flexion of the graft. The client should be instructed to use an abdominal pillow when coughing or deep breathing to prevent incision splitting. Test-Taking Strategy: Focus on the strategic word ‘priority’ to select correct options to be included in the care plan. Focus on the data in the question and the surgical procedure. Not that the client had a graft stent and think about the impact of vascular patency to answer correctly. Review: care following an Abdominal Aortic Aneurysm with graft Level of Cognitive Ability: Creating Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Adult Health: Cardiovascular Giddens Concepts: Caregiving, Perfusion HESI Concepts: Caregiving, Perfusion Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 794). St. Louis: Saunders. Awarded 3.0 points out of 4.0 possible points. 32.ID: 9477042167 The nurse notices that an older client’s skin is very dry. What actions would be appropriate for the nurse to implement into the care plan? Select all that apply. A. Ensure adequate hydration Correct B. Wait 15 minutes after bathing to apply lotion C. Instruct the client to avoid caffeine and alcohol Correct D. Rub skin surfaces dry in order to remove dead skin E. Use lavender scented lotion, which can help add moisture to the skin Incorrect Rationale: The skin functions to protect the body. In order to promote good skin health, hydration is important. Ensuring adequate hydration can help hydrate the skin from the inside out. Dehydration is avoided by eliminating substances such as caffeine and alcohol. Lotion can be beneficial if applied 2 to 3 minutes after bathing when skin still has moisture. Rubbing the skin can further dry the skin. Scented soaps, lotions, and oils can dry out the skin. Test-Taking Strategy: Focus on the subject of the question, actions to prevent and treat dry skin. Read each option and think about how it may or may not further dry the skin. Review: measures to prevent and treat dry skin Level of Cognitive Ability: Creating Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process: Planning Content Area: Adult Health: Integumentary Giddens Concepts: Caregiving, Tissue Integrity HESI Concepts: Caregiving, Tissue Integrity Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 741). St. Louis: Saunders. Awarded 1.0 points out of 2.0 possible points. 33.ID: 9477036653 The nurse is caring for an older Japanese American man being treated in the oncology unit for prostate cancer. In order to provide culturally competent care, the nurse should include what actions in the care plan? Select all that apply. A. Address client by first name to promote a trusting relationship B. Routinely assess for pain, as Japanese Americans often remain stoic Correct C. Provide personal space boundaries if client is in a semi-private room Correct D. Allow for family to visit and participate in the decision-making process Correct E. Encourage the client to verbally express their feelings and thoughts often Rationale: The client of Japanese descent often remains quiet and stoic, and therefore may not voice pain and should be assessed frequently. The nurse should pay attention to non-verbal signs of pain. Providing personal space boundaries may help alleviate tension and allowing family to partake in decision-making is an integral part of providing culturally competent care. Some Japanese American clients may be offended if called by their first name, and may not wish to talk frequently. Test-Taking Strategy: Focus on the subject of the question, culturally competent care for the Japanese American client. It is necessary to understand the common characteristics of this culture in order to answer correctly. Review: Culturally competent care for Japanese American Level of Cognitive Ability: Creating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process: Planning Content Area: Fundamentals of Care: Cultural Awareness Giddens Concepts: Caregiving, Culture HESI Concepts: Caregiving, Cultural/Spiritual Reference: Giger, J. (2013). Transcultural nursing: Assessment & interventions (6th ed., p. 317). St Louis: Mosby. Awarded 3.0 points out of 3.0 possible points. 34.ID: 9477035276 The nurse is caring for a client in the emergency department who is being treated for major burns and smoke exposure. What information in the medical chart would warrant the nurse to call the Rapid Response Team immediately? Refer to chart. A. Asthma B. Hoarse voice Correct C. Blood pressure of 98/62 mmHg D. Blood glucose of 68 mg/dL (3.7 mmol/L) E. Rationale: Clients with major burns are at risk for respiratory compromise. A hoarse voice is an impending sign that the client may soon lose his airway due to obstruction or swelling. This would indicate the need to immediately activate the rapid response team as intubation is required. A history of asthma may impact respiratory status, however, the presence of asthma alone does not warrant a call to the rapid response team. The client’s blood glucose reading is low, and should be treated, however, this can be done by the RN assigned to the client and does not warrant a rapid response team. Hypovolemia is associated with burns and would explain the low blood pressure reading. Test-Taking Strategy: Note the strategic word ‘immediately’. Use the ABC – airway, breathing, and circulation to assess airway first. In this case, a hoarse voice would indicate a problem with the airway. Review: Burn care Level of Cognitive Ability: Synthesizing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Analyzing Content Area: Critical Care: Emergency Situations/Management Giddens Concepts: Clinical Judgment, HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 522). St. Louis: Saunders. Awarded 1.0 points out of 1.0 possible points. 35.ID: 9477032603 The nurse is caring for a 55-pound child on the pediatric medical surgical unit being treated for Lyme disease. The health care provider has prescribed ceftriaxone (Rocephin) intramuscular 50 mg/kg/day in two divided doses. The nurse should administer how many milligrams per dose? Fill in the blank. mg Correct Correct Responses A. 625 Rationale: Ceftriaxone (Rocephin) is a third generation cephalosporin used to treat Lyme disease. Use the medication calculation formula to calculate the correct dose. Convert pounds to kilograms by dividing the number of pounds by 2.2 (1 kg = 2.2 lb) 55 ÷ 2.2 = 25 kg mg × kg = client's dose 25 × 50 = 1250 mg /day divide by total number of daily doses 1250 mg/day ÷ 2 = 625 mg per dose Test-Taking Strategy: Focus on the subject, a medication calculation. Use the appropriate formula to determine the correct dose. Once you have performed the calculation, ensure it makes sense and check your answer with a calculator. Review: Medication Calculations Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Implementation Content Area: Fundamentals of Care: Medication/IV calculations Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of Awarded 1.0 points out of 1.0 possible points. 36.ID: 9477035297 The nurse is caring for a client with joint pain and is educating the client on pharmacological management of pain with acetaminophen. What statements made by the client would indicate a need for further teaching? Select all that apply. A. “This medication is safe to take with my warfarin.” Incorrect B. “I should avoid eating grapefruit while taking this medication.” Correct C. “I should not take this medication more often than 3 times per day.” Correct D. “To prevent a stomach ache, I should take this medication with food.” Correct E. “I should report any skin itching or yellowing of the skin to my healthcare provider.” Incorrect Rationale: Acetaminophen works by blocking pain receptors. Grapefruit does not impact the ability of this medication and can be taken together. Dosing can occur every 4 to 6 hours as long as a daily maximum of 4000 mg is not exceeded. Gastrointestinal side effects are not common with this medication, and therefore, can be taken on an empty stomach. Acetaminophen does not inhibit platelet aggregation and can safely be taken with blood thinners. Side effects such as liver toxicity, which include skin itching or yellowing of the skin should be reported immediately to the healthcare provider. Test-Taking Strategy: Focus on the strategic words “need for further teaching.” These words indicate a negative event query and the need to select the incorrect client statements. Focus on the medication name and think about its properties to assist in answering. Review: Pain management and acetaminophen Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamental of Care: Pain Giddens Concepts: Client Education, Pain HESI Concepts: Pain, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 51). St. Louis: Saunders. Rosenjack Burchum, Rosenthal (2016) p. 868. Awarded 0.0 points out of 3.0 possible points. 37.ID: 9477032625 The nurse is providing discharge education to a client that was admitted for treatment with Addison’s crisis and is reviewing the medication hydrocortisone. What statements made by the client would indicate teaching was effective. Select all that apply. A. “ I should take this medication twice a day.” Correct B. “Weight gain is common and I should expect it.” Incorrect C. “If I forget a dose, I should take two pills the next time.” Incorrect D. “I may notice my cheeks become fat and rounded but this is okay.” E. “If I notice any swelling or fluid retention, I should notify my healthcare provider.” Correct Rationale: Hydrocortisone is used in the treatment of Addison’s disease. Adverse effects such as weight gain, moon face, and fluid retention are not expected and may indicate over-correction and a dose adjustment is needed. This medication can be taken once or twice daily, and should not be doubled if a dose is missed. Test-Taking Strategy: Focus on the strategic word ‘effective’ to select correct statements made by the client. Think about the pathophysiology associated with Addison’s disease and the effects of hydrocortisone on the disorder. This will assist in answering correctly. Review: Treatment for Addison’s disease Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process: Evaluation Content Area: Pharmacology: Endocrine Medications Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1384). St. Louis: Saunders. Awarded -1.0 points out of 2.0 possible points. 38.ID: 9477038285 The nurse is caring for a client in active labor. The nurse notices that the fetal heart rate pattern is demonstrating late decelerations. Which position should the nurse assist the client into? Refer to figures 1-4. A. B. Correct C. Incorrect D. Rationale: Late decelerations are a nonreassuring fetal heart rate that implies a decrease in placental sufficiency. To promote adequate oxygenation and blood flow to the fetus, the client should be assisted to a side lying position. Re- positioning may improve perfusion and the fetal heart rate. Positions such as prone and dorsal recumbent should be avoided to prevent compression of the vena cava and decreased blood flow. Knee-chest position may improve comfort, but side lying is best for perfusion. Test Taking Strategy: Focus on the subject, maternal positioning for late decelerations. Recall that late decelerations imply placental insufficiency, so assist the client to a position that will promote blood flow to the placenta. Review: Labor positioning. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Maternity/Intrapartum Giddens Concepts: Perfusion, Safety HESI Concepts: Perfusion, Safety Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., p. 422). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. 39.ID: 9477043150 A client is being treated on the medical surgical unit for a deep vein thrombosis (DVT). The client will be discharged home on oral anticoagulants. What information in the client’s medical record would warrant the need for teaching? Refer to chart. Hi st or y a n d P h ys ic al L a b o r a t o r y F i n d i n g s M e d i c a t i o n s Ir o n- d e fic ie nt a n e m ia S o d i u m 1 4 2 m E q / L ( 1 4 2 m m o l / L ) L i s i n o p r i l 1 0 m g o r a l l y d a i l y 1 0 p ac k ye ar hi st P o s i t i v e V i t a m i n D or y of s m ok in g D - D i m e r 4 0 0 I U d a i l y A. Sodium result B. D-Dimer result C. Vitamin D 400 IU daily D. 10 pack year history of smoking Correct Rationale: A deep vein thrombosis (DVT) is the most common type of venous thromboembolism (VTE). DVTs occur most often in the legs, but can also occur in the upper arms. Smoking increases the risk of DVT formation, and clients should educated on the importance of quitting. The sodium result is within normal limits. The positive d-dimer result is expected, as it is a marker for DVT’s. Vitamin D supplementation does not impact DVTs or anticoagulation therapy. Test Taking Strategy: Focus on the subject, deep vein thrombosis and anti- coagulation therapy. Note the strategic words “need for teaching.” Think about the pathophysiology associated with DVT and the risk factors. Recall the implications of a DVT and treatment considerations to correctly answer this question. Review: Deep Vein Thrombosis Level of Cognitive Ability: Analyzing Client Needs: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Adult Health: Cardiovascular Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 848). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 40.ID: 9477039802 The post-operative client is experiencing moderate pain and requests pain medication from the nurse. The prescription reads: morphine 4 mg intravenous (IV) push every three hours as needed. The morphine is supplied in an ampule of 10 mg/mL. How many milliliters should the nurse administer? Fill in the blank and record your answer using the one decimal place. mL Correct Correct Responses A. 0.4 Rationale: Use the medication calculation formula to determine correct dosing. Desired x Volume = milliliters per dose Available 4mg x 1 ml = 0.4 mL 10mg Test Taking Strategy: Focus on the subject of the question, a medication calculation. Follow the formula and then check your answer to ensure it makes sense. Use a calculator to verify the answer. Review: Medication Calculations Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Implementation Content Area: Fundamental of Care: Medications/IV calculations Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 710-711). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 41.ID: 9477041034 The nurse is caring for an older client who is being treated for malnutrition. Which actions by the nurse would be the most appropriatewhen providing for this client’s care and comfort? Select all that apply. A. Ask if the client lives alone. Correct B. Evaluate the fit of the client’s dentures. Correct C. Educate the client on how to choose healthy foods. Correct D. Determine if the client qualifies for any food services. Correct E. Recommend that the client choose over-the-counter medications for ailments. Rationale: The minimum nutritional requirements of the human body remain consistent from youth through old age, with a few exceptions. Older adults need an increased dietary intake of calcium, vitamin D, vitamin C, and vitamin A because aging changes disrupt the ability to store, use, and absorb these substances. A sedentary lifestyle and reduced metabolic rate require a reduction in total caloric intake to maintain an ideal body weight. Malnutrition or nutrition-related problems can occur in older adults when these needs are not met. When caring for the malnourished client, the nurse should evaluate the client’s living situation. Older clients, who live alone, are more likely to become malnourished. The nurse should also evaluate the fit and comfort of dentures. The client is less likely to eat if dentures are poor fitting. It should not be assumed that the client understand what foods are considered healthy and which are not. The nurse should be prepared to determine the client’s level of knowledge and educate as necessary. Food services, such as meals on wheels, provide food to the older client who may not be able to obtain food on their own. The nurse should assess the client to determine if this assistance would be an option. Over-the-counter medications can cause changes in taste, placing the client at a greater risk for a decreased appetite. The client should speak with the health-care provider before beginning any over-the-counter medication. Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Note the subject, the actions by the nurse that would assist in providing for the client’s care and comfort. Eliminate option 5, because this action could potentially place the client at a greater risk for malnutrition. Review: Malnutrition in the older client. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Nutrition Giddens Concepts: Health Promotion, Nutrition HESI Concepts: Health, Wellness, and Illness, Nutrition Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 17). Philadelphia: Saunders. Awarded 4.0 points out of 4.0 possible points. 42.ID: 9477032683 The nurse is planning care for a client who is confused. The nurse should include which actions in the client’s care plan? Select all that apply. A. Allow a pet visit Correct B. Play soft, calming music Correct C. Toilet the client every 2 to 3 hours Correct D. Evaluate the client for signs of pain Correct E. Apply restraints as needed if the client becomes agitated Rationale: Acute and chronic confusion affect many older clients in both the hospital and nursing home. Whereas chronic confusion states such as dementia are not reversible, acute confusion or delirium may be avoidable and is often reversible when the cause is resolved or removed. The nurse should plan care that keeps the client as comfortable and peaceful as possible. If possible, the nurse should allow a pet visit. The nurse should also ensure a comforting environment. Many times clients who are confused are unable to express the need to be toileted, which can increase agitation. It is also important that the nurse evaluate the client for pain, and treat the pain immediately. Applying restraints should be a last option. Restraints often increase agitation and lead to the client becoming violent. Test-Taking: Focus on the subject, “care for a client who is confused.” Determine which actions the nurse should take to provide the best care to this client. Eliminate option 5, because this action could lead to increased agitation or violence. Review: Confusion. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Fundamentals of Care: Safety Giddens Concepts: Care Coordination, Cognition HESI Concepts: Cognition, Collaboration/Managing Care Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 28). Philadelphia: Saunders. Awarded 3.0 points out of 4.0 possible points. 43.ID: 9477038218 The nurse is working in the emergency department when a client with heat exhaustion is brought in. Which actions would be the appropriate in order to effectively treat the client? Select all that apply. A. Remove any restrictive clothing. Correct B. Administer salt tablets to the client. C. Apply cool water soaks to the client. Correct D. Give the client an oral rehydrating solution. Correct E. Apply ice packs to the client’s neck and groin. Correct Rationale: Heat exhaustion is a syndrome resulting primarily from dehydration. It is caused by heavy perspiration, as well as inadequate fluid and electrolyte intake during heat exposure over hours to days. Clients feel ill, and their clinical manifestations resemble the flu. If untreated, heat exhaustion can lead to heat stroke. The nurse should reduce the client’s temperature immediately. This can be done by applying cool water soaks to the client, removing any restrictive clothing, orally rehydrating the client with a sports drink or rehydrating solution, and applying ice packs to the client’s body. The nurse should avoid giving the client salt tablets, as these can cause stomach irritation, nausea, and vomiting —which can lead to further dehydration. In addition, they can alter the electrolyte balance. Test-Taking Strategy: Focus on the subject, treating heat exhaustion. Think about the physiological body processes that occur in heat exhaustion. Determine which actions would be the most beneficial to a client with heat exhaustion. Eliminate option 2, because this action could cause harm to the client. Review: Heat exhaustion. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Safety Giddens Concepts: Clinical Judgment, Thermoregulation HESI Concepts: Clinical Decision-Making/Clinical Judgment, Thermoregulation Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 1683). St. Louis: Mosby. Awarded 3.0 points out of 4.0 possible points. 44.ID: 9477032654 The nurse is caring for a client who has just come in to the emergency department to receive treatment. The client reports a bite from a brown recluse spider. The nurse assesses the bite mark and notes that it is possibly infected. Which actions should the nurse take? Select all that apply. A. Apply ice to the site. Correct B. Contact a surgeon immediately. C. Apply a non-sterile dressing to the site. Incorrect D. Cleanse the area with a topical antiseptic. Correct E. Assess the date of the client’s last tetanus shot. Correct Rationale: Brown recluse spider venom causes cell damage. The bite may be described as painless or stinging to sharp and painful. Some victims are unaware that they were bitten until intense local aching and pruritus develop over minutes to hours. The central bite site may appear as a bleb or vesicle surrounded by edema and erythema, which may expand over the course of hours as the toxin spreads to surrounding tissues. The nurse should take immediate action to prevent further damage to the bitten area. Applying ice to the site helps decrease the enzyme activity of the venom and assists in decreasing swelling of the tissue. Cleansing the area with a topical antiseptic and applying a sterile dressing can help decrease the risk of infection, and prevent a current infection from worsening. The nurse should also assess the date of the client’s last tetanus shot, and prepare to administer the vaccine if necessary. It is not necessary to contact a surgeon immediately. If necrosis is present then a surgeon may be needed for debridement. Test-Taking Strategy: Focus on the subject, care to a client who is a victim of a bite from a brown recluse spider. Focusing in the data in the question will assist in eliminating option 2 because there is no indication that a surgeon is needed. Eliminate option 3, because a non-sterile dressing could lead to infection or worsen infection. Review: Brown recluse spider bites Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health: Integumentary Giddens Concepts: Clinical Judgment, Tissue Integrity HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 144). Philadelphia: Saunders. Awarded 1.0 points out of 3.0 possible points. 45.ID: 9477033492 The nurse is educating a client on how to prevent altitude sickness. Which statements indicate that the teaching has been effective? Select all that apply. A. “I will drink plenty of water.” Correct B. “I will wear sunscreen and high quality goggles.” Correct C. “I will plan a quick ascent when changing to a higher altitude.” D. “I will refrain from consuming alcohol when I am at a high altitude.” Correct E. “I will pay attention to the manifestations of altitude-related illnesses.” Correct Rationale: High altitude illness, also known as high altitude sickness or altitude sickness, cause pathophysiologic responses in the body as a result of exposure to low partial pressure of oxygen at high elevations. Although most consider high altitude to be an elevation over 5000 feet (1524 meters), millions of people worldwide who ascend to or live at altitudes above 2500 feet (762 meters) are at risk for acute and chronic altitude sickness. The nurse should educate the client on how to recognize and prevent altitude sickness and basic measures to treat sickness, until help can be obtained. The nurse can determine that teaching has been effective when the client identifies the following as being important: remaining hydrated, wearing sunscreen, using high quality goggles, refraining from alcohol use and recognizing the symptoms of altitude-related sickness. The client should prepare for a slow ascent, rather than a quick ascent. This allows the client to become acclimated to the altitude. Test-Taking Strategy: Note the strategic word, “effective” and focus on the subject, preventing altitude sickness. Think about the effects of altitude changes. Noting the word “quick” in option 3 will assist in eliminating this option. Review: Altitude sickness. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamentals of Care: Safety Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 151, 154). Philadelphia: Saunders. Awarded 4.0 points out of 4.0 possible points. 46.ID: 9477032646 The nurse is educating a child’s parents on using the behavior modification technique of discipline. Which statement should the nurse make to the parents? A. “All behaviors should be acknowledged.” Incorrect B. “Rewards are given at the end of the training period only.” C. “Negative behaviors are recorded where the child can see them.” D. “Corporal punishment should not be used to encourage good behaviors.” Correct Rationale: The behavior modification technique of discipline rewards positive behavior and ignores negative behavior. This technique requires parents to choose selected behaviors, preferably only one at a time, that they desire to stop. They choose others that they want to encourage. The basic technique is useful for any age from toddlerhood through adolescence. Corporal punishment can lead to child abuse if the disciplinarian loses control. It can also lead to false accusation of child abuse by either the child or other adults. Because of the high cost and low benefit of this form of punishment, parents should avoid its use. When educating the paents, the nurse should provide accurate information such as: ignoring negative behaviors, giving rewards throughout and at the end of the training period and recording negative behaviors out of the client’s view. Test-Taking Strategy: Focus on the subject, statement the nurse should make about behavior modification. Think about the components of behavior modification technique and read each option carefully to assist in answering correctly. Also note the closed-ended words “all” in option 1 and “only” in option 2. Review: Behavior modification Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Pediatrics Giddens Concepts: Client Education, Communication HESI Concepts: Communication, Teaching and Learning/Patient Education Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of h ed. pp. 24-26). St Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 47.ID: 9477033475 The nurse is caring for a client who has been diagnosed with bladder cancer. Which action should the nurse take as a priority when planning psychosocial care for this client? A. Assess all urine for the presence of blood B. Question the client about insurance coverage C. Assess the client’s ability to cope with the diagnosis Correct D. Ask the client if there is a history of cancer in the family Rationale: Urothelial cancers are malignant tumors of the urothelium—the lining of transitional cells in the kidney, renal pelvis, ureters, urinary bladder, and urethra. Most urothelial cancers occur in the bladder. Thus the term bladder cancer is often used to describe this condition. The nurse should take time when planning care in order to ensure that client specific care is given. When planning care that includes the psychosocial needs, the priority action for the nurse should be to assess the client’s ability to cope with the cancer diagnosis. Other important aspects of caring for this client are to assess the urine and determine the client’s medical history, including family history of cancer but these are physiological aspects. Questioning the client’s insurance coverage is not typically a nursing function. Test-Taking Strategy: Focus on the strategic word, “priority” and the subject, psychosocial care. Determine which action would help maintain the client’s psychosocial integrity. Eliminate options 1, 2, and 4, because while these actions fulfill other client and hospital needs, they do not specifically meet the client’s psychosocial needs. Review: bladder cancer and psychosocial needs. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health: Urinary and Renal Giddens Concepts: Communication, Elimination HESI Concepts: Communication, Elimination Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1512). Philadelphia: Saunders. Awarded 1.0 points out of 1.0 possible points. 48.ID: 9477043106 A client has come to the emergency department complaining of burning with urination. What should the nurse consider a priority when providing care in order to maintain the client’s psychosocial integrity? A. Use medical terminology when speaking to the client. B. Provide the client with as much privacy as possible during the examination. Correct C. Explain to the client that all questions will be answered at the time of discharge. D. Administer medications as soon as they are prescribed by the health care provider. Rationale: Infections of the urinary tract and kidneys are common, especially among women. In caring for the client, the nurse should consider ways in which to maintain psychosocial integrity. Providing the client with as much privacy as possible during the examination is the best way to achieve this, and should be considered a priority by the nurse. Using medical terminology may be confusing to the client. The nurse should explain all actions and procedures to the client before they occur. Administering medications as soon as prescribed is important, but does not necessarily maintain the client’s psychosocial integrity in this situation. Test-Taking Strategy: Focus on the strategic word, “priority” and the subject, maintaining the client’s psychosocial integrity. Noting the word, privacy, in option 2 will direct you to this option. . Review: measures to maintain a client’s psychosocial integrity. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health: Renal and Urinary Giddens Concepts: Caregiving, Clinical Judgment HESI Concepts: Caregiving, Clinical Decision-Making/Clinical Judgment Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 1068-1069). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 49.ID: 9477036669 The nurse is educating an older client on sources of stress. Which statements by the client indicate that the teaching has been effective? Select all that apply. A. “Relocating to a nursing home causes stress.” Correct B. “Financial hardships can be a cause of stress.” Correct C. “A lifestyle change such as retiring can cause stress.” Correct D. “A history of anxiety can be a source of stress in the older person.” Incorrect E. “The birth of a new grandchild is often a source of stress for the older person.” Rationale: Stress can accelerate the aging process over time, or it can lead to diseases that increase the rate of degeneration. It can also impair the reserve capacity of older adults and lessen their ability to respond and adapt to changes in their environment. Although no period of the life cycle is free from stress, the later years can be a time of especially high risk. While educating the client on sources of stress, the nurse should evaluate the knowledge of the client. It is important that the client understand the sources of stress, so that they can be avoided when possible. Sources of stress for the older client include: relocation, financial hardships, and lifestyle changes. A history of anxiety is not often a source of stress for the older client. The birth of a new grandchild is often a joyous experience for the older client. Test-Taking Strategy: Focus on the subject, sources of stress for the older client. Also note the strategic word, effective. Eliminate options 4 and 5, because these are not identified as sources of stress for the older client. If the client made these statements this would be an indication that more education is needed. Review: Sources of stress in the older client. Level of Cognitive Ability: Evaluating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Developmental Stages: Early Adulthood to Later Adulthood. Giddens Concepts: Client Education, Stress HESI Concepts: Caregiving, Stress and Coping Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 19). Philadelphia: Saunders. Awarded 2.0 points out of 3.0 possible points. 50.ID: 9477041068 The nurse is caring for a client with bipolar disorder. When creating a care plan for this individual, which should the nurse include? Select all that apply. A. The client will understand what bipolar disorder is. Correct B. The client will ask the nurse to refill the prescriptions each month. C. The client will be able to manage the symptoms of bipolar disorder. Correct D. The client will perform activities of daily living (ADLs) independently. Correct E. The client will state the importance of taking medications as prescribed. Correct Rationale: Mood and affect is a psychosocial concept that underlies all other concepts in the significant impact it has on health outcomes. While caring for the bipolar client, it is important that the nurse create a plan of care, in order for the client to have the best outcome. The nurse should ensure that the client understands important concepts such as: what bipolar disorder is, how to manage the symptoms and the importance of taking medications as they are prescribed. The nurse should also assess the client’s ability to realistically solve problems of daily living, such as obtaining more medications. The client should be able to call the pharmacy to refill medications, instead of relying on the nurse. Test-Taking Strategy: Focus on the subject, “a plan of care for a client with bipolar disorder.” Think about the psychopathology of bipolar disorder and what needs the client may have. Eliminate option 2, because this would encourage the client to rely on the nurse instead of being independent. Review: Bipolar disorder. Level of Cognitive Ability: Creating Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Mental Health Giddens Concepts: Care Coordination, Client Education. HESI Concepts: Care Coordination, Teaching and Learning/Patient Education References: Giddens, J. (2013). Concepts for Nursing Practice. (1st ed., p. 299). St. Louis: Mosby. Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 289-230). St. Louis: Saunders. Awarded 4.0 points out of 4.0 possible points. 51.ID: 9477035263 The nurse is creating a plan of care for a client that will undergo a total joint replacement. What should the nurse include in the client’s plan of care? Select all that apply. A. Teach interventions to reduce client anxiety Correct B. Educate the client on what to expect after surgery Correct C. Complete a physical assessment before the surgery Correct D. Include the client’s family in discussions about the surgery Correct E. Allow time for the surgeon to address questions after the surgery Rationale: The client's readiness for surgery is critical to the outcome. Preoperative care focuses on preparing the client for the surgery and client safety. The nurse should include activities in the plan of care that will focus on preparing the client for surgery such as interventions that will reduce the client’s level of anxiety and education on what to expect after surgery. The nurse should perform a physical assessment and alert the surgeon to any findings that would interfere with the surgery. When possible, the client’s family should be included in discussions pertaining to the surgery. The nurse should allow time for the surgeon to meet with the client and family before (not after) the surgery to address any questions or concerns. Test-Taking Strategy: Focus on the subject, “preoperative plan of care.” Eliminate option 5, because the client should have the opportunity to speak with the surgeon and have all questions addressed before the surgery. Review: Preoperative care Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamentals of Care: Perioperative Care Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Infection Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 241). Philadelphia: Saunders. Awarded 4.0 points out of 4.0 possible points. 52.ID: 9477036632 The nurse is caring for a client with a blood pressure of 80/54 mmHg. Which actions should the nurse take because of the risk of hypovolemic shock? Select all that apply. A. Insert a large-bore intravenous (IV) line Correct B. Anticipate administering blood products Correct C. Keep intravenous fluids to be administered cold D. Anticipate administering Ringer’s lactate solution Correct E. Perform assessments and monitor the client closely Correct Rationale: Hypovolemic shock occurs when there is a decrease in the circulating blood volume in the body. When treating a client in hypovolemic shock, the nurse should insert a large-bore IV line, administer Ringer’s lactate or 0.9 % normal saline solutions, perform assessments and monitor the client closely, and anticipate administering blood products. These treatments will restore circulating blood volume to the client. Intravenous fluids should be warmed prior to administration to the client. Test-Taking Strategy: Focus on the subject, “treating hypovolemic shock.” Recall the pathophysiology associated with hypovolemic shock to assist in answering correctly. Eliminate option 3, because intravenous fluids should be warmed prior to administration. Review: Hypovolemic shock. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical Care: Emergency Situations/Management Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 133, 789). Philadelphia: Saunders. Awarded 4.0 points out of 4.0 possible points. 53.ID: 9477041022 The nurse is providing care to a client. After assessing the client, the nurse determines that the client’s self ability to change position is compromised. Which actions should the nurse take to reduce the risk of skin break down? Select all that apply. A. Assess the skin daily B. Implement a turning schedule C. Decrease the risk for skin shearing Correct D. Keep the client’s skin clean and dry Correct E. Document skin breakdown prevention measures in the plan of care Correct Rationale: If a client is unable to change positions the nurse should take special care in protecting skin integrity and preventing breakdown. After assessing the client, the nurse should implement a turning schedule for this client, and determine a method of moving the client to prevent shearing. The nurse should create a plan of care and document skin breakdown prevention measures so that other members of the health care team can continue care for this client. It is important that the nurse keep the client’s skin clean and dry at all times, changing soiled linens whenever needed. The nurse should plan to assess the client’s skin frequently to determine if there have been any changes to integrity; checking daily is too infrequent. Test-Taking Strategy: Focus on the subject, “reducing the risk of skin breakdown.” Determine which actions the nurse can take to reduce the client’s risk of skin breakdown. Eliminate option 1, because of the word “daily;” the nurse should frequently assess the client’s skin throughout the shift. Review: measures to maintain skin integrity Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Adult Health: Integumentary Giddens Concepts: Clinical Judgment, Tissue Integrity HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 127). Philadelphia: Saunders. Awarded 2.0 points out of 4.0 possible points. 54.ID: 9477036644 The nurse is creating a plan of care for a client with a respiratory infection. Which actions should the nurse include in the plan of care to prevent the spread of infection? Select all that apply. A. Clean the client’s room daily Correct B. Wash hands when they are soiled Incorrect C. Wear gloves when giving a bath to the client Correct D. Keep fingernails short and without nail polish Correct E. Place a mask on the client’s face when transporting to other departments Correct Rationale: Infection control within a healthcare facility is designed to reduce the risk for health-care associated infections (HAI). The nurse must implement measures to prevent the spread of infection. The nurse should include the following in a plan of care for the client: daily room cleaning to remove infectious material; using personal protective equipment, such as gloves, when giving the client a bath to prevent the spread of infection; keeping fingernails short and without nail polish because of the risk of harboring bacteria; and use of a mask when the client is transported to other departments to prevent spread. In addition, other departments that the client is being transported to should be aware of the risk of respiratory infection. The nurse should wash hands after every client contact or more frequently if needed, not just when they are soiled. Often hands may not look soiled, but can have infectious material on them. Review: health-care associated infection prevention. Test-Taking Strategy: Focus on the subject, “preventing the spread of a respiratory infection.” Determine which actions by the nurse prevent infection from being spread. Eliminate option 2, because hands should be washed after each client contact not just when soiled. Review: measures to prevent the spread of infection Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Fundamentals of Care: Infection Control Giddens Concepts: Clinical Judgment, Infection HESI Concepts: Clinical Decision-Making/Clinical Judgment, Infection Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 438). Philadelphia: Saunders. Awarded 2.0 points out of 4.0 possible points. 55.ID: 9477039814 The nurse is caring for a client with cancer who has a sealed implant of a radioactive source. Which actions should the nurse take to promote safety for staff and visitors? Select all that apply. A. Keep the client’s door closed Correct B. Limit each visitor to 1 hour per day C. Wear a lead apron while providing care Correct D. Assign the client to a semi-private room E. Remove dressings and linens from the room as they are soiled Incorrect Rationale: Solid or sealed radiation sources are implanted within or near the tumor. These sources can be temporary or permanent. Most implants emit continuous, low-energy radiation to tumor tissues. Safety for staff and visitors should be a priority for the nurse and are focused on preventing exposure to the radiation. Therefore, ways to promote safety include wearing a lead apron while providing care. The nurse should always keep the lead facing the client, never turning away from the client. The door to the client’s room should be kept closed. Visitors should be limited to one-half hour a day, and should remain 6 feet (1.8 meters) from the source of radiation. The client should be assigned to a private room with a private bathroom, and not in a semi-private room. All dressings and linens should be kept in the room until the source of radiation has been removed. Test-Taking Strategy: Focus on the subject, “promoting safety for staff and visitors from a client with a sealed implant of a radioactive source.” Recall that implants emit continuous, low-energy radiation to tumor tissues and that exposure to others is a concern. Then read each option and determine if the action will protect staff and visitors. Review: Radioactive implants. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Safety Giddens Concepts: Caregiving, Safety HESI Concepts: Caregiving, Safety Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 413). Philadelphia: Saunders. Awarded 1.0 points out of 2.0 possible points. 56.ID: 9477034751 The nurse provides information to a unlicensed assistive personnel (UAP) about caring for a client with neutropenia. Which statements by the UAP indicate that teaching has been effective? Select all that apply. A. “I should practice good hand washing.” Correct B. “The client needs mouth care at least every 12 hours.” Correct C. “The client may not have a high fever if infection occurs.” Correct D. “Any sores or skin irritations should be reported right away.” Correct E. “I need to take precautions to protect myself from the client’s illness.” Rationale: Monitoring for manifestations of infection is critical for the hospitalized client with neutropenia. The nurse should communicate the importance of this to the UAP, and actions that can be taken to reduce infection. The UAP should state the importance of taking precautions to protect the client from potential infections. The UAP should be able to state the need to practice good hand washing, as well as the client’s need for mouth care at least every 12 hours. The UAP should understand that any rashes or open sores should be reported right away, and that the client may not have the classic signs of infection, such as a high fever, due to the decrease in white blood cells (WBCs) that occurs in neutropenia. Test-Taking Strategy: Focus on the subject, “effective teaching in the care of a client with neutropenia.” Think about the pathophysiology associated with neutropenia to answer correctly. Review: care of the client with neutropenia Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health: Oncology Giddens Concepts: Client Education, Infection HESI Concepts: Teaching and Learning/Patient Education, Infection Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 420). Philadelphia: Saunders. Awarded 3.0 points out of 4.0 possible points. 57.ID: 9477034736 The nurse is caring for a client who expresses an interest in alternative therapies to reduce the risk of illness and disease. What noninvasive activities should the nurse recommend to the client? Select all that apply. A. Yoga Correct B. Meditation Correct C. Biofeedback Correct D. Acupuncture E. Herbal therapy Incorrect Rationale: Integrative health care encompasses complementary and alternative therapies in combination with conventional Western modalities of treatment. Many popular alternative healing modalities offer human-centered care based on philosophies that recognize the value of the client’s input and honor the individual’s cultural beliefs, values, and desires. When caring for this client, the nurse should recommend noninvasive activities such as yoga, meditation, and the use of biofeedback. Acupuncture and herbal therapies are invasive modalities. Test-Taking Strategy: Focus on the subject, “noninvasive activities.” This will direct you to the correct options. Review: invasive and noninvasive alternative therapies Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of Care: Culture Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health Promotion, Teaching and Learning/Patient Education Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 86). St. Louis: Mosby. Awarded 1.0 points out of 3.0 possible points. 58.ID: 9477035254 The nurse is educating a new registered nurse (RN) about the Healthy People 2020 goals. Which statements by the RN indicate that teaching has been effective? Select all that apply. A. “Healthy People 2020 aims to promote healthy behaviors.” Correct B. “Healthy People 2020 aims to make healthcare more affordable.” C. “Healthy People 2020 aims to improve the health of the geriatric population.” Incorrect D. “Healthy People 2020 aims to eliminate preventable disease, disability, injury, and preventable death.” Correct E. “Healthy People 2020 aims to create social and physical environments that promote good health for all.” Correct Rationale: Healthy People 2020 provides science-based 10-year national objectives for improving health and preventing disease in the United States. The nurse should evaluate the new RNs understanding of the information, and provide additional education as needed. The teaching has been effective when the new RN can state that Healthy People 2020 aims to promote healthy behaviors, eliminate preventable disease, disability, injury, and preventable death; as well as to create social and physical environments that promote good health for all. Healthy People 2020 strives to create a society that is healthy for all populations, however, the objectives do not include making health care affordable. Test-Taking Strategy: Note the strategic word, effective. Focus on the subject, “Healthy People 2020 objectives.” It is necessary to know these objectives to answer this question correctly. Review: Healthy People 2020 objectives. Level of Cognitive Ability: Evaluating Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Leadership/Management: Prioritizing Giddens Concepts: Health Promotion, Health Care Quality HESI Concepts: Health Promotion, Quality Improvement/Health Care Quality Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., pp. 5, 19-20). St. Louis: Mosby. Awarded 1.0 points out of 3.0 possible points. 59.ID: 9477036685 The nurse is completing a health history on a client who is 12 weeks pregnant. Which findings should alert the nurse to the risk of potential parenting problems? Select all that apply. A. The client reports feeling depressed Correct B. The client has new health insurance C. The client states that she likes hospitals D. The client states that the father is not supportive Correct E. The client is homeless and often stays in local shelters Correct Rationale: Situational factors such as the family's ethnic and cultural background and socioeconomic status are assessed while the history is obtained. The nurse should be alert to how the client is currently feeling about the pregnancy, as well as the client’s risk or actual appearance of depression. The nurse should also determine if the family is supportive of the pregnancy; lack of support can lead to parenting problems later on. The homeless client is at a high risk of parenting problems due to the lack of permanent residence; the nurse should address this problem immediately for the best outcome. Test-Taking Strategy: Focus on the subject, “risk of potential parenting problems.” Determine which findings in the health assessment should alert the nurse to the risk of potential parenting problems. Eliminate options 2 and 3, because these do not suggest a potential risk. Review: situational issues in pregnancy. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Maternity Giddens Concepts: Health Promotion, Reproduction HESI Concepts: Health Promotion, Sexuality/Reproduction Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., pp. 310-311, 330). St. Louis: Elsevier. Awarded 3.0 points out of 3.0 possible points. 60.ID: 9477035241 When conducting the preoperative interview with the client, the client reports an allergy to shellfish. Which agent is most likely to cause an allergic reaction in this client? A. Latex B. Medical tape C. Providone-Iodine Correct D. Intravenous (IV) fluids E. Rationale: The client's readiness for surgery is critical to the outcome. Preoperative care focuses on preparing the client for the surgery and client safety. Preoperative interviews are conducted in order to gather client information before the surgery. This allows time for interventions and special considerations to be made. The nurse should anticipate this client to have an allergic reaction to providone-iodine, also known as betadine. It is important that the nurse report the allergy to shellfish to the surgeon right away so that another method of skin cleansing can be chosen. Latex, IV fluids, and medical-tape are not considered cross allergens for shellfish. Test-Taking Strategy: Note the strategic words, most likely. Focus on the subject, “a client with a shellfish allergy.” Determine what could cause an allergic reaction in the client. Eliminate options 1, 2, and 4 because these options are not shown to cause reactions in a client with a shellfish allergy. Also think about the association between shellfish and iodine. Review: Allergy to shellfish Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Fundamentals of Care: Safety Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 241, 245). Philadelphia: Saunders. Awarded 1.0 points out of 1.0 possible points. 61.ID: 9477034795 Which actions should the nurse take to adequately prepare a client for a thoracentesis? Select all that apply. A. Explain the procedure to the client Correct B. Instruct the client not to move during the procedure Correct C. Teach the client to take slow, deep breaths during the procedure Incorrect D. Tell the client to expect a stinging sensation from the anesthetic Correct E. Inform the client that it is common to feel pressure from the needle insertion Correct Rationale: Thoracentesis is the aspiration of pleural fluid or air from the pleural space. It can be used for diagnosis or treatment. In preparing the client for a thoracentesis, the nurse should thoroughly explain the procedure to the client, allowing time for the client to ask questions. The nurse should also instruct the client not to move during the procedure, and therefore the client should not cough or take deep breaths, in order to avoid puncture of the lungs or pleura. The client should be informed to expect a stinging sensation and pressure as the needle is inserted. Test-Taking Strategy: Focus on the subject, “preparing a client for a thoracentesis.” Think about the purpose of the procedure and how it is done by the health care provider. Eliminate option 3, because the client should be instructed not to move during the procedure and therefore needs to avoid taking deep breaths during the thoracentesis. Review: thoracentesis. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamentals of care: Diagnostic tests Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care, Safety Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 559-560). Philadelphia: Saunders. Awarded 2.0 points out of 4.0 possible points. 62.ID: 9477038228 The nurse is providing discharge teaching to the client who had a thoracentesis about the manifestations of a pneumothorax. Which statements should the nurse make to the client to help the client recognize signs/symptoms of a pneumothorax? Select all that apply. A. “Frequent coughing should be reported.” Correct B. “Be sure and report any bluish color to the skin.” Correct C. “A pneumothorax can cause a feeling of air hunger.” Correct D. “Discomfort on the unaffected side should be evaluated immediately.” E. “Presents of a slanted trachea in the neck region need to be reported.” Correct Rationale: The client, who is being discharged following a thoracentesis needs to be instructed about the manifestations of complication including a pneumothorax. Signs and symptoms of a pneumothorax include: cyanosis, often noticed around the lips; pain on the affected side, frequent coughing, a feeling of air hunger, and a slanted trachea. Clients with these signs and symptoms will need to be evaluated right away. Discomfort on the unaffected side is not associated with a thoracentesis or pneumothorax. Test-Taking Strategy: Focus on the subject, signs/symptoms of a pneumothorax. Read each option carefully. Eliminate option 4 because of the words “unaffected side” and reported immediately.” Review: signs/symptoms of a pneumothorax Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Fundamentals of Care: Diagnostic Tests Giddens Concepts: Client Education, Safety HESI Concepts: Safety, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 561). Philadelphia: Saunders. Awarded 3.0 points out of 4.0 possible points. 63.ID: 9477035287 The nurse is caring for a client on a ventilator. Which symptoms should alert the nurse to the possibility of absorption atelectasis? Select all that apply. A. Crackles in the lungs Correct B. Diminished lung sounds Correct C. Decrease in blood pressure D. Increase in red blood cell count E. High oxygen saturation readings Rationale: Nitrogen in the air helps maintain patent airways and alveoli. Making up 79% of room air, nitrogen prevents alveolar collapse because it does not cross the alveolar-capillary membranes and remains in the airways and alveoli. When high oxygen levels are delivered, nitrogen is diluted, oxygen diffuses from the alveoli into the circulation, and the alveoli collapse. Collapsed alveoli cause atelectasis (called absorption atelectasis), which is detected by auscultation. The nurse providing care to the ventilated client should be alert for signs of absorption atelectasis. These symptoms include: crackles in the lungs and diminished lung sounds. The nurse should intervene when these symptoms are present. High oxygen saturation, decreased blood pressure, and an increase in the red blood cell count are not typical signs of absorption atelectasis. Test-Taking Strategy: Focus on the subject, “the symptoms of absorption atelectasis.” It is necessary to understand the pathophysiology associated with this condition to answer correctly. Think about the pathophysiology and what occurs in the lungs as a result of this condition. This will assist in selecting the correct options. Review: symptoms of absorption atelectasis Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Aduklt Health/Respiratory Giddens Concepts: Gas Exchange, Perfusion HESI Concepts:. Oxygenation/ Gas Exchange, Perfusion Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 565). Philadelphia: Saunders. Awarded 2.0 points out of 2.0 possible points. 64.ID: 9477042192 The nurse is caring for a client with heat stroke, who is being cooled with a cooling blanket. Which actions should the nurse take to ensure that the intervention is effective? Select all that apply. A. Administer antipyretics B. Rapidly lower the core temperature Correct C. Monitor temperature continuously until it is stable Correct D. Monitor for patency of the airway and prepare for intubation if necessary Correct E. Prepare to insert an intravenous line for administration of fluids as needed Correct Rationale: Victims of heat stroke have a profoundly elevated body temperature (above 104 °F [40°C]) and need to be treated immediately with cooling measures to rapidly lower the body temperature. The nurse would monitor the temperature continuously using a rectal thermometer or other acceptable temperature measuring method. An intravenous line is inserted to administer fluids such as 5% dextrose in the event of hypoglycemia that can occur as a complication. The nurse should not administer antipyretics. Antipyretics can interrupt the change in the hypothalamic set point and are not expected to work on a healthy hypothalamus that has been overloaded, as in the case of heatstroke. In addition, they can be harmful in some situations. Test-Taking Strategy: Focus on the subject, “treating a client with heat stroke.” It is necessary to understand the pathophysiology associated with heat stroke to answer correctly. Remember that antipyretics are not a part of the treatment plan for a client with heat stroke. Review: management of heat stroke Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Critical care: Emergency situations/management Giddens Concepts: Care Collaboration, Thermoregulation HESI Concepts: Collaboration/Managing Care, Thermoregulation Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 138-139). Philadelphia: Saunders. Awarded 3.0 points out of 4.0 possible points. 65.ID: 9477042129 Which interventions should be included in the care of a client with a chest tube? Select all that apply. A. Change the chest tube each shift. B. Assess the insertion site for signs of infection. Correct C. Assess the water seal chamber for a continuous, strong bubbling. D. Keep the drainage system lower than the level of the client’s chest. Correct E. Alert the health care provider (HCP) if drainage in the tube stops in the first 24 hours. Correct Rationale: Caring for a client with a chest tube involves an adequate understanding of chest tubes and interventions needed to ensure sterility and patency. The chest tube site should be assessed for signs of infection and the drainage system should always be kept below the level of the client’s chest to ensure adequate drainage. If drainage stops in the first 24 hours, the HCP should be notified immediately because there could be a blockage in the tube. The chest tube is not changed each shift and the system needs to remain closed and patent. A continuous strong bubbling in the water seal chamber indicates an air leak, requiring further investigation. Test-Taking Strategy: Focus on the subject, chest tube care. Think about the physiological functioning of a chest tube and the purpose of a chest tube to assist in answering correctly. Review: Chest tube care. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health: Respiratory Giddens Concepts: Gas Exchange, Safety HESI Concepts: Oxygenation/ Gas Exchange, Safety Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 637). Philadelphia: Saunders. Awarded 3.0 points out of 3.0 possible points. 66.ID: 9477032637 The nurse is providing care to a client with chronic peripheral arterial disease (PAD). Which assessments findings should alert the nurse to the onset of an acute arterial occlusion? Select all that apply. A. Cyanosis of the skin in the affected extremity Correct B. Skin temperature cool to touch in the affected extremity Correct C. Client complaints of problems moving the affected extremity Correct D. Complaints of sudden and severe pain in the affected extremity Correct E. Bounding pulse in the affected extremity below the level of the occlusion Rationale: Although chronic peripheral arterial disease (PAD) progresses slowly, the onset of acute arterial occlusions may be sudden and dramatic. Acute arterial occlusion is serious and occurs when blood flow in a leg artery stops suddenly. If blood flow to the toe, foot, or leg is completely blocked, the tissue begins to die and can lead to gangrene. Intervention is needed immediately to restore blood flow. Manifestations of acute arterial occlusion are due to a lack of blood flow and include cyanosis, cool skin temperature, severe pain, problems moving the affected extremity, and a lack of a pulse. There would be no pulse as a result of the occlusion and blocked artery. Test-Taking Strategy: Focus on the subject, “assessment findings of an acute arterial occlusion.” Think about what an acute arterial occlusion is. Noting the word “occlusion” will assist in eliminating option 5 because no pulse would be present. Review: chronic peripheral arterial disease and acute arterial occlusion Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Critical care: emergency situations and management Giddens Concepts: Clinical Judgment, Perfusion HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 792). Philadelphia: Saunders. Awarded 3.0 points out of 4.0 possible points. 67.ID: 9477039882 Which manifestations are specifically noted in a client with right-sided heart failure.? Select all that apply. A. Ascites B. Hepatomegaly C. Breathlessness Incorrect D. Dependent edema Correct E. Neck vein distention Correct Rationale: Right ventricular failure is associated with increased systemic venous pressure and congestion. Therefore, manifestations are noted in the systemic circulation and can include ascites, hepatomegaly, dependent edema and neck vein distention. Breathlessness and other pulmonary manifestations are often a sign of left-sided heart failure. Test-Taking Strategy: Focus on the subject, “manifestations of right-sided heart failure.” Remember “Left and lungs.” Left-sided heart failure manifestations are pulmonary signs whereas right-sided heart failure produces signs noted in the systemic circulation. Review: manifestations of right-sided and left-sided heart failure. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integraed Process: Nursing Process/Assessment Content Area: Adult Health: Cardiovascular Giddens Concepts: Gas Exchange, Perfusion. HESI Concepts: Oxygenation/ Gas Exchange, Perfusion Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 749, 789). Philadelphia: Saunders. Awarded 0.0 points out of 4.0 possible points. 68.ID: 9477031490 The client with heart failure is preparing to be discharged from the hospital. Which interventions should the nurse include in the client’s discharge teaching plan? Select all that apply. A. Teach the client coping strategies Correct B. Develop a regular exercise program C. Educate the client about dietary restrictions D. Give the client a minimal role in the self-management program E. Provide the client with a list of current medications and dosing times Correct Rationale: Any client discharged from the hospital should be encouraged to become involved in as much self-care as possible and the client’s condition allows. Coping strategies are helpful for most clients to manage any stress that may arise. An exercise program is also important to maintain strength and circulation. Dietary restrictions may be necessary for the client with heart failure and may include fluid restrictions and sodium restrictions. Clients need to clearly understand how to administer prescribed medications and a written list of instructions is extremely helpful to ensure safety and compliance. Test-Taking Strategy: Focus on the subject, “discharge teaching for a client with heart failure.” Think about the pathophysiology associated with heart failure to assist in answering correctly. Also, eliminate option 4 noting the words “minimal role” in this option. Review: Heart failure and home care management Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health: Cardiovascular Giddens Concepts: Client Education, Health Promotion HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 757). Philadelphia: Saunders. Awarded 3.0 points out of 4.0 possible points. 69.ID: 9477038275 The nurse is educating a client on how to self-manage care at home, following an admission to the hospital for heart failure. Which statements by the client indicate that teaching has been effective? Select all that apply. A. “I will weight myself daily.” Correct B. “I will wear my oxygen at night as prescribed.” Correct C. “I will follow up with my health care provider (HCP) as scheduled.” Correct D. “I will report new signs and symptoms to my home care nurse when she visits.” Incorrect E. “I have my medications and dosages written down for easy review and administration.” Correct Rationale: Health teaching is essential for promoting self-management. Many clients with heart failure are readmitted to hospitals because they do not maintain their prescribed treatment plan, including lifestyle changes. The client should state the importance of daily weights to monitor for increases indicating fluid retention, wearing oxygen at night to prevent hypoxia, keeping follow-up appointments for monitoring status, and having medications and dosages written down and available for review and administration. The client should not wait for the home care nurse to report new signs and symptoms, but should report them immediately to the HCP in charge of care. Waiting could lead to worsening heart failure and complications such as pulmonary edema. Test-Taking Strategy: Note the strategic word, effective. Focus on the subject, heart failure and client self management at home. Think about the pathophysiology associated with heart failure and the complications that can occur to select the correct options. Eliminate option 4 because waiting to report new signs and symptoms could result in worsening heart failure. Review: Heart failure. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Adult Health: Cardiovascular Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 757). Philadelphia: Saunders. Awarded 3.0 points out of 4.0 possible points. 70.ID: 9477033404 The client has been diagnosed with valvular disease. Which interventions should the nurse be prepared to discuss with the client? Select all that apply. A. Surgical management Correct B. Required dietary changes Incorrect C. Medication management Correct D. Placing limits on physical activity Correct E. Monitoring for an irregular heart rhythm Correct Rationale: Management of valvular heart disease depends on which valve is affected and the degree of valve impairment. When caring for a client with valvular disease the nurse should be prepared to discuss interventions. These include surgical and medication management, as well as placing limits on physical activity. Monitoring for an irregular heart rhythm is also a common intervention for clients with valvular disease. Required dietary changes is not specific to valvular heart disease although diet changes would be necessary for other cardiac disorders such as coronary artery disease. Test-Taking Strategy: Focus on the subject, interventions for valvular disease. Think about the pathophysiology associated with valvular disease. Eliminate option 2, because of the word “required” and because diet does not typically have an effect on valvular disease. Review: Valvular disease. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity. Integrated Process: Teaching and Learning Content Area: Adult Health: Cardiovascular Giddens Concepts: Client Education, Infection HESI Concepts: Infection, Teaching and Learning/Patient Education Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 761). Philadelphia: Saunders. Awarded 2.0 points out of 4.0 possible points. [Show More]

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